title: Exploring the influence of trust relationships on motivation in the health sector: a systematic review.
abstract: BACKGROUND
  Dedicated and motivated health workers (HWs) play a major role in delivering efficient and effective health services that improve patients' experience of health care. Growing interest in HW motivation has led to a global focus on pay for performance strategies, but less attention has been paid to nurturing intrinsic motivation. Workplace trust relationships involve fair treatment and respectful interactions between individuals. Such relationships enable cooperation among HWs and their colleagues, supervisors, managers and patients and may act as a source of intrinsic motivation. This paper presents findings from a qualitative systematic review of empirical studies providing evidence on HW motivation, to consider what these studies suggest about the possible influence of workplace trust relationships over motivation.
  
  
  METHODS
  Five electronic databases were searched for articles reporting research findings about HW motivation for various cadres published in the 10-year period 2003 to 2013 and with available full free text in the English language. Data extraction involved consideration of the links between trust relationships and motivation, by identifying how studies directly or indirectly mention and discuss relevant factors.
  
  
  RESULTS
  Twenty-three articles from low- and middle-income countries and eight from high-income countries that met predetermined quality and inclusion criteria were appraised and subjected to thematic synthesis. Workplace trust relationships with colleagues, supervisors and managers, employing organisation and patients directly and indirectly influence HW motivation. Motivational factors identified as linked to trust include respect; recognition, appreciation and rewards; supervision; teamwork; management support; autonomy; communication, feedback and openness; and staff shortages and resource inadequacy.
  
  
  CONCLUSIONS
  To the authors' knowledge, this is the first systematic review on trust and motivation in the health sector. Evidence indicates that workplace trust relationships encourage social interactions and cooperation among HWs, have impact on the intrinsic motivation of HWs and have consequences for retention, performance and quality of care. Human resource management and organisational practices are critical in sustaining workplace trust and HW motivation. Research and assessment of the levels of motivation and factors that encourage workplace trust relationships should include how trust and motivation interact and operate for retention, performance and quality of care.
authors.affiliation: Health Policy and Systems Division, School of Public Health and Family Medicine, University of Cape Town, Observatory, 7925, Western Cape, South Africa. Dickson.Drookello@gmail.com.
authors.forename: Dickson R O
authors.initials: DR
authors.lastname: Okello
authors.affiliation: Health Policy and Systems Division, School of Public Health and Family Medicine, University of Cape Town, Observatory, 7925, Western Cape, South Africa. Lucy.Gilson@uct.ac.za.|Health Economics and Systems Analysis Group, Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK. Lucy.Gilson@uct.ac.za.
authors.forename: Lucy
authors.initials: L
authors.lastname: Gilson
mesh_terms: D003299:Cooperative Behavior; D003695:Delivery of Health Care; D006282:Health Personnel / Q000523:psychology*; D006801:Humans; D007400:Interprofessional Relations; D007588:Job Satisfaction; D009042:Motivation; D011787:Quality of Health Care; D035502:Trust; D017132:Workplace