The implementation of pharmaceutical care through patient-centered clinical pharmacy services improves the rational use of medications resulting in better patient outcomes (1–4). Despite the clear benefits, the transition from product-focused to patient-focused pharmacy practice has been rather slow in many middle to low-income countries. This slow uptake of clinical pharmacy services in such countries is generally related to infrastructure and resource limitations [(5–7)]. Additionally, lack of motivation has been identified in South Africa (SA) as a factor for the scarce number of pharmacists working in the wards (8). In spite of this, there is a lack of qualitative research on the work motivation of medical specialists (9), especially investigation into the motivation of clinical pharmacists. Limited data are available on the application of motivational theories to address motivation-related issues among healthcare workers in Africa. In this study we aimed to explore the motivation of clinical pharmacists, and differences in motivation in relation to personal and professional factors/characteristics, in order to provide the opportunity to create the best possible work environment for them.

The motivation of professionals plays a vital role in professional development and in their overall quality of work and performance (9, 10). Self-determination Theory (SDT) is among the current major motivational theories in psychology, as well as in Health Professions Education. Research on SDT has been applied effectively to examine what motivates individuals to work, however there is a scarcity of existing literature on work performance motivation and its determinants (9), as well as the use of SDT in the profession of clinical pharmacy. SDT describes motivation as dynamic and dependent on three basic psychological needs (BPNs), i.e., autonomy (experiencing a sense of volition), competence (feeling capable of achieving targeted outcomes) and relatedness (feeling connected to others). This theory describes motivation along a continuum that ranges from amotivation to intrinsic motivation (IM) (11) as illustrated in Figure 1.

The SDT does not solely quantify motivation, but also emphasizes the importance of the quality of motivation, classifying two types of motivation; autonomous motivation (which includes identified regulation and intrinsic motivation and is described as being generated from within or through personal endorsement), and controlled motivation (which includes external and introjected extrinsic motivation (EM) and is described as being generated from external or internal pressure or rewards) (12). Autonomous motivation (AM) has been associated with better performance, more positive well-being and greater resilience among health care professionals (13, 14). Controlled motivation (CM) is not the desired motivation type and is associated with burnout (10, 15). Amotivation, however, is the complete absence of motivation or purpose (12).

Factors previously found to influence the motivation of health care professionals are patient care, working with colleagues, work environment, technical issues, organizational and administrative tasks, job content and financial benefits (9, 16). Similar to any other healthcare profession, the universal performance of clinical pharmacists depends on their motivation and job satisfaction derived from certain intrinsic and extrinsic motivators (17–19). Where motivation is negatively influenced, feelings of emotional frustration are evoked, in turn decreasing the well-being, performance and, thus the quality of patient care (9). Additionally, job dissatisfaction is related to burnout, which is associated with negative effects on professional well-being (19–22).

The profession of pharmacy is maturing as a clinical profession in South Africa (SA) and has experienced significant development and growth over the past 10 years (8). However, as of yet, the discipline cannot be registered as a specialization at the South African Pharmacy Council (SAPC), and as a result no official clinical pharmacist posts are available (8). The healthcare system in SA constitutes a two-tiered health system, that is the public and private health care systems, serving ~84 and 16% of the country's population, respectively (23). South Africa, additionally, experiences human resource challenges in terms of healthcare service delivery. The shortage of pharmacists, especially in the hospital environment, has been acknowledged (24–26), leading to an increased burden on institutional pharmacists to provide product-focused tasks, like dispensing (24). Clinical pharmacists have not yet been appointed in allocated posts in the public sector, and the private sector has created ward-based pharmacist or clinical practice pharmacist posts, to bridge the gap. However, each hospital group or institution has its own post/job descriptions, also with differences in time available to spend in the wards for the delivery of pharmaceutical care. This can be explained by the existing human resource shortage, combined with the suboptimal use or lack of technical support staff (24, 26) which makes it challenging to allocate pharmacists to work in a clinical ward on a daily basis. Moreover, not being fully integrated in the hospital environment, clinical pharmacists cannot optimally fulfill their role in providing adequate pharmaceutical care (27). The COVID-19 pandemic has further complicated this; movement beyond the hospital pharmacy has been limited because pharmacists have been preferably allocated to deliver dispensing-like services. As clinical pharmacy in SA still faces numerous challenges regarding its implementation, the shortage of pharmacists with the necessary clinical expertise in turn leads to an increased need for clinical pharmacy services. The involvement of clinical pharmacists in providing services like medication reconciliation, antibiotic stewardship and anticoagulant monitoring highlights their role in the multidisciplinary team and shows how clinical integration impacts the provision of pharmaceutical care (2, 28–31).

