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Journal of Nursing Administration:

The Intrinsically Motivated Nurse: Help and Hindrance from Evaluation Feedback Sessions

Baard, Paul P. PhD; Neville, Susan M. PhD, RN

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Paul P. Baard, PhD, Associate Professor of Communications and Management, Fordham University, Graduate School of Business Administration, New York, Susan M. Neville, PhD, RN, Assistant Professor of Nursing, Hunter College of the City University of New York, Hunter-Bellevue School of Nursing, New York.

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Self-determination theory describes the working conditions necessary for the experience of self-motivation. Performance evaluation sessions represent extraordinary opportunities to enhance motivation, yet often are approached with anxiety. An innate desire for feedback meets with a learned response of fear, by both the evaluator and evaluatee. Psychological fusion theory explains the source of this conflict and what nurse executives can do to use these sessions for motivational impact while ameliorating the attendant stress.

A number of motivational dynamics come into play in the formal, interpersonal exchanges called evaluation sessions. Depending on how they are handled, nurses can either be drawn toward greater intrinsic motivation to strive for excellence in practice or pushed into an amotivated state where doing the minimum to survive becomes the foremost goal.

Although there is debate about how evaluation discussions should be constructed,1 the need for individuals for feedback—to affirm desirable behaviors as well as to grow by repatterning or changing less useful behaviors—would seem inarguable. Although widely regarded as essential for motivation and professional development,2 these interpersonal exchanges often become emotionally charged.3 Whereas frequent and timely feedback generally is advocated, an annual summary session is purposeful.4

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Motivation and Work

Deci5 identified three motivational subsystems affecting human behavior: intrinsic, extrinsic, and amotivation. Although everyone experiences some level of each of these inclinations, under different circumstances individuals can be “pulled” toward one or another by variables in their present environments.6,7

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Intrinsic Motivation

Intrinsic or self-motivation is characterized by enjoyment of an activity itself, largely apart from consequences outside of the endeavor. When we play our favorite sport or engage in a hobby just for the inherent satisfaction it provides—rather than for a trophy or prize, we are under the influence of intrinsic motivation. Employees characterized by this intrinsic type of motivation often are labeled “self-starters” and require less monitoring than others.

Although nearly all adults go to work primarily to earn a living (an extrinsic motivation), there are times when an outside reward is not foremost on peoples' minds. For example, a particular challenge may await a nurse at the hospital or community setting, or there might be an opportunity to have unusual impact that day. Intrinsic motivation is the “. . . innate, natural propensity to engage one's interests and exercise one's capacities, and in doing so, to seek and conquer optimal challenges.”8(p43) The primary rewards for intrinsically motivated behavior are “. . . the experiences of effectance and autonomy”8(p32)—the feeling one is having impact. This kind of drive is at the heart of what Maslow9 described as self-actualization, which he considered the highest level of human motivation.

Intrinsic motivation has been associated with longer involvement in endeavors, greater persistence with tasks, and higher levels of satisfaction and creativity.8 In the professional domain, intrinsically motivated individuals might be described as those deriving satisfaction from accomplishing their tasks well, and expecting to learn and to be involved with other members of their work unit. Intrinsically motivated persons feel a heightened degree of self-determination in their professional roles.7,10

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Extrinsic Motivation

People do many activities largely to gain a reward or recognition, or to avoid an ill consequence such as guilt or punishment, including being fired. This is “carrot and stick” motivation, long a staple of managers in all settings. People operating primarily under this influence are considered extrinsically motivated. This type of motivation is associated with feelings of anxiety and pressure11 and has been linked with less long-term persistence8 and depression.12

Because some form of extrinsic motivation is involved in professional endeavors, intrinsic motivation theorists recently have introduced the concept of self-determined extrinsic motivation. This is a type of drive triggered by incentives (e.g., a paycheck), yet done in a way that evokes characteristics associated with intrinsic motivation.13 Supervisors who provide an atmosphere that allows nurses to satisfy certain innate needs will encourage this richer motivation.

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Those experiencing a sense of futility, of either feeling incapable of meeting a perceived expectation or failing to see any relevance of an activity to personal interests or goals, are considered amotivated. Amotivation, a term coined by Deci,5 stems from sensing a lack of control in a situation. It leaves an individual questioning the value of the activity itself (“I don't know why I work here”). Amotivation includes a feeling of personal helplessness14 and has been found to be associated with minimal compliance or dropping out entirely from an activity. In the work realm, an amotivated person would be the one who does the bare minimum, only enough to avoid being fired.

