Nurses’ understanding and perception of career ladder system are related to work motivation: A multicenter cross-sectional study in Aceh, Indonesia

Abstract

Objective

To analyze the relationship of nurses’ understanding and perception about the career ladder system with the work motivation.

Method

Using a cross-sectional design, this study was done in three hospitals in Aceh province, Indonesia. A total of 352 nurses recruited through a simple random sampling method filled out the questionnaires. Univariate analysis, Pearson correlation test, and linear regression were performed for data analysis.

Results

There was a significant relationship between understanding and perception of the career ladder system and the work motivation of the nurses (p = 0.0001, α = 0.05). The most dominant factor influencing the nurses’ work motivation was the perception of the career ladder.

Conclusions

Nurses having positive view on their career ladder system are more likely to have better work motivation. Education on the career ladder system in nursing can be a motivation reinforcement strategy for the nurse managers and the hospitals.

Introduction

Nurses with good work motivation provide better and more productive services.¹ In contrast, those lacking work motivations are less likely to participate in the task.² Work motivation is therefore vital to drive performance and retention of the nurses at the hospitals. Work motivation can grow either intrinsically or extrinsically. The former is typically stronger as intrinsic motivation can genuinely move individuals to carry out their duties with high enthusiasm, regardless of the environmental influences.³

One potential source of intrinsic motivation for nurses is the career ladder system.⁴ This system is a form of organizational recognition of the nursing profession by assuring for nurses to move towards the level of career they want to achieve.^5,6 Nurses’ engagement with the career ladder is shown to have a positive correlation to their intention to devote themselves to work as well as their productivity, competitiveness, and motivation to attain new skills and opportunities for their future career development.^4,7

The career ladder is used to differentiate the implementation of nursing practice for each level so that it can facilitate professional development, improve staff relations, appreciation, competency, and boost work motivation.⁸ The hospitals which implement a good career path will reap many long-term benefits.^6,9 The implementation of the clinical nurse career ladder system has been shown to have an impact on improving retention, performance, the satisfaction of nurses, and the quality of care.^4,10–13 Prior studies show the success of the career ladder that leads to nurses’ higher motivation to continue formal and non-formal education and to get promotions.¹⁴ Lack of clear career ladder explains why many nurses have no desire to involve themselves in the career ladder because they think it only adds on their responsibilities without promising benefits.¹⁵

A large case study conducted at eight hospitals representing different regions in Indonesia found that the career ladder system in Indonesia is still weak and nurses are not allocated according to their competency, resulting in poor quality of nursing care.⁵ It remains unclear, however, how nurses in Aceh perceive and understand the career ladder system as clinical nurses, hence this present study. Improved understanding and perception of career ladders are expected to increase nurses’ work motivation that can contribute to the better quality of healthcare services.

Method

A cross-sectional study was carried out at three government hospitals in Banda Aceh, Aceh Province, Indonesia. 352 nurses were recruited using a simple random sampling method in the inpatient wards and intensive care units. The inclusion criteria were: staff nurse, working three shifts, and not having a leave. Head nurses or nurse managers were excluded from this study.

The questionnaire used to assess the nurses’ perception of the career ladder system was adopted from Hariyati's study⁵ (Cronbach's alpha = 0.85). Another questionnaire was developed by the researcher based on Herzberg's theory. Cronbach's alpha for the questionnaire assessing nurses’ understanding was 0.78, and that of nurses’ motivation was 0.90.

Descriptive analysis, Pearson tests, Mann–Whitney and Kruskal–Wallis tests were performed in this study. Afterward, the most dominant factors that influence motivation were examined using multivariate linear regression statistical test. This study had obtained ethical approval from the ethical review from the ethical committee of Faculty of Nursing, Universitas Indonesia (number 142/UN2.F12.D/HKP.02.04/2018).

Results

The mean age of the participants was 30.95 years-old. In average, the participants of this study had been practicing as a nurse for 4.99 years with the mean monthly salary of IDR 4,436,875 (approximately 290 USD). The majority of the participants were female (85.8%), had a diploma in nursing (63.9%). In terms of the career ladder, 63.5% of them were in the basic clinical career (called 1st-degree clinical nurse in Indonesia). Most of them were non-civil servant nurses (83.2%).

As can be seen in Table 1, the mean score of the participants’ understanding of the CLS was 33.93 (71%). The perception of CLS was 75.11 on average. Whereas, the score of the work motivation of the participants on average was 86.59 (80.17%).

Table 1.

Nurses’ understanding of and perception of the clinical career ladder system and nurses’ work motivation (N = 352).

Variables	Mean	Median	SD	Min–Max	95% CI
Hospital A
Understanding	33.93	35	6.47	8–48	33.25–34.61
Perception	57.11	56	5.58	31–70	56.52–57.69
Motivation	86.59	86	7.85	64–105	85.77–87.41
Hospital B
Understanding	34.83	35	6.39	8–48	33.37–36.29
Perception	57.55	56	4.47	50–70	56.53–58.58
Motivation	85.18	82.50	7.56	74–102	83.45–86.91
Hospital C
Understanding	33.75	35.50	5.58	20–41	31.39–36.11
Perception	54.17	54	2.53	51–61	53.10–55.24
Motivation	87.63	86	7.03	79–100	84.65–90.60
Overall
Understanding	33.93	35	6.47	8–48	33.25–34.61
Perception	57.11	56	5.58	31–70	56.52–57.69
Motivation	86.59	86	7.85	64–105	85.77–87.41

Table 2 shows that there was a significant relationship between the understanding of the clinical nurse career ladder system and the nurses’ work motivation (p = 0.0001). The statistical result also indicates a significant link of nurses’ perception of the career ladder system with their work motivation (p = 0.0001).

