FEMALE IN THE HEALTHCARE: EXPLORING FEMALE NURSES MOTIVATION IN JAVANESE HOSPITALS, INDONESIA

Javanese regions in Indonesia have been known to suffer from nurse shortages and low nurse motivation. These situations may hinder their performance. Gender and cultural aspects are essential to developing motivational strategies, but they are rarely considered in Indonesia. This study intended to explore the current situation in Javanese hospitals that affect the work motivation of female nurses. This study was a literature review. The keywords used for the search were “motivation,” “need* OR motive* OR goal* OR incentive* OR value*,” “work OR job OR career,” “policy OR regulation*,” “female OR women OR woman,” “nurse*,” “hospital*,” “government”, “Javanese OR Indonesia”, “low middle income country* OR developing country*” and “performance .”Data were obtained from electronic databases and grey literature. We used a conceptual framework to analyze 65 relevant articles. We found that female nurses in Javanese hospitals were seeking monetary means, supports to balance work-family, and means to boost their self-esteem and self-actualization. Government and hospital managers had been providing motivational incentives, yet the use of the incentives was still limited and inadequate. Hospital managers may provide a combination of financial and non-financial incentives to improve female nurses’ motivation, emphasizing non-financial incentives rather than financial incentives. More research is helpful in exploring what motivates Javanese female nurses.


INTRODUCTION
Healthcare workers (HCW) have been recognized as the pillar of the health system [1]. In a hospital, nurses are considered HCW with the most prolonged contact duration with patients [2]. Since healthcare delivery is labor intensive in nature, nurses' willingness to do the given task -or the socalled motivation-will directly mediate the quality and efficiency of health services [3,4].
Motivation can be defined as the individual willingness to strive towards organizational goals, which is formed through interaction between individuals, the work environment, and the broader societal context 3 It is important to note that motivation is related to the following concepts: • Needs: the essential requirement for a person's survival and well-being [5] • Motives: the inner state that directs one's behavior towards actions [6] • Goals: the aim of an action that one intends to accomplish [7] • Incentives: any means that can be used to satisfy needs or motives [8] • Values: a conception that affects action choices [9] Many factors influence motivation. In the work context, these include cultural values, governmental policies, organizational management capacities, individual personality, needs, motives, goals, and gender [3,4,10].
WHO suggests that a high-quality, capable, and motivated HCW is essential to achieve health goals [1]. Motivation will determine HCW performance, as well as health care system performance. A study by Dieleman and Harnmeijer can be used to explain how HCW motivation and performance are related. In their study, Dieleman and Harnmeijer argued that performance is determined by four factors: the availability of sufficient HCW, competence, productivity, and responsiveness [11]. Aside from competence, these factors are positively related to motivation. For instance, improving motivation will result in increased retention. Thus, HCWs' availability in health facilities will be increased [12]. Additionally, improved motivation is also related to increased productivity and responsiveness [11].

Exclusion Criteria
We excluded articles which could not be fully accessed. The article also excluded if the discussion within the article did not involve variables in the conceptual framework or if information about desired variables was insufficient.

Analysis
The researchers developed a conceptual framework to guide and facilitate the exploration and analysis. The conceptual framework used in this study is a modification of the motivational framework proposed by Mathauer and Imhoff , combined with the performance framework by Dieleman and Harnmeijer [4,11]. The original Mathauer and Imhoff framework looks at three motivational determinants: cultural, organizational, and individual. In the modified framework, we added the "government" component. The governmental level is set under the cultural level since cultural values may guide the government's choices and decisions [20]. Additionally, it is set above organizational and individual levels who will be implicated by its policies [3]. In addition, the authors of this study also selected two performance variables from Dieleman and Harnmeijer's framework, namely staff availability and productivity [11].
In comparison with other theories of motivation, Mathauer and Imhoff's framework looks at motivation comprehensively by considering both internal and external aspects of motivation. At the same time, other theories, such as Maslow and Herzberg, only look at one component. Another essential feature of this framework is its capability to capture the cultural aspect of motivation. Such capability is essential for this study to analyze motivation from a gender point of view since the gender concept is socially constructed [21]. Dieleman and Harnmeijer's framework is also used to establish a clear connection between motivation and performance.
According to this framework, motivation results from internal and external determinants interaction. The internal determinants comprise individual needs, motives, and goals. External determinants are cultural norms and values, government policies, and human resource management (HRM) tools [3,4]. HRM tools denote incentives in the following table.
The level of motivation will then affect staff retention, availability, and productivity. There are several indicators related to availability and productivity. For availability, these include absenteeism, turnover rate, and staff overtime. For productivity, the indicators include intervention provided per HCW per facility [11].

Cultural Level Javanese values and its influence to work settings
The Javanese culture generally has a distinctive collectivist orientation and high-power distance [22,23]. Collectivist culture stresses interdependent self-concept and social networking, while high power distance culture highlights the desire to maintain hierarchical order and pursue status [23].
In Java, collectivism is manifest in the values of "rukun" (harmony) and "musyawarah" (mutual consensus process) [22,23]. The harmony or "rukun" norm underlines the need to maintain good relationships with others and avoid conflict; and tends to restrict assertiveness towards others [22,24]. Having a conflict with others can be pretty distressing to Javanese people, to the extent that it becomes one of the main reasons why Javanese hospital nurses leave their current workplace [25]. In addition, demonstrating ambition explicitly and having a sense of competitiveness is less tolerable in Javanese culture since it is perceived as something that will disturb "rukun" [22,23]. These values might result in discouragement of strong individual performance in the workplace. Meanwhile, the mutual consensus process or "musyawarah" implies that participation in decision-making is highly valued [23,26].
The high-power distance culture influences the way society treats the elder and leadership preferences [9]. In the Javanese setting, a study in Central Java found that the nurses showed less cooperative behavior towards the younger, more qualified nurse managers than the older ones.

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Thus, it undermines some managerial functions in the hospital [27]. In terms of leadership, the paternalistic (benevolent-autocratic) leadership style is often preferred by the Javanese [23,28]. The leader is considered a "father" who will give direction to the subordinates, whereas the subordinates have a moral obligation to comply [26]. This statement might explain why the Javanese in the workplace tend to display passive, submissive behavior [23]. Pekerti and Sendjaya also added that the charismatic, team-oriented leadership style is universally accepted in the workplace [22].

Women's role in Javanese Culture
The social system of the Javanese society is patriarchal by nature. Women are responsible for taking care of the family and doing the housework, whereas the role of breadwinners is the men. The traditional Javanese view of women's roles is "macak" (to look attractive), "manak" (to bear children), and "masak" (to cook) [29].
Exposure of new and progressive ideas has gradually changed public views on these traditional roles of Javanese women. This view is especially true for the young generation. Despite the change of view, Javanese women are still likely to prioritize family and family's needs above their individual preferences [29,30]. For instance, Javanese women might willingly leave their job to care for their children or follow their husband if the husband is transferred to another workplace [29]. Pujianto has confirmed this premise, as his study reveals that following the husband is the main reason for quitting a job at Javanese hospital for female nurses [25]. In addition, as the Javanese women typically work to help the family's financial situation, they are expected to leave the job once the husband's earnings are sufficient [29].

Governmental Level Policies for working women
Several laws regulate women workers in Indonesia, including the Ratification of the UN Convention on the Elimination of All forms of Discrimination Against Women, the ILO convention on Maternity Protection, the Manpower Act, the Human Right Act, and the Health Act [31]. The law serves as a basis for equal remuneration between men and women for the equal value of work [32]. Employers are obliged to provide nutritious food and transportation for women working the night shift (between 11 pm to 7 am) for women working on the night shift [33]. These Acts also protect women from being dismissed during pregnancy, childbirth, miscarriage, or breastfeeding. For instance, women are entitled to 3 months of fully paid maternity leave.

Health policies
The health sector in Indonesia has undergone decentralization since 2001. Under decentralization, districts have more autonomy in terms of employment and facilities payment [14]. As a result, in Central and East Java, many public hospitals that hold the status of "Badan Layanan Umum (BLU)" or Public Service Agency have been given the flexibility to hire health professionals as contract workers [34,35]. In addition, BLU hospitals are also given the autonomy to manage the incentives pay system [34]. Therefore, the decentralization in Indonesia has created an opportunity to increase the availability of nurses in Javanese hospitals, as well as an opportunity to provide better incentives and pay systems.
However, the complex bureaucracy in civil service might hinder the desirable outcome. For example, Mustofa reports that complex administration in civil service has resulted in delayed payment of incentives pay, thus, creating dissatisfaction among nurses [12]. Furthermore, a lack of flexibility to transfer funds across line items, such as for training, might negatively affect staff motivation [36].

Organizational Level Financial Incentives
JH has been providing nurses with numerous financial incentives. Some financial incentives are given regularly on a monthly basis; namely, fixed basic salary and incentives pay. The incentives pay refers to the monthly bonus generated from hospital profit shares. Certain criteria are used to calculate individual shares [37]. Details of these criteria in one hospital might be different from that of other hospitals. However, in principle, the hospitals use similar criteria based on pay for position, pay for performance (for example, work volume), and pay for people (for example, education level and specialization) [37,38]. Other incentives are given intermittently, for example, study allowances, health insurance, religious holiday bonus, occupational accident insurance, retirement allowances, and death grants [12,37,39,40].
Financial incentives are one of the managerial incentives that nurses typically complain about, particularly the monthly financial incentives [38,41,42]. A study in Central Java shows that dissatisfaction with fixed salaries is the main reason for nurses to quit their jobs, followed by incentive pay in second place [25]. Complaints made for fixed salaries are pay rates under regional standards or lower than surrounding hospitals, particularly salaries for contract workers [25,43].
In term of incentives pay, the nurses acknowledge that the current incentives pay system are more transparent than the previous system [13,38]. Moreover, a pay system based on performance, which the nurses perceived as pay based on actual daily work volume, is also desired by most nurses [13]. However, in reality, there is no link between the current incentives system and the actual performance of the nurses. For example, work volume, which is the criteria used for pay for performance, is still associated with one's status rather than the actual daily work volume [37]. Consequently, many nurses complained that the number of incentives received was not reflecting the actual effort they had made [13].

Non-financial incentives
In Javanese hospitals, supervision is done regularly. However, one study reported that supervision might be done less frequently than once a month due to the insufficient number of supervisors and the supervisor's high burden of administrative work [35,44]. Supervisory skills could be improved in general. For example, Mustofa reported that feedback regarding good and bad practices should be given [13]. He added that the supervisors perceive supervision as a routine and meaningless activity, indicating a poor understanding of supervision. Some performance elements could be better supervised [45]. It is reasonable since most supervisors have never taken managerial training beforehand [39]. On the other hand, the relationship between the nurses and the supervisor is typically good [42,46]. Supervisors frequently give the nurses time and opportunities to address personal or family issues. However, the nurses often feel reluctant to discuss these issues with their supervisors since the relationship between supervisors and subordinates is typically formal and distant [46,47].
Recognition is usually given formally. It includes rewards such as awards or merchandise for the year's best nurses; and awards for 10, 20, and 30 years of service [47,48]. No data was found to confirm the use of informal recognition. However, the reward has been used less frequently than punishment [49,50,51,52]. Moreover, managers must explain what, how, and why a reward is given. Therefore, the reward has little effect on improving nurses' performance [53].
Training and professional development occur internally and externally, emphasizing technical or clinical training; few training programs are directed to improve management or leadership skills [12,37,47]. However, training content could be more helpful and applicable due to the unavailability of some instances or types of equipment [13,52]. Regarding professional development, managers are reported to be supportive by providing easy access to study leave. In terms of opportunity, no discrimination report has been made [46,53,54]. Even so, the opportunity to do so remains limited since financial support from hospitals still needs to be increased [53]. Promotion or career advancement models do not exist in many Javanese hospitals [35,39,41,53,55]. If it does exist, the promotion process tends to be unclear or unfair [13,42,52].
Performance appraisals are done annually, using criteria such as service, integrity, commitment, discipline, cooperation, and leadership [40]. However, Mustofa found that the performance appraisal practice needs to identify individual professional development needs [13]. Consequently, it needs to improve individual competencies and performance.
Concerning leadership, it is likely that low-level managers adopt consultative (coaching/selling) leadership style [55,56]. Little discussion is used, allowing subordinates to give their opinion about specific issues. The superior will still give subordinates direction and make decisions [13,56]. Further information about the leadership style adopted by middle and top managers could not be found.

In terms of communication, a lack of communication between nurses and managers often occurs.
For instance, communication in the ward might be hindered since meetings before shift might be unavailable in some wards, or the nurses come late to work or leave faster than the schedule [13].
In higher-level management, the nurses are rarely involved in the decision-making process and often feel that the hospital policies need to be more supportive [42].
The issue of communication becomes increasingly crucial in JH, particularly because Javanese hospitals tend to hold conservation value as organizational value [42]. Members are expected to follow tradition, culture, and religious beliefs when this value becomes the organization's norm. This value tends to create resistance against changes or new policies, as shown in experience in some Javanese hospitals. It does not mean that the value holders do not want changes; instead, they are pretty cautious about the impact of the changes [42]. In other words, resistance will likely occur if the organization members have enough information about new policies or changes and their impact.

Individual Level
The individual level is influenced by several factors, including needs, motives, and goals work [3,4].
In terms of needs, most female nurses expressed the need for policies that help them to maintain a balance between work and family [52]. These needs are elated to the work-family conflict they frequently experience, in which carrying out the role as a mother and housewife has distracted female nurses from doing their work correctly and has caused stress [40,47,52,57,58]. For instance, female nurses are frequently responsible for dropping their children at school, picking them up, or even taking care of their children in the workplace, thus adding more unproductive time in the workplace [13]. The work-family conflict in Java also affects other aspects, such as quality of work, attendance, and punctuality [57].
As for motives and goals to work, Indriyani found that female nurses in her study mainly work to provide financial support for families. Other reasons include expanding their knowledge, achieving self-actualization, feeling proud, and feeling meaningful [57].
Overall, these findings can be categorized into four big motivational themes. The first theme is workfamily balance-related motivation. The second theme is finance-related motivation. The third theme is self-esteem-related motivation, which is the motive to feel proud. Finally, the fourth theme is selfactualization-related motivation, which aims to expand knowledge, feel meaningful, and achieve selfactualization.
In summary, female nurses' motivation in Javanese settings is related to finance, work-life balance, self-esteem, and self-actualization. Numerous shortfalls in motivational tools explained previously have negatively affected the motivation of female nurses working in Javanese hospitals, resulting in individual and organizational poor performance. To motivate people, managers should provide the right incentives to meet employees' needs, motives, and goals [6]. These incentives include various financial and non-financial incentives [11]. To meet these needs, motives, and goals, hospital managers shall use the appropriate type of financial and non-financial incentives.
Regarding financial incentives, hospital managers in Indonesia might consider higher, adequate salaries. Adequate salaries have been highlighted by WHO as one of the key drivers of health workers' motivation [1]. These incentives are seen not only as means to fulfill the individual's basic needs but also as a means of recognizing a health worker's value [4,59]. Moreover, low salaries might lead to overworked health workers if health workers try to supplement income by taking another job; thus, low salaries may negatively affect productivity [11,60]. Characteristics of adequate salaries include realistic, competitive, and paid timely [12,59].
Higher salaries become essential motivational strategies, particularly in developing countries; in these countries, low salaries have been identified as a significant reason for dissatisfaction and have led to decreased retention [10]. However, it should be noted that when salaries are paid without taking into account performance (for example, fixed basic salaries), there is little encouragement for nurses to work hard [61].
Although female nurses highly desire a higher salary in Javanese hospitals, sufficient financial resources are needed in countries such as Indonesia. It is even more challenging in the public sector considering the low public spending on health (approximately 2% of GDP) [62]. In addition, changing salaries might be challenging, as salaries are under the control of the Indonesian government and hospital owners, not hospital managers.
Financial incentive alone is not sufficient to improve motivation. Therefore, a combination of financial and non-financial incentives is essential to achieve the desired effect on motivation and performance [4,59]. These may include flexible and part-time work arrangements, supportive supervision, and transformational leadership.