In a study by Bronkhorst et al. (8), pharmacists across SA experienced some form of barrier to perform their role optimally, with the main barrier perceived to be lack of dedicated time to deliver clinical services. Furthermore, this study suggested that additional investigation into the work motivation for clinical pharmacists, may be necessary to establish the success of a practice Two other studies also found that clinical pharmacists are not involved in ward rounds, because they are over-burdened with other work responsibilities (32, 33). Nevertheless, globally it was recorded that within a fully implemented model of integrated pharmaceutical care, the change in scope relieves the clinical pharmacists of their dispensing responsibility, enabling them to work fulltime delivering clinical pharmacy services (2, 31, 34, 35).

The purpose of the present study was to investigate the motivation of clinical pharmacy graduates to perform clinical pharmacy-related services, and what personal (demographics), and work environment factors are associated with their motivation. Accordingly, the research questions for this study were as follows: (1) How can the quality of motivation (AM/CM) of clinical pharmacists to perform clinical ward-based activities be characterized? (2) Which factors are related to clinical pharmacists' quality of motivation (AM/CM)?

Our study contributes to the literature by validating SDT in a target group that has not been studied before, and where motivation could be a key factor in establishing the success of clinical pharmacy practice in middle to low-income countries.

Out of 114 graduates, 74 completed the survey (response rate 65%). This includes 60 participants (from the 97 graduates of 2000–2018) part of the first data collection wave in 2019; and 14 participants (from the 17 graduates of 2019 and 2020) part of the data collection in 2021.

The standardized Cronbach alphas were 0.91, 0.84, and 0.82 for AM, CM, and amotivation, respectively, indicating a high level of internal consistency. The assumption of a normal multivariate distribution was met. A CFA was conducted on the AMS as this was not validated among clinical pharmacists before. Factor loadings above 0.4 are considered good or significant, all factor loadings were adequate, ranging between 0.418 and 0.927, and are presented in Table A1. These results, [together with the Root Mean Square Error of Approximation (RMSEA) of 0.038] suggested that the AMS constituted a valid and useful scale to measure motivation according to the multidimensional perspective of SDT.

Table 1 shows the mean overall motivation of the respondents, as well as the population's demographics with their corresponding mean scores on types of motivation. Differences between mean scores were tested for significance by using a t-test.

The study comprised of a relatively young population, only 12.2% respondents were ≥40 years.

Higher amotivation was found among graduates not practicing as clinical pharmacists compared to those employed in a dedicated position (p = 0.005). Higher amotivation was also found for graduates who do not receive additional financial benefits for delivering clinical pharmacist-related services (p = 0.013). No other significant relationships were found, motivation was not associated with age, gender, work setting, years of work experience, whether additional clinical pharmacy related training was received, nor whether motivational methods are in place in the work setting.

The motivational methods, clustered into those that either stimulate AM or CM are shown in Table 2.

Overall, the motivational methods that stimulate CM were perceived to be the most effective (53%), especially incentives given for excellent work performance.

Qualitative data was collected post-hoc to elucidate some of the results. Participants answered questions on how their employment status influences their work motivation (whether employed as a dedicated clinical pharmacist or not). They also answered questions on the influence of receiving an additional income for delivering clinical pharmacy-related services on their work motivation. How they perceived the motivational method options “Incentives/rewards” and “Recognized achievements,” provided as part of the survey questions, was also explored.