Table 2.

Relationship of understanding and perception of the clinical nurse career ladder with work motivation.

Variable	Motivation
	r	p
Knowledge of nurses	0.281	0.0001
Perception of nurses	0.65	0.0001

Furthermore, Table 3 presents the perception of career ladder system as the most important determinant of the nurses’ work motivation. The linear regression model is as follows: Nurse's work motivation = 33,768 + 0.925 perception.

Table 3.

Final modeling of multivariate linear regression.

Independent variables/confounding	Motivation
	Coefficients B	p	R^2	Constant
Perception	0.925	0.001^*	0.432	33.768

*

Statistically significant difference (p < 0.05).

Discussion

The results showed that nurses’ understanding of career ladder was low. This may be related to lack of socialization of such career ladder system in the hospitals. The understanding of nurses about the career ladder will influence their attitude towards the implementation of the clinical career ladder in the hospital. Nurses’ lack of knowledge about the career ladder will also be a barrier for nurses to participate in the career ladder.¹⁶ Conversely, a good understanding of the career ladder system will open career opportunities for nurses.¹⁷ Good understanding of career ladder will minimize barriers that can interfere with the implementation of the career ladder and also guide nurses in following the application for career promotion as well.¹⁵

The result of this study indicates a significant relationship between the understanding of the clinical career ladder and the nurses’ work motivation (p < 0.05). This finding confirms the previous study results which reported increased work motivation and lower retention associated with nurses’ knowledge about the career ladder system.¹⁵ Nurses who understand properly their career ladder are more likely to have a better expectation and career opportunities.^5,17

Understanding of career ladder will positively influence the professional development of the nurses. The nurses with good comprehension of how their career ladder works tend to show positive behavior.¹⁸ Knowledge enhancement and involvement of nurses in the career ladder will motivate nurses to provide excellent and evidence-based nursing care.¹⁹ Prior study results indicate that nurses who occupy the highest career ladder are those with higher intelligence and a good grasp on career ladders.⁶

Nurse managers have an important role in the success of career ladder implementation.⁴ Support to improve and maintain nurses’ understanding of this program can be done by involving nurses in the process of education, training, and guidance from the experts so that they can carry out self-development as needed.^5,20

In terms of perception on the career ladder system, the results of our statistical analysis showed the mean score of 57.11 (79%). This result can be considered as good enough as the career ladder in the hospitals had only been running for a year with minimum socialization. A prior study suggested that nurses who better understood and perceived career ladder system tended to have lower satisfaction level of the implementation of the career ladder system.⁵ This is because the implementation of the career ladder is below the expectations of nurses. Nurses might set the standard with their acquired knowledge and found the disparity in practice, hence the less satisfaction.

By contrast, this study found a statistically significant relationship between the clinical career ladder perception and the nurses’ work motivation. This result is in line with a previous study which explained the purpose of career ladder implementation for increasing the work motivation of nurses.¹⁹ Career ladder system should typically satisfy nurses with their work because of the recognition and appreciation they can get according to their career achievement.⁶ Improving perception about career ladder is a way to improve job satisfaction and staff retention.²¹ Career ladder has a positive impact on professional growth, autonomy in care, and comfort in work.²²

The present study results indicated that the most influential factor of work motivation was perception. Nurses with good perception on career ladder system are more likely to have increased work motivation. This finding supports prior study results which pointed out that a good understanding of the career ladder would spur the nurses’ motivation in performing difficult and challenging jobs.²³ Other previous studies also reported that positive perception about the implementation of nursing career ladder increased the independence in providing care and clinical decision making as well as improved job satisfaction and motivation to pursue knowledge development and better career pathway.^16,17

Our multivariate analysis results showed that 43.2% of the variation of nurses’ work motivation could be explained by perception variable which meant that there were still 56.8% variables or other factors that could influence motivation. According to Herzberg, motivation can be driven by internal and external factors.^7,24,25 Other factors that can affect the work motivation of nurses by 56.8% can come from extrinsic motivation or other variables that were not examined in this study.

Some strategies that can be done to maintain and improve nurses’ perception on the career ladder system include training, support from the work environment, and nurses engagement in the career ladder programs.^26,27 Improving the implementation of a career ladder program can stimulate increased responsibility and accountability, knowledge and skills improvement, work motivation, all of which may lead to a better perception of this program.¹⁵ Meanwhile, to overcome the unexpected things, compensation enhancement can be made in the program so that nurses can be motivated and continue to participate in the program.²⁸

To conclude, nurses who have a positive view on their career ladder system are more likely to have better work motivation. Education on the career ladder system in nursing can be a motivation reinforcement strategy for the nurse managers and the hospitals. Better implementation of the career ladder system in the hospitals can contribute to better understanding and perception of the nurses about the career ladder. Nurses should be aware of the importance of career ladder system for their recognition and development opportunities as well as the improved quality of their service. This study, however, is limited in its generalizability. Future studies should be done with more representative sample size and established tools to capture the fundamental problems related to the nursing career ladder system.

Conflict of interests

The authors declare no conflict of interest.

Acknowledgments

This work is supported by Hibah PITTA 2018 funded by DRPM Universitas Indonesia No. 1840/UN2.R3.1/HKP.05.00/2018.