MEANING IN MOTIVATION: DOES YOURORGANIZATION NEED AN INNER LIFE?

EILEEN E. MORRISON

GEORGE C, BURKE III

LLOYD GREENE

ABSTRACT

Leaders of health care organizations are increasinglyinterested in ways to attract, retain, and gain commitment from theiremployees. This interest is created in part because high turnover ratesand the lack of corrunitment negatively affect the provision of care andthe bottom line in their organizations. In a quality and cost conscioushealth care environment, health care managers need to fmd solutionsfor these difficult issues; solutions that are effective, efficient andsustainable. What can be done?

This article reviews, amplifies, and extends work that has beendone in the area of "meaningfulness of work" in the context ofemployee retention and commitment. It begins with an exploration ofthe problems caused by lack of employee engagement and commitmentincluding their impact on quality and costs. It then summarizes both thetheoretical and applied research in the area of meaning and work. Italso introduces the basic principles of Viktor Frankl's logotherapy(Frankl, 1998) as a foundation for encouraging the integration ofmeaning and work. The seminal work by Pattakos (2004) is used todemonstrate how Frankl's principles can be applied to healthcare worksettings. Finally, the article provides suggestions for increasingemployee commitment and engagement through identifYing meaningand purpose in work.

BACKGROUND AND SIGNIFICANCE

It is rare to have a discussion with heath careleaders or corporate executives, for that matter, without thetopic of employee commitment becoming part of theconversation (O'Malley, 2000). The desirability of

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employee commitment is hardly surprising given thecontext of its definition: psychological attachment,emotional bonding, and long-term focus. However,employee commitment is not universally present inorganizations. In fact, a survey conducted by the HudsonInstitute found that only 42% if employees believe thattheir employers deserve their allegiance (O'Malley, 2000).

A lack of commitment contributes to high turnoverrates and poor morale which negatively affects the bottomline in health care. In fact, turnover can cost a healthfacility 3.4-5.8% of their operating budget (Waldman &Kelly, 2004). For some hospitals, the turnover rate canexceed 20% (Arthur, 2002) which threatens quality of care,profitability, and the fiscal viability of the organization.

Since nurses represent a major employee sector inhealth care, they can serve as an indicator of the costsassociated with turnover. According to the JointCommission of Accreditation of Healthcare Organizations(JCAHO),

It costs approximately 100% of a nurse'ssalary to fill a vacated nursing position ....Assuming a turnover rate of 20%, thecurrent average turnover rate among healthcare workers, and a hospital employing 600nurses at $46,000 per nurse per year willspend $5,520,000 a year in replacementcosts. (2005, p. 9)Turnover rates affect more than replacement costs.

They may influence such areas as costs per discharge andquality assessment scores. According to JCAHO (2005),hospitals with high turnover rates had higher costs perdischarge than those with lower rates. Logically, whennurses were retained, the hospitals also did better on qualityscores including mortality rates and length of stay. JCAROsuggests that a culture of retention be created to decrease

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nurse turnover and free up funds for activities that mightalso improve morale.

The lack of employee commitment and engagementalso affect more than turnover. According to JeARO(2005), morale among health care employees demonstratesan almost perfect correlation with patient satisfactionscores. In addition, when spirituality is considered to be animportant part of an organization's culture, productivityand even market dominance can increase (Jurkiewicz &Giacalone, 2004).

Health care organizations have attempted toimprove morale through contests, incentives, buttons,special parking places, etc. These efforts, while havingsome value, have primarily focused on extrinsicmotivational strategies that do not produce long-termresults. Atchison (2006) suggests· that it might be moreprovident to attempt to influence an employee's intrinsicmotivation for more sustained change. For example, thismight be done by providing a corporate culture thatremoves barriers and increases the employee's potential tofind meaning in his or her work.

CREATING MEANING IN THE HEALTH CAREWORKPLACE

Interest in exploring the interconnection andpossibly interdependence between work and meaning inlife is emerging. For example, Mathew Fox (1994) in TheReinvention of Work, suggests that all work has thepotential to provide meaningful existence. He advocatesthat life and livelihood ought not to be separated but shouldflow from the same source: spirit. This brings meaning toexistence in a truly integrated way.

