Times are tough. Lots of medical practices are struggling to keep up with even the modest inflation of the costs of doing business. For many, salary increases for staff members are out of the question. When this is the case, staff morale and loyalty could slip.

No one who's worked in an environment where the morale is poor needs an explanation of why this issue is important. When the staff is unhappy, everyone is unhappy. Patients can tell when things aren't "right" with the employees, and that perception can alter their view of the doctor and the quality of care. When the employees are fighting, the patients often feel like hostages in the battle.

Low morale leads to higher turnover of personnel, too. That means more time spent without top-notch workers in every job, and more management time spent on recruiting and training. But when morale is high, workers take pride in their jobs and work hard to keep them. They want to remain on the team, and may be motivated by more than a paycheck.

Understanding the motivation pyramid

So, how do you keep morale up and staff members loyal when pay increases aren't in the picture? Borrow a page from the book of psychology. Psychologist Abraham Maslow identified what he called the hierarchy of human needs. His model works well to explain what motivates workers.

His thesis: Different things motivate people at different times. They build, like the layers of a pyramid. Lower-order needs must be satisfied before higher-order needs can motivate behavior. Maslow places physiological needs like food, clothing and shelter at the bottom of the pyramid. Next come safety, social needs, and the desire for self-esteem. Maslow's capstone: something he called self-actualization.

As an example, consider a diver below a coral shelf on the barrier reef. His alarm sounds -- 10 minutes of air left. He looks up and sees three great white sharks circling between himself and the boat. What to do? Stay put! Maybe the sharks will swim away. Any other motivation is irrelevant when sharks are in the way. But when the air gets down to 5 minutes, the diver heads for the boat. At that moment, he is motivated by the physiological need for air more than by his fear of sharks.

Here's a closer look at the needs at different levels of the hierarchy and what you can do to make sure they're fulfilled:

�        Physiological. Physiological needs, such as food, clothing and shelter, are at the bottom of the pyramid. You can't motivate workers with talk of team spirit if they're worried about feeding or housing their families. But if they're taking home at least adequate paychecks, you've fulfilled that motivation level.

�        Safety. The next possible distraction is the fear that they might be fired. This second level of motivation, the safety level, correlates with a feeling of job security. Workers worried about being fired are often found in the break room, reading the want ads.
The safety needs of employees are met by the paycheck and benefits package.
That's how they put food on the table and pay the rent. But an individual's sense of security can be threatened by a reduction in benefits or fear of loss of the job. If that's in an employee's mind, you can't expect a motivation level much higher than rock bottom fear. For example, a casual remark by you about how tough times are can strike terror into the heart of a receptionist who hears the hint of a layoff.

�        Social. Maslow's third level of motivation, social, is also called the "belonging" or "love" level. Here, the sense of interacting with other people and being part of a group or team motivates workers. If workers don't feel like part of a team, they can exhibit destructive behavior, such as trying to make other employees look bad in an attempt to make themselves look better. Because belonging is a third-level motivator, it must be present if you're going to try to push workers higher up the motivation pyramid.
Social motivators can include group functions, such as luncheons, after-work parties, and ceremonies such as bestowing personalized business cards on a new employee right away. Wearing the practice uniform is another way of getting "on the team." But holding a company picnic won't be a team-building motivator if employees are worried about safety concerns.
De-motivators at the social level include playing favorites (or being seen by others as doing so) and criticizing employees in front of others. If a nurse has the idea that a co-worker is more "on your team" than she is, morale will suffer and motivation may drop from the esteem level to the social level.
The rule in management is praise in public and correct in private. Be careful how you react when an employee comes up with a goofy idea in a staff meeting. It's easy to hurt people's feelings, and motivation can plummet past the social level to the safety region if an employee feels humiliated in public.

�        Esteem. The next higher level of motivation -- esteem -- refers to an individual's sense of personal worth. It's where high achievers want to be. At this level, the individual has gone beyond the organization and is motivated by a higher calling. When employees take personal pride in their work and who they are, they're functioning at the esteem level.
That means employees need to know clearly what the standard for each job is and when they've completed it well. Then they can give themselves applause at the end of the day. Taking personal pride in the work is the mark of a mature, well-motivated employee.
But the most powerful esteem motivator is recognition from others within the organization. You can show respect for workers -- and raise their esteem -- by noticing the quality of their work. Their status rises and so does their motivation to do even more. Public compliments and positive performance reviews fulfill this function. So does asking an employee's opinion. When you do that, it's a sure sign of respect. It often costs nothing to include employees in the management decision-making process, informing them of your thinking and asking for their input.

De-motivators

Doing anything to drop an employee to a lower level of the pyramid causes immediate reduction of motivation. If your staff members suffer low morale, it could be because they feel inadequate in their skills (esteem), excluded from the team (social), or at risk for unemployment (safety). Your job is to keep pushing workers up the pyramid by recognizing what will motivate them at each level.

Consider the example of an office manager for a successful surgeon we know. She had run his practice well for 4 years. But last year, he needed to move into smaller quarters across town. He left much of the detail of the move to her, to the point of leaving the country for 2 weeks while she managed the physical move.

At first, she felt gratified by his expression of confidence in her ability to handle the project without his supervision. She spent long hours coordinating contractors and supervising the packing and physical move, installing the equipment, and decorating the office herself. She gave up her entire Independence Day weekend to be sure the doctor would have a working office to return to after his vacation. Her esteem level was high.

But when the doctor returned, he went right to work seeing patients. His only comment was a criticism of some wall decor she had purchased for the waiting room: "Lose the froufrou; it's not my taste." Whatever thanks she got from the doctor was lost after this admonishment. She began to question whether she had actually done an adequate job and, by the time we got to the office, she was a nervous wreck wondering if she was secure in the job. Her morale was at the safety level and she was unhappy because she knew what working at the esteem level was like and she preferred it.

When employees reach the pinnacle

She's a perfect example of how Maslow's hierarchy works. When employees are motivated at a higher level, they most likely will understand if no budget is available for raises.

If your pay and benefits are below community standard, you can't expect much enthusiasm or loyalty from your staff. But if you're meeting the standard, a round of raises won't raise morale. Once a motivation level is satisfied, motivation has to come from one of the higher-order needs.

Because individual employees are rarely motivated by the same things, you'll need to consider what each one needs next to continue raising the morale and loyalty level. And, once you've got employees at the esteem level, just get out of their way and let them show you some self-actualizing smoke!

Jeffrey J. Denning is a practice management consultant with Practice Performance Group, Long Beach, Calif.; and editor of UnCommon Sense, a monthly practice management strategy and tactics newsletter. Contact him at (562) 595-1728.