Amotivation accounts for “survivors syndrome,” a common occurrence after the massive reengineering efforts affecting most aspects of the workplace.15 When restructuring has taken place, nurses wonder what they can do to avoid being fired next. Three “survivors” in a department are expected to produce the same quantity and quality that previously had come from a six-person team. Ironically, at a time when greater cooperation and teamwork are essential, colleagues act aggressively toward each other, hoping that by demeaning the work of others they might be spared the next time downsizing occurs. They also might distance themselves from coworkers, attempting to minimize their own pain when friends get fired during the next round of layoffs. They sense and experience a lack of control in the situation—there seems to be little they can do to avoid “getting the ax” at some unpredictable point.

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Deci and Ryan's Self-Determination Theory

A number of motivational frameworks have examined issues in organizations, all assuming that higher levels of motivation will result if opportunities to satisfy important psychological needs are met. These concepts have been linked to behaviors, attitudes, and general well-being in the work-place and in schools.

Perhaps the most rigorous, recent research program based on a theory of human needs concerns intrinsic motivation and self-determination.8,16 This theory proposes that individuals in a given social context will be more self-motivated and experience greater well-being to the extent that their environments allow them to satisfy certain psychological needs, namely those for autonomy, competency, and relatedness. Thus, self-determination theory identifies how factors in an organizational environment salient to the experience of intrinsic motivation can provide the opportunity for members to experience a sense of self-determination, optimal challenge, and a feeling of caring about and being cared for by others. These internal needs become even more central to a nurse's holistic sense of professional self in light of the recent changes in healthcare and patterns of delivery.

By identifying specific institutional behaviors found to create an atmosphere supportive of intrinsic or self-motivation, nurse executives can assess current organizational activities that have been found to impact motivation.7 Such an approach may be used to guide those in leadership roles as to which specific steps might be taken and which avoided.

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The Need for Autonomy

Support for autonomy pertains to the amount of perceived self-determination one enjoys in a given situation or relationship. The requirement is to feel like the “origin” of one's behavior, perceiving an internal locus of causality.8,17 Administrative support for professional work autonomy could appear in the form of individual and collective empowerment regarding nursing practice and practice-related issues. Nurses continue to chart the domain of practice as health policy and care delivery patterns respond to the reengineering, repatterning, and reallocation of resources. Decreased length of stay, cost-effective nursing care and patient care outcomes, and increased index of satisfaction are the guiding forces mapping change.

McCloskey18 observed that when nurses experience autonomy they are more satisfied, are more committed to the organization, have more work motivation, and are intent to remain on the job. Autonomy in a nurse's environment has been defined in terms of characteristics of the position that allowed or encouraged individual decision making with operational activities.19 Control over one's environment is viewed as an essential part of motivation.20

The notion of hierarchial power is particularly anathema to most nurses.21 Pressure and attempts at coercing compliance, both through excessive rules or elaborations of acceptable conduct as well as by manipulative incentives, constitute violations of this prerequisite for intrinsically motivated—or self-determined extrinsically motivated—behavior. A sense of powerlessness—the extent to which nurses believe they are not permitted necessary job-related independence to exercise judgment in their professional practice—was found to be a major source of job dissatisfaction among nurses employed in hospital settings.22 Even the use of “rewards,” including the publication of lists of best performers in the hope that this would inspire others to do more, is an example of a controlling organizational behavior that might undermine this need of individuals to act in a relatively autonomous manner.11,23

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The Need for Competence

The competency dimension of the theory describes one's innate desire to pursue growth, to be optimally challenged as to current skill or knowledge level, and to experience personal effectance.8,24 Nurses need to know and feel that their patient care makes a difference. Support for competency might appear in the ability nurses perceive they have to learn new practice competencies and to contribute to improvements in the institution. Hoelzel25 found that nurses prefer to work with supervisors who have influence both upward and outward.

The experience of competency could be affected by the quality of the work expected—i.e., if tolerance of poor performance is the norm, this innate need to be effective is violated. However, if there exists an intolerance of error in that nurses are, in effect, punished for attempting to go beyond narrowly prescribed task functions in an attempt to contribute more, this need to stretch one's abilities is similarly frustrated. Individuals are best able to be fully engaged in their work when they operate in an optimal range—avoiding the boredom that comes with complete routinization yet not pushed to a high likelihood of failure that a maximal challenge might bring about.

Feedback and validation are essential administrative strategies because individuals must know when they are performing well to feel effectual. Similarly, one must know when adjustments to performance are required. However, competency—or effectance motivation—does not simply pertain to task performance. A staff nurse who suddenly starts to experience difficulty in his/her practice could be experiencing a feeling of overwhelming anxiety or frustration related to decreased staffing, increased responsibilities, and restructuring of the workplace—not about his/her ability to give excellent nursing care. The salient competency issue is a broader one involving the impact of organization change on the nurse's career path.

Competency generally entails the exercise of current abilities, such as using one's talents or skills. Threats to satisfying this prerequisite to the experience of intrinsic motivation in the practice setting include minimally challenging or overwhelming tasks, negative approaches to growth—such as placing an emphasis on a nurse's short-comings, and providing minimal opportunity to use one's level of professional expertise. Most feedback in organizations tends to be negative in nature,8 fostering a sense of ineffectivenes in one's job. Blame inflicted by a top administrator on a nursing supervisor quickly gets passed along as fault-finding in a nurse.

A feeling of competence is essential if one is to experience intrinsic motivation. The opposite of this is feeling incapable, leading to amotivation—a sense of being “out-of-it” or simply out of favor with those in power.

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The Need for Relatedness

The final component of self-determination theory, relatedness, has to do with caring for others, and being cared for by them in return.16 In matters of job-related behavior, this could include the experience of coming to know others with whom one works, and of perceiving an atmosphere conducive to sharing salient concerns with them. The increasing attempts by organizations to enhance teamwork address this innate need to feel connected. McCloskey sees such social integration as critical for job contentment.18

The relatedness dimension also can be violated inadvertently. Incentive and recognition plans, e.g., the “employee of the month,” pit one colleague against another, undermining this desire to cooperate, not compete.11,26 Supervisors either explicitly or implicitly create negative comparisons with a nurse's peers; thus, they frustrate this natural tendency to care for colleagues. A “dog-eat-dog” work environment, although a reality in many corporate cultures, is not conducive to the experience of relatedness or connectedness in the special collegial professional world of the nurse. Such mutual caring is a prerequisite for the experience of intrinsic motivation.

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Interpersonal Conflict

Most nurse executives know how important it is to provide challenging work, empower others, and promote teamwork. Yet violations of each of these principles occur routinely in healthcare settings, as they do in corporate environments. Why do those in supervisory capacities criticize too often, overcontrol, and pit people against one another?

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Psychological Fusion

The failure of an individual to differentiate herself or himself from the perceived attitudes of others creates stress in organizations. It leads to a preoccupation with approval. The discipline of family systems psychology identifies a dysfunctional process rampant in current stressed work environments: psychological fusion.27-29 This pattern of interaction stems from insufficient self-definition by an individual, resulting in a dependence on others to meet a desire to feel approved and accepted. Any criticism, real or imagined, is perceived as threatening to one's “self.” Thus, critical feedback—necessary for growth—is resisted as intimidating to psychological survival.

The consequence of fusion is distance. A person caught up in fusion often will implode; while raging inside, he or she appears cool on the surface, yet is no longer willing to engage in social intercourse with the other. However, the conflicted individual might explode—venting anger in a conspicuous manner, then visibly distancing from the “threatening” source. In either event, the fused individual is rendered unable to be in close emotional proximity to the other, precluding meaningful interaction. This dynamic is illustrated in the lower portion of Figure 1.

Figure 1
Figure 1
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When a supervisor avoids, delays, or minimizes an evaluation meeting with a nurse because of fears of that individual's anticipated negative response or over-reaction to criticism, that supervisor has “fused” with her/his direct report, inappropriately taking responsibility for another. “Will I hurt her (his) feelings by providing critical feedback?”

Such thinking reveals a taking responsibility for both sides of a discussion, as if the supervisor could somehow “make” the nurse think or respond in a particular way. Certainly the supervisor can be empathetic, choosing appropriate assertive language and providing negative feedback in the richer context of a largely positive assessment (if accurate). But the fusion occurs when the supervisor takes responsibility for the nurse's reaction. Fusion also explains why supervisors themselves fear being hurt by the nurse—what if she/he challenges the rating the supervisor assigns, or protests to an administrator?

A recent issue of a prominent business journal addressed such interpersonal conflict.30 It offered a case study describing how one team member, acting only in his role as peer to other department heads, succeeded in decimating the work of the group by his aggressive verbal actions toward colleagues. The team leader struggled with the issue of providing critical feedback to the offender. The concept of psychological fusion was used to explain how grown adults could end up being “driven” from the room by the aberrant's verbal behavior, and what might be done to ameliorate this problem.

One cannot provide a motivational environment in which workers are free to take chances, grow, and cooperate if fusion is a significant issue at the individual or group level. Although an organization chart may suggest a top administrator has six high-level nurse executives from which to draw counsel, if that leader has encouraged a fused environment in which the greatest concern is to appease the person in charge, that manager effectively has reduced sources of advice to none or few.

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Containing Psychological Fusion

It is because of an excessive level of psychological fusion that a supervisor or a nurse fears being hurt in the feedback encounter. If the evaluatee makes an honest self-assessment before the review, she or he will be less vulnerable to an emotional reaction to critical input because the information would already be known and accepted. If one has accepted the totality of oneself, i.e., having strong points as well as weaknesses, then confirmation or discovery of either of these becomes less threatening.

Supervisors can best ameliorate the effects of psychological fusion by recognizing it in themselves and in others. Having done so, they are then able to proceed unilaterally in providing the feedback expected of them. When they observe this phenomenon occurring in others, they are able to guide the afflicted individuals through a more nonfused way of responding to critical feedback.

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Applications to Performance Reviews

To gain full motivational value from these annual evaluation sessions, and to promote the growth of the relationship between both parties, nurse executives would be well-served to attend to a number of factors that arise from and impact intrinsic motivation.

Several principles drawn from the previous discussion, as they apply to feedback or evaluation sessions, follow.

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Nonfusion: Presume Employees Want Feedback and Can Handle It

Sometimes supervisors anticipate an over-reaction by a team member who hears something other than compliments. This concern stems from taking over-responsibility for the feelings of others, a fused position. Everyone needs feedback; it is essential for continued growth. Certainly, positive feedback is preferred to negative feedback, but if a complete picture is presented in a constructive way, one grows by hearing where and how further development can occur. Figure 1 illustrates a proactive process the supervisor might use to guide the nurse in handling critical evaluation feedback.

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Competence: Treat Deficiencies Merely as Problems to Be Solved

To appeal to the competency drive, the session should have a plan for continuing growth as its final product. Be sure that criticisms are focused on specific behaviors (which are more readily correctable), not on inferred character traits (which are easily debatable), and keep a perspective in mind: if the overall performance of the nurse has been good, the session's verbal content should reflect that fact. The session ought to conclude with a plan for continued growth. Goals should be well defined, realistic, and based on attainable outcomes.

When feedback is viewed as an opportunity for the supervisor and the nurse to identify an area for improvement, a plan of action designed to promote growth is likely to result (Fig. 2). The evaluation forms now used by many organizations reflect such an uplifting approach to criticism, and the degree to which the subordinate is able to self-monitor progress toward goals, the more the autonomy need also is preserved.

Figure 2
Figure 2
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Autonomy: Use an Informational, Noncontrolling Approach

Preserving the nurse's need to be self-determining is best accomplished by the use of assertive, not aggressive, speech. Presenting options to the individual helps him/her shape a well-fitting program and take responsibility for it. Supervisors should resist the urge to provide solutions that feel imposed, and therefore are perceived as controlling. Similarly, positive and negative feedback should be allowed to coexist, joined together with and as a conjunction, not by but which often is perceived by the listener as negating everything that preceded the comma before the but).

By choosing an assertive style (Fig. 3), administrators can support a nurse's need to be self-determining. Typically, statements beginning with “I” carry a more assertive tone than do those starting with “You.” For example, “I believe a course in time management will enable you to. . .” is more likely to be accepted than “You need a course in. . .” Similarly, presenting several options that facilitate choice assists the staff nurse in the process of self-determination regarding professional needs and goals. Collaboration between administration and service is a proactive strategy that supports effective communication and empowerment, and prevents helplessness—often the precursor to burnout.

Figure 3
Figure 3
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Relatedness: Build a True Sense of Team

To appeal to the desire for relatedness or connectedness, a good starting place for supervisors is to think of themselves as part of that team, although they may be the leaders of it (Fig. 4). To the extent possible, let plans for a subordinate's development include involvement with other members of the group. Paring those with complementary skills on assignments is a positive management strategy and a way of accomplishing transfer of learning as well as supporting relationships. Supervisors must be careful not to undermine such an opportunity by suggesting one nurse's strength is more important to the organization than those of other nurses, thereby promoting competition, not cooperation.

Figure 4
Figure 4
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When evaluation sessions promote a sense of “We're in this together,” this need is being addressed. When distrust and blaming are dominant themes, the eagerness to participate in a cooperative manner is frustrated. Similarly, when individuals engage in triangulation—speaking ill of a person or group in the organization not present for the discussion—they undermine any real sense of team. Collaborative mentor relationships are a way of both accomplishing transfer of learning as well as supporting team unity.

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Despite the current stressful work environment, the reflective nurse executive can creatively support motivation. Those in leadership roles must reach first for those things that inherently make the nursing profession more enjoyable and rewarding, and then ensure the working environment reasonably meets the nurses' innate needs.

If a supervisor approaches a direct report with the presumption that she/he desires to do good work, the process of promoting a motivational environment will have begun. Similarly, when that nurse executive recognizes psychological fusion and limits it as a variable in how nurses deal with one another, the workplace will become one in which challenge, excellence, and cooperation can thrive. It truly will have been reengineered.

Feedback is essential if one is to continue to grow. Professional development is required if one is to experience intrinsic motivation. The informed supervisor can use evaluation and feedback opportunities to stay in touch with a nurse's changing needs. Rather than a dreaded exchange, a carefully planned and thoughtfully executed feedback session can become a motivational opportunity for both.

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