Detailed findings from the analysis, with quotes from the interview data are presented in Table 3 below.

All of the interviewees confirmed that the position they are employed in has an influence on their motivation. Those who were employed in a clinical pharmacist position explained that being employed in a full time capacity enables them to deliver clinical services and knowing what is expected of them, motivates them to practice. This shows how autonomy needs are to some extent fulfilled in dedicated positions. In turn, the interviewees employed in dispensing pharmacist positions explained that they would have been more motivated to do clinical activities if they were in dedicated posts, highlighting some of the challenges like lack of support from colleagues and management, as well as incomprehension of their role by doctors and nurses. This lack of support explains how the quality of motivation for practice depends on an environment that fosters a feeling of relatedness.

While not all graduates received additional income to deliver clinical services, most graduates confirmed that a monetary incentive influenced their motivation. However, one graduate admitted that the extra financial benefit is not enough to increase motivation for practice.

The motivational method “incentives/rewards,” as included in the survey, was associated by all interviewees with a monetary incentive or reward (like a salary increase or extra leave). Furthermore, the participants associated “recognized achievements” with, for example, “a certificate to recognize work done well,” or through acknowledgment from management such as “an email going out to the hospital group saying these people have done this.” The motivational method “recognized achievements” was also identified to stimulate controlled motivation, as it was associated to function as an extrinsic motivator in the form of a reward, as well as an extrinsic motivator in stimulating a feeling of being visible to others.

To our knowledge, this is the first study reporting the quality and quantity of clinical pharmacists' motivation for delivering clinical services in middle to low-income countries.

This study found high overall motivation among clinical pharmacists in SA. This includes a higher mean AM score, as well as higher mean CM score, compared to a study in the Netherlands (47), which measured the quality of motivation of pharmacists for continuous education. This finding raises a concern, because according to SDT, high AM combined with a high CM is associated with burnout (49). Sequentially, burnout, again leads to possible professional consequences like higher chances of quitting the field of work (50), and an overall negative effect on professional well-being and advancement of the clinical pharmacy profession (19–22). Participants furthermore presented with a low mean score on amotivation, corresponding with the low amotivation found in pharmacists in the Netherlands (47). General SDT literature suggests that supporting or thwarting one or more of the three psychological needs, in turn influences the degree to which motivation is autonomous, and the concomitant health behaviors and health-related outcomes are positive (13).

South Africa's two-tiered health system (23), requires consideration of the different work environments and the influence of these settings on the work motivation of clinical pharmacists. However, no significant association was found between the work motivation of clinical pharmacists practicing in either private or public healthcare sector hospitals. Similar to our findings, the type of hospital did not have an influence on the work motivation of medical specialists (14). The hypothesis was that clinical pharmacists employed in the private sector would be more autonomously motivated, as the ratio of pharmacists to patients in the private sector are much higher, and the private sector has created ward-based pharmacist or clinical practice pharmacist posts to accommodate clinical pharmacists. A possible explanation could be that pharmacists who choose to specialize as clinical pharmacists, with the knowledge that no official posts exist, and especially those choosing to work in the public health care sector, with substandard working conditions (51), could already be more intrinsically motivated for the field. This supports the recommendation that more qualitative research is needed to understand the association between the work motivation of clinical pharmacists and their BPN satisfaction.

Gender was not related to clinical pharmacists' motivation to practice, which is in contrast with other studies on healthcare professionals which have reported that females are more autonomously motivated than males (45, 47, 52). Age and work experience also did not have a significant association with clinical pharmacists' work motivation. This is different from findings of other motivation studies, where specialists younger than 50 years scored higher on AM, and specialists and pharmacists with <15 years' experience scored higher on CM (14, 47). One potential explanation could be that in general the clinical pharmacist respondents' comprise a younger population, the majority with ≤5 years of work experience as compared to the participants in the other studies.