Flexible or part-time work arrangement permits female health workers to accommodate family issues [1,10]. The arrangements include permanent part-time and compressed working hours [63]. Cox and Blake suggest that flexible working hours have significantly decreased short-and long-term absenteeism, improving employee retention [64]. Another study in the UK suggests that flexible and part-time opportunities link with increased nurses' job satisfaction [65]. However, intervention effectiveness in addressing work-family conflict in those studies is unclear.
Female nurses may highly desire this incentive since they perceive the work-family conflict as extremely disruptive [52]. However, permanent part-time work is unlikely to be successfully implemented in the Javanese public sector. Under central government regulation, all contract staff will be converted to permanent civil servants [66]. Moreover, since part-time status in Java is frequently associated with lower salaries than full-time status, the nurses are unlikely to accept permanent part-time status. In contrast, with careful planning, compressed working hours might work effectively in Java. It should be noted that the incentive requires managers with good communication and basic planning capacities, which can be accomplished through, basic in-house managerial training available in Javanese settings [12]. The biggest challenge would be an organizational barrier since the status of being full or part-time workers in a public hospital is decided by the government rather than hospital managers.
Another suggested non-financial incentive is supportive supervision. Supportive supervision is one of the most effective tools for improving health workers' satisfaction, motivation, and performance [1,67]. It contains two elements that contribute to improving performance: supervision itself and a supportive style of supervision.
The supervision element provides the staff opportunity for professional development a performance improvement through shortcomings correction and feedback [4,67]. In addition, in order to improve performance effectively, supervision needs to be done regularly, and feedback needs to be given in a direct, timely fashion [4].
Meanwhile, the supportive style element will facilitate performance improvement by aligning organizational and staff goals [4]. The supportive style pursues two-way communication between supervisor and supervisee [12]. This type of supervision often uses joint problem-solving and acknowledgment of good practice [12]. In addition, using a supportive style allows the supervisors to consider health workers' personal needs, goals, and concerns. As health workers feel they are being cared for, their' retention levels can be increased [4].
Female nurses are highly likely to accept this incentive in Javanese settings due to its relevance to collectivist values. These values seek a good relationship with others or "rukun" [22], which supervisors can achieve through supportive words. However, having been influenced by the highpower distance culture, the supervisors might prefer a style that is rather benevolent-autocratic (paternalistic) than participative [23]. The supportive supervision effect can be enhanced with transformational leadership. Transformational leadership is characterized by a closer relationship between leader and subordinates, mutual trust, and openness [68]. In this type of leadership, the subordinate's individual needs and capabilities are considered, and individual contribution is appreciated [68,69]. Therefore, this leadership may fulfill female nurses' need for recognition. In addition, transformational leadership fosters creativity and encourages subordinates to pursue growth and achievement [69].
The major limitation of this study is the need for more data about nurses' ethnicity. This has compelled us to use the indirect method to identify which studies use Javanese nurses for the study population. Therefore, the term used as the subject of this study is "female nurses in Javanese hospitals (JH)" instead of "Javanese nurses." This term is used to accommodate the possibility that nurses of other ethnicities are also included in the study population. Other limitations include the lack of qualitative data about motivational determinants in JH. Consequently, we have to use many unpublished, not peer-reviewed, articles. Additionally, some issues in the Javanese context need to be analyzed more deeply.

CONCLUSION AND SUGGESTION
Female nurses' motivation in Javanese settings is related to finance, work-life balance, self-esteem, and self-actualization. Government and hospital managers had been providing motivational incentives, yet the use of the incentives still needed to be enhanced and improved. To motivate these nurses, the provision of incentives should involve financial and non-financial incentives and align with the needs, motives, and goals of female nurses. However, hospital managers should not heavily emphasize the provision of financial incentives. The use of non-financial incentives should be optimized since it is more sustainable in the long term and can enhance motivation more effectively. More research is needed to investigate Javanese female nurses' motivation more profoundly, mainly qualitative research.