Michael O'Malley (2000), in CreatingCommitment, identifies the antecedents of commitment andlists five general conditions for action that employers can

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take to support the creation of commitment and meaning.These are: 'fit and belonging", status and identity", "trustand reciprocity", emotional reward", and "economicinterdependence" (p. 35). Ann Coombs (2002), in TheLiving Workplace, writes that in 1998, none of thecompanies with which she worked focused on spiritualityor meaning. Today, about half of those do focus on theseareas. "People are thinking about the words 'meaning' and'purpose' more than ever before (Coombs, 2002, p.46).Although this need for commitment and meaning in workseems to be trans-generational, according to Borkowski(2005), Generation X employees (born between 1963 and1977) are going to be more interested in fmding meaningfulwork then they are in special parking places or fancyoffices. In essence, finding meaningfulness in the form ofspirituality, values, or the opportunity to discern what isreally important provides employees with the ability toachieve their full in potential as people. They feel valuedand supported and this is fundamental to enacting the coreof commitment in engagement.

According to Ashmos and Duchon (2000 p. 139) inSpirituality at Work: A Conceptualization and Measure, "itis recognition that employees have an inner life thatnourishes and is nourished by meaningful work that takesplace in the context of community." Mitroff and Denton,coauthors of A Spiritual Audit of Corporate America(1999), suggest that, in general, "spirituality is a belief inthe interconnectedness of life or the basic desire to findultimate meeting and purpose in one's life and to live anintegrated life" (p. 16)

In addition to the theoretical work that is ongoing inthis area, there are many application examples and attemptsat quantifying meaningfulness and spirituality in theworkplace. Ashmos and Duchon (2000) designed anemployee inventory which gathers data on spirituality andmeaningfulness at work. Their questionnaire was

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developed utilizing employees from four hospital systemsin four different U.S. cities. Their intent was to assessorganizational culture as a baseline for improvingcommunity, connection, and meaning it work. Both theVeteran Affairs Hospital in Brockton Massachusetts, andBarnes-Jewish hospital in Saint Louis have demonstrated intheir research that a focus on spirituality and meaning canimprove patient outcomes including reduced length of stay(Hudson, 1996). In addition, a financial institution that isnot related to health care, has created a process ofenvisioning and storytelling to create meaningfulness, and apassion for and commitment to their organization (Pulver,2000).

This review of literature supports the growingnotion that inner life, chiefly in the form of linkingmeaningfulness to work life, is critical if not essential toaddressing employee commitment and engagement. Thenext sections of this article build on the foregoingtheoretical and application examples. These sections aredesigned to explore a specific set of ideas which amplifyand extend the work in this area.

Historical Background on Meaning TheoryViktor Frankl, founder of logotherapy (Meaning

Theory), began his career as a physician (neurologist) andstudied under the greatest minds of his time: Freud andAdler. In 1941, Frankl was deported to the concentrationcamp at Theresiendstat and survived four different camptransfers including Auschwitz and Birkenau. While inthese camps, he endured almost unimaginable suffering,but used this experience as a way to field test and validatehis burgeoning theory of meaning. His observationalresearch confirmed his theoretical position that people witha clear sense of meaning and purpose were able toovercome the extreme suffering of the camps and retaintheir humanity and dignity (Klingberg, 2001). When

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Frankl was released, he wrote The Doctor and the Soul(1986) which began his life work in logotherapy.

Basic Concepts ofLogotherapyLogotherapy is both a philosophy and an approach

to daily life which is centered on the premise that fIndingmeaning in the moment and the search for ultimatemeaning are essential to human existence. In addition toaccepting that people are more than physical beings,logotherapy assumes that life has meaning regardless of thecircumstances. In addition, humans always have freedomof choice but must also accept responsibility for thosechoices (Sjolie, 2002).

For Frankl, all human life has value. He posits that"Human life has inestimable value and that it is purposeful;that each individual is unique, and is endowed with innatedignity. We are called to live with authenticity orintegrity to fulfill our vocation of destiny, our uniquemeaning" (Graber, 2003, p.55). Frankl viewed people ashaving three dimensions: soma (body), psyche (mind), andnODS (spirit). Of these three, the spirit is the most essential.