Additional clinical pharmacy related training at the current work setting was not related to clinical pharmacists' work motivation. Contrarily, on-site training has previously been found to be a predictor of general motivation in health care workers (53). SDT literature further acknowledges that feeling competent (which additional training can enhance) is crucial for AM. Our findings suggests that the available on-site training may not stimulate specialists' feelings of competence. The offered training options may not be tailored to their needs (47).

Clinical pharmacists who were not employed in a dedicated specialist position reported higher amotivation to practice. One reason might be that clinical pharmacists who are not in dedicated positions, cannot optimally fulfill their role in providing adequate pharmaceutical care (27), in turn leading to diminished professional autonomy (being able to determine and set standards for professional practice). This was confirmed by one of the interviewed clinical pharmacists. In line with SDT (12), repeatedly engaging in autonomously motivating activities stimulates AM. Van der Burgt et al. (54) likewise also confirmed that when a specialist has a higher AM for work, it stimulates their daily task-related motivation (in this case, motivation to deliver clinical services).

Another factor significantly associated with the work motivation of clinical pharmacists, was whether they received an additional income for service delivery. Findings showed that receiving an income benefit did seem to make a difference, as most clinical pharmacists who were not compensated were found to have higher amotivation for practice. A study on the factors influencing the motivation of clinicians in a low-income country found similar results, where a higher salary was associated with motivation and noted as a prerequisite determinant for any other intervention to change motivation using non-financial ways (55). However, this contradicts the general SDT literature which says that financial incentives harm autonomous motivation in the long run. This is also different from findings showing that external material rewards had the least influence on medical specialists' motivation in the Netherlands (14). We hypothesize that we found this because the clinical pharmacists think that their current income (in non-clinical pharmacist positions) is not commensurate with their qualification. This could have the effect of BPN frustration, especially autonomy frustration. They might be seeing additional income as something they deserve for this imbalance and getting this additional income makes them feel valued. This needs to be tested in further qualitative research.

From the interviews, most participants explained that challenges of not being in a dedicated position include: lack of support from colleagues and management, as well as lack of understanding from other health care professionals regarding their role. Working with colleagues, in a way that is experienced as positive, is motivating as it fulfills that need among clinical pharmacists. On the flipside, working with colleagues can influence motivation negatively when there is diminished feeling of being related to one another (9, 14, 56). In line with these results clinical pharmacists in the present study experienced higher amotivation when they did not feel supported and related to other health care professionals.

This study used self-report measures, consisting of self-assessment scales where respondents tend to overestimate themselves (60) which could mean results provided are an overestimation of the level of work motivation of clinical pharmacists. Furthermore, the AMS questionnaire has not frequently been used in health care professionals (40, 42), and it has only been validated in high school and college students. Therefore, more experience with this and other scales is necessary to demonstrate the validity of the instrument in practicing health care professionals. Although it was a relative small sample size, considering that the overall population is also small, together with the common knowledge that specialists are sent an overwhelming amount of questionnaires, the response rate was considered good for this population. The study was conducted in the context of a specific country, therefore the findings may not be applicable to other clinical practices. Furthermore, although SDT is a universal theory and has been validated in many life domains, not much is known about the motivation of clinical pharmacists. More research in other healthcare contexts is necessary to determine generalizability of the study findings. Lastly, an additional limitation is the potential effect of the COVID-19 crisis on the results. The second data collection wave took place in 2021, affecting 12% (14; n = 114) of participants. The recent pandemic has a known additional strain on health care workers who already perceived their jobs as highly demanding (61).

Clinical pharmacists had a high mean AM and CM, and low mean amotivation. Higher amotivation was found in graduates who are currently not practicing in dedicated clinical pharmacist posts, as well as higher amotivation in graduates who do not receive additional financial benefits for clinical services. In line with SDT literature, the interviews revealed that relatedness and autonomy are the most important factors for clinical pharmacists' work motivation. A work environment that drives AM, instead of CM can improve professional wellbeing, service implementation and prevent possible adverse events.

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

The studies involving human participants were reviewed and approved by Sefako Makgatho Health Sