In the present study, we sought to examine the correlation between the motivation of PHWs and their intention to leave, at the same time to examine the psychometric properties of a Chinese translation of the WMSHW. The current results provide supportive evidence regarding the cross-cultural reliability and validity of the inventory implying that WMSHW opens a new field of research in relation to work motivation of Chinese health workers by introducing a scale that measures motivation compositions and levels. The data show that the majority of PHWs investigated had a moderate level of motivation with controlled motivation dominantly existed, and 65% of PHWs were with moderate or high level of turnover intention. It is also found that higher autonomous motivation and those being highly motivated by all types of drivers are more likely to be with lower turnover intention.
This study is the first time to measure the work motivation of PHWs in China as the drivers of working hard and ensuring the validation of scale is the basis for further exploration of the correlation between motivation and intention to leave. The translated and cross-culturally adapted WMSHW demonstrated good structural validity and internal consistency among Chinese sample. We used the well-established translation and back-translation guidelines to assure equivalence in varied aspects between source and target versions. During the translation of the English WMSHW into Chinese, a minor cultural discrepancy was encountered and one item of the WMSHW has been modified accordingly: ‘supervisor’ was replaced with ‘leader’ as this word is closer to Chinese culture. Compared with previous studies that measure work motivation, this is the first study to confirm the structure of WMSHW with the population working at health institutions in China without sacrificing any item.
The result of CFA showed that the modified five-factor model had a better fit than the other models and was selected as the best-fitting model, which was consistent with the original scales. In line with a previous study testing the latent structure of work motivation based on SDT in seven languages [30], fit indices in the Chinese version demonstrated slightly lower than the original English version. Culture may have played a role in shaping the understanding of work motivation. Although values of RMSEA are barely within the scope of adequate model fit, our option was not to modify the model considering that the current results suggest that the five-factor model may be a theoretically adequate model for the data based on SDT. Therefore, the current results showed that a Chinese translation of the WMSHW demonstrates a five-dimensional factor structure representing IM, IDEN, INTRO, EXT-S, EXT-E as hypothesized. Specifically, the IDEN dimension combines integrated regulation and identified regulation which has proven difficult to separate in previous research [30, 41].
In line with previous studies [29, 42], the correlation between the two factors was identified as moderate, indicating that they are related although they measure different compositions of work motivation. Furthermore, strong internal consistency of the Chinese WMSHW was demonstrated, as evidenced by all Cronbach’s alpha coefficients over 0.8. In the Chinese WMSHW, the Cronbach’s alpha for the total scale (0.94) was much higher than in the English (0.89) versions, and Cronbach’s alpha for the five subscales was also higher than in the English version (0.92) [31].
This study firstly used the WMSHW to measure and categorized PHWs into four types based on motivation composition. As explained by SDT, the self-determination continuum of motivation includes five major dimensions of drivers covering from controlled motivation to autonomous motivation. So we rated four types of groups as PHWs without any controlled or autonomous drivers for work (low motivation), PHWs with more external controlled drivers (controlled motivation), PHWs with more internal autonomous drivers (autonomous motivation), PHWs with strong drivers from both controlled and autonomous factors (highly motivated). Previous studies [43, 44] mainly used job satisfaction as a proxy to measured and categorized the motivation of PHWs. The boundaries between motivation and job satisfaction measurements are blurred in existing studies. The reasons include: firstly, the influencing factors of job satisfaction have a lot of overlap with determinants of motivation [45, 46]; secondly, job satisfaction is an effective consequence of motivation, and a status of harmony between drivers’ of health workers and organization environments [5]; lastly, scales directly measuring motivation per se as the drivers of working hard are lacking. The measurement of job satisfaction cannot substitute the measurement of motivation. Compared with the category of being satisfied or dissatisfied, category-based WMSHW can identify complex compositions of drivers and diverse levels of motivation.