Part of the spiritual dimension is the human abilityto rise above circumstances (self transcendence) and careabout something or someone beyond the self. This abilityis what makes people fully human. The ability of selftranscendence also provides a link between humans and theultimate meaning or the universal order of things. Meaningtheory is founded on three pillars which have beendescribed by various authors (Barnes, 2000; Frankl, 1985;Graber, 2003; Lukas, 2000). These pillars represent theconcepts of freedom of will, will to meaning, and meaningin life.

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Freedom of WillThe concept of freedom of will stresses that all

human beings have the freedom to make choices in anygiven situation. Sometimes the choice is limited to one'sattitude toward the situation, but attitude is still a choice.However, freedom of will does not mean absolving theindividual from responsibility. In fact, responsibility is anequal partner with choice. Individuals cannot blame othersfor the consequences of their choices. They must takeownership.

Will to MeaningFinding meaning in life and work is a prime

motivator for human existence (Frankl, 1985). Meaning isunique for each person and can only be discovered (neverdictated by another). When life is perceived to bemeaningless, people experience an existential vacuum oremptiness (Barnes, 2000). In American culture, thisemptiness is often superficially filled through food, drugs,sex, work, shopping, or self-destructive behaviors.

Meaning in LifeHuman life has "unconditional meaning, which

cannot vanish under any circumstance" (Lukas, 2000, p. 6).Individuals can fmd life's meaning in a variety of ways,including living actively and engaging in meaningful work.A situation or daily event can offer personal meaning forthe individual who is open to it. For example, in work,meaning can be found even in ordinary tasks such ascleaning the floors or delivering mail. These tasks becomemeaningful when the employee chooses to see them asservice to others. Meaning is created because the task isconnected to something higher than the individual.

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FINDING MEANING IN WORK

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Frankl (1985) stresses that people must take anactive role in finding their unique life meaning. He statedthat there are

... three principal ways in which man canfind meaning in life. The first is what hegives to the world in terms of his

creations; the second is what he takesfrom the world in terms of encounters andexperiences; and the third is the stand hetakes to his predicament in case he must facea fate he cannot change. That is why lifenever ceases to hold meaning .... (Frankl,1988, p. 70)

Each of these ways can be used to determine meaning inlife and all can be found in work that is meaningful.

In The Doctor and the Soul, Frankl (1986) explainsthat people can find meaning in life through work thatallows them to use their creativity and uniqueness for thebenefit of others. This type of work allows them to bothgive to THE world and to learn from it. Through itsfoundation in beneficence, health care offers a singularopportunity to achieve meaningful work.

A seminal publication by Alex Pattakos (2004 p.vi)applies Frankl's logotherapy to the work setting in the formof seven core principles. These principles can also serve asa foundation for understanding how to affect intrinsicmotivation in the work place. These Pattakos' principlesare:

1. Exercise the freedom to choose your attitude.2. Realize your will to meaning.3. Detect the meaning of life's moments.4. Don't work against yourself.5. Look at yourself from distance.

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6. Shift your focus of attention.7. Extend beyond yourself.

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By exercising their ability to choose their attitudetoward any work situation, employees have the ultimatefreedom (principle 1). For example, suppose a JCARO exitinterview team makes negative comments about activitiesin a department. Employees can choose to see thesecomments as criticism and become resentful. They couldalso choose to view this feedback as way to makeimprovement to better serve their patients. The latter choicecan drive action and positively impact morale.

In order to realize meaning in work, employeesmust view work as being concerned with something that isbigger than they are (principle 2). Given this premise, thework of health care should be inherently meaningful sinceit is about service to patients, families, and the community.Once employees apply a service-centered orientation totheir health care daily practices, they tend to be less likelyto leave or resign. Further, they tend to have greaterconcern for the quality of their work. Even when theinevitable "bad days" occur, employees can maintain theirdedication to their jobs by keeping the big picture ofservice to patients in mind.

Principle 3 suggests that meaning can be found evenin the small things. This requires attending to small thingsand fmding value in them. For example, a CEO notices thata member of housekeeping consistently does the tasksassigned to his or her job. The CEO stops to thank thisperson for the work that he or she does. While this is a verysmall gesture, it has the ripple effect of assisting thehousekeeper in finding meaning in his or her work.

Employees also need to work in support ofthemselves (principle 4). For example, sometimesadministrators become so fixated on project completionthat they set themselves up for failure. By being fearful and

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trying to maintain total control, they are not trustful enoughto delegate appropriately. The result is that they becomeoverworked and exhausted, and the project is notsuccessfully completed. By using this rnicromanagementprocess, administrators are actually working againstthemselves.

Pattakos (2004) states that only human beings arecapable of taking a self-distancing approach to life(principle 5). This means that employees can take anobjective look at themselves and their behaviors. They arealso capable of laughing at their own humanness andfoibles. While health care is a very serious business, theability to be objective and express an appropriate sense pfhumor creates a healthier work environment and improvesmorale.

Unquestionably, health care is a stressful workenvironment. Stress can seem overwhelming and "Evenwhen we do love our jobs, we all experience bad, evenugly, days" (Pattakos 2004 p. 134). However, even withthe stress, the power is in knowing that there are choices.When stress happens, employees always have a choice.They could resign and go home, stay and be miserable, orseek to find some meaning in the situation. The third optionis obviously the best for both the patient and theorganization.

For example, suppose a nurse has almost finishedhis 14-hour shift and a call button goes off in the room ofan elderly patient. This is the same patient who has pushedthe call button five times in the last half hour. This nursemight be having a bad day or even an ugly one. Whatchoices does the nurse have? Pattakos suggests that whenhe answers the call button, he can shift his focus ofattention (principle 6). He can cope with the situation byimagining that the patient is his own beloved grandmother.How would he want her treated?

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The last principle of meaning in work asks thequestion, "Why are we doing this work?" If the answer is"for the money", there is never enough. If the answer is"power", there is always someone more powerful. Pattakossuggests that when employees engage in work that goesbeyond meeting their personal needs, they can findmeaning that transforms them. Helping employees findand understand meaning in work and how it can contributeto meaning in life certainly has the potential to increasecommitment, reduce turnover and improve morale.

PRACTICAL SUGGESTIONS FOR FINDINGMEANING IN WORK

Logotherapy or meaning theory holds the potentialto positively impact job satisfaction and staff turnover inthe health care industry by influencing the internalmotivation of its employees. Since health care isexperiencing tight budgets and challenges from manysources, it would seem prudent to consider approachingmotivation from this view in addition to the traditionalreward-based systems. The following are the suggestionsfor applying logotherapy to enhance morale and decreaseturnover.

Applications for LeadersIn making change in an organization, leaders must

always start with themselves. The following aresuggestions to assist leaders in this process.

1. Start with yourself.Begin by revisiting why you chose to be a health

professional. Was your decision a calling, a way to make adifference, or was it based on economic necessity? Doesyour work as a health administrator provide meaning inyour life? Can you describe why your work is meaningfulfor you? Understanding your own motivation to work will

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assist you in dialoguing with others about their meaning inwork.

2. Create an environment where employees can findtheir own meaning in work.

This requires more than giving out tee shirts orbuttons. It begins with a cultural shift to influence moraleand turnover through internal rather than externalmotivation techniques. Making this shift includesintroducing policies and procedures that promotemeaningful work, providing training opportunities on howto fmd meaning in work, and giving a strong and consistentmessage.

The message can begin with employee orientationwhere the CEO explains the organization's mission andvision..Rather than just saying the words, he or she muststress the significance of the mission in terms of itscontribution to the health ofthe patient and the community.He or she then must go beyond the explanation and "walkthe talk". This means helping employees find theirconnection to the organization's mission and vision.Employees tend to remain loyal and productive inorganizations when they connect to the mission andunderstand their roles in making it a reality. Turnover canbe reduced when they see themselves as the threads thathold the organization together.

