title: Validating a tool to measure auxiliary nurse midwife and nurse motivation in rural Nepal.
abstract: BACKGROUND
  A global shortage of health workers in rural areas increases the salience of motivating and supporting existing health workers. Understandings of motivation may vary in different settings, and it is important to use measurement methods that are contextually appropriate. We identified a measurement tool, previously used in Kenya, and explored its validity and reliability to measure the motivation of auxiliary nurse midwives (ANM) and staff nurses (SN) in rural Nepal.
  
  
  METHODS
  Qualitative and quantitative methods were used to assess the content validity, the construct validity, the internal consistency and the reliability of the tool. We translated the tool into Nepali and it was administered to 137 ANMs and SNs in three districts. We collected qualitative data from 78 nursing personnel and district- and central-level stakeholders using interviews and focus group discussions. We calculated motivation scores for ANMs and SNs using the quantitative data and conducted statistical tests for validity and reliability. Motivation scores were compared with qualitative data. Descriptive exploratory analysis compared mean motivation scores by ANM and SN sociodemographic characteristics.
  
  
  RESULTS
  The concept of self-efficacy was added to the tool before data collection. Motivation was revealed through conscientiousness. Teamwork and the exertion of extra effort were not adequately captured by the tool, but important in illustrating motivation. The statement on punctuality was problematic in quantitative analysis, and attendance was more expressive of motivation. The calculated motivation scores usually reflected ANM and SN interview data, with some variation in other stakeholder responses. The tool scored within acceptable limits in validity and reliability testing and was able to distinguish motivation of nursing personnel with different sociodemographic characteristics.
  
  
  CONCLUSIONS
  We found that with minor modifications, the tool provided valid and internally consistent measures of motivation among ANMs and SNs in this context. We recommend the use of this tool in similar contexts, with the addition of statements about self-efficacy, teamwork and exertion of extra effort. Absenteeism should replace the punctuality statement, and statements should be worded both positively and negatively to mitigate positive response bias. Collection of qualitative data on motivation creates a more nuanced understanding of quantitative scores.
authors.affiliation: Nick Simons Institute, Box 8975, EPC 1813, Sanepa, Lalitpur, Nepal. jmorrison@nsi.edu.np.
authors.forename: Joanna
authors.initials: J
authors.lastname: Morrison
authors.affiliation: Institute for Global Health, University College London, 30 Guilford Street, London, WC1N 1EH, UK. n.batura@ucl.ac.uk.
authors.forename: Neha
authors.initials: N
authors.lastname: Batura
authors.affiliation: Nick Simons Institute, Box 8975, EPC 1813, Sanepa, Lalitpur, Nepal. ritathapa@nsi.edu.np.
authors.forename: Rita
authors.initials: R
authors.lastname: Thapa
authors.affiliation: Nick Simons Institute, Box 8975, EPC 1813, Sanepa, Lalitpur, Nepal. regina.basnet@gmail.com.
authors.forename: Regina
authors.initials: R
authors.lastname: Basnyat
authors.affiliation: Institute for Global Health, University College London, 30 Guilford Street, London, WC1N 1EH, UK. j.skordis-worrall@ucl.ac.uk.
authors.forename: Jolene
authors.initials: J
authors.lastname: Skordis-Worrall
mesh_terms: D000041:Absenteeism; D000293:Adolescent; D000328:Adult; D001291:Attitude of Health Personnel; D005260:Female; D017144:Focus Groups; D006801:Humans; D007630:Kenya; D008875:Middle Aged; D008880:Midwifery; D009042:Motivation; D009390:Nepal; D009721:Nurse Midwives; D009740:Nursing Staff; D011247:Pregnancy; D015203:Reproducibility of Results; D019035:Rural Health Services; D012424:Rural Population; D011795:Surveys and Questionnaires / Q000592:standards*; D000078329:Workforce; D055815:Young Adult