It was found that the health workers with low motivation, controlled motivation, autonomous motivation and highly motivated (higher scores on both autonomous and controlled drivers) took 19.6%, 32.2%, 10.1% and 38.1% of the total number of participants respectively. Based on the assumption of STD, human beings tend to make decisions by themselves and health workers with autonomous drivers, i.e. doing what they love and can make decisions for themselves, so those with the highest autonomous motivation are the most motivated compared with health workers with other drivers or those without drivers [7]. So the four groups of health workers provide a possible method to order the motivation level from the lowest level (low motivation group) to the highest level (highly motivated group). We found that 38.1% of PHWs have the strongest driving forces from both external incentives and enjoyment of work, and this group had a relatively well motivation status. There were still 19.6% of PHWs in the investigated area being rated as low motivation, and 32.2% of PHWs being dominantly driven by controlled factors, like monetary incentives or avoidance of punishment. These two groups took more than half (51.5%) of investigated PHWs, so overall the motivation of PHWs still was at a moderate level. Existing studies on work motivation of health workers working in China PHIs all used job satisfaction [46, 47] or perception of health workers as determinants of motivation [46, 47] to assess the motivation status and all have the similar findings, i.e. 74% of PHWs were satisfied with present work [46]. This study also found that only 10.1% of PHWs are dominantly driven by passion and enjoyment at work. For PHWs in China, a large number of studies have reported the low level of income level and poor work environment. Under this context the existing needs can not be fully met, it is less likely for PHWs to have the pursuit for enjoyment of work tasks [49]. The dominant role of existence need can also be reflected by the findings of this study: health workers mainly driven by controlled factors took 32.2% of investigated PHWs in this study; at the same time, in the driving forces of highly motivated participants (38.1%), the impetus of controlled factors was also as strong as the forces of autonomous factors; the sum of the above two groups means that the majority of participants are in the stage being driven by monetary rewards and other forms of material benefits.
The data analysis showed that compared with the “low motivation” group (those having no drivers to work hard), the groups with any type of motivation, including controlled, autonomous, both controlled and autonomous, were all more likely to have lower turnover intention. Though there are no studies that directly measure motivation for PHWs in China, previous studies using job satisfaction as a proxy to measure reported similar findings: lower satisfaction as an important indicator of low motivation, was correlated with higher turnover intention no matter in China and other LMICs [10, 50, 51].
The negative relationship between motivation and intention to leave was found to become stronger with the level of motivation increasing: highly controlled cluster (OR: 0.47; 95% CI: 0.35-0.63), highly autonomous (OR: 0.27; 95% CI: 0.18-0.41) and highly motivated (OR: 0.20; 95% CI: 0.15-0.27). Autonomous motivation is more effective in reducing turnover intention compared with controlled motivation, and this result implies those PHWs with real interest or pure enjoyment in the activities related to primary health care have less intention to leave the existing work position. As agreed by SDT and other motivation theories, being motivated is a status of harmony between personnel goals and organization goals, so those PHWs with natural enthusiasm on their tasks are nearer to the status of harmony even under disadvantaged environments. Autonomous motivation can help health workers keep optimistic in work, and cope with the feelings of dissatisfaction, stress, and burnout. Though there are no similar studies on the relationship between different compositions of motivation and turnover intention of health workers, the studies in other industries have found that employees with the pursuit of individual development, interests and achievement were more likely to have positive feelings compared with those with financial benefits and prestige as major drivers [52, 53].
We also found that controlled motivation can work in reducing the extent of turnover intention compared with those without any driving forces. In this study, the PHWs in the “low motivation” group are those having the lowest score on any drivers of working hard, which means those people having no purposes or desires, thus they usually do not expect any achievements from their efforts or do not have confidence on the competency of themselves. The PHWs with no motivation usually perform as having no willingness to make efforts in work and responding passively to external environments. PHW workers with controlled motivation, though they are rated as the lower level of motivation in the STD continuum of motivation, their pursuit for the basic living substances can work to some extent in retaining them in the existing work position.
The present study has several limitations that should be noted. First, the Chinese WMSHW has been tested only among health workers working at primary health care facilities, so further psychometric testing in secondary-level and third-level hospitals and other health settings would contribute to reject or confirm the generalizability of the instrument. Secondly, although our study translated and adapted the English-language scale into the Chinese language using standard procedures, the cultural differences between Western countries and China may limit the ability to measure work motivation in Chinese cultural contexts. Thirdly, because limited studies assessing the motivation level directly are published for us to compare, our findings on categories of PHWs based on motivation level, and the relationship between motivation and turnover intention are mainly discussed based on motivation theories.