No environmental change can occur withouttraining. Training efforts will be needed to preparemanagement to both understand and become champions forrecognizing meaning in work. In addition, employees needinformation on how to create their own meaning in workand how they connect to the organization. For example,when a nurse starts an IV, this is more than a clinicalprocedure. He or she is contributing to the healing missionof the organization.

3. Be sure to recognize even the small (butimportant) employee mission-centered contributions.

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Through management by walking around andobservation, managers can recognize even the smallpractices that enhance the patient care experience. Forexample, the staff member is observed taking the time toassist lost family members by actually taking them to theirdestination. This action needs to be recognized and praised.Although this is not as dramatic as a heart transplant, it stillmakes a difference in the patient's perception of qualityand compassionate care.

In addition, management can empower employeesto have greater control over their work environment and tosolve problems on the spot. For example, if a patient makescomplaint about food service, any employee can beauthorized to apologize on behalf of the facility and to takeaction to remedy the situation. Once the situation isremedied, the employee can write a note of apology and/orpurchase a small gift as a token of sincerity. Health carefacilities are beginning to implement this customerrelations practice that allows employees to action when it isneeded with great success.

Applications for EmployeesA thematic relationship exists between Frankl's

work and Pattakos' principles (see Table 1). For example,Frankl argues that "Freedom of Will" is a source ofmeaningfulness. Pattakos builds on this by pointing outthree ways to achieve it: "Choice in Attitude," "Don'tWork Against Yourself," and "Shift the Focus ofAttention". Leaders who want to encourage thedevelopment of this theme might design jobs so that theyinclude opportunities for autonomy and creativity. Inaddition, they could establish work teams that have powerequalization and self management and/or role exchange.

As an amplification of Frankl's "Meaning in Life"category, Pattakos argues for "Detect Meaning in Life'sMoments," and Look at Yourself at a Distance". These

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themes could be encouraged by taking 5 or 10 minutes atthe start of staff meetings to have people talk about whathad meaning for them in a recent work experience or relatehow their work supports their values. Another alternativefor developing this theme is to have employees tell storiesabout the organizational lore, humorous occurrences, orhistorical milestones. While these are not the only ways toapply Frankl and Pattakos' themes to the workplace, thepoint is that there are practical ways to encourage theconnection between meaningfulness and work life.

Table 1Relationship between the Principles ofFrankl and Pattakos withA l' t· E Ilpp,lca zon xamplesFrankl's Principles Pattakos' Principles Applications

Freedom of Will Choice in Attitude Job DesignDon't work Team Structureagainst Yourself Feedback SystemsShift focus of Attention Performance Evaluations

GenuinenessEncouraging Individuality

Will to Meaning Realize will to Meaning EducationExpand beyond Yourself Leadership Development

ReframingProblem solvingPatient Feedback SystemsPatient/family/staffDiscussion GroupsEncouragingCommtmity Service

Meaning in Life Detect meaning Sense Makingin life's Moments Introspection Exercises

Look at Yourself Identi fy ing Strengthsfrom a Distance Encouraging Creativity

Encouraging the use ofhumorInternal CommunityBuilding ActivitiesValues DetectionStart meetings withReflectionsHave Staff tell Stories

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CONCLUSION

Logotherapy or meaning theory is not just anotherfad or quick answer to employee motivation. Its roots are inthe observational research of Viktor Frankl who found thatmeaning in life could be experienced even among thosewho were imprisoned in Nazi concentration camps.Pattakos offers advice on how to translate these theoreticalconstructs into the work settings in general. However,application to health care is just begilming to be addressed.

In order to improve employee commitment inengagement, managers should not rely entirely on extrinsicforms of motivation. The impetus for continuedproductivity and high morale must come from a sense ofmeaning and purpose in the work itself. Leaders mustexamine their sources of intrinsic motivation, provide aculture that encourages this level of exploration for allemployees, and develop methods that assess and sustainthis approach. Health care organizations that practice anycomponent of this approach must be committed toincreasing commitment in engagement through animprovement in the inner lives of employees. If thisapproach is treated as just another method to improveproductivity it will not work. While there is no pure modelin this undertaking, the work of Frankl and Pattakos appearto be valuable as a place to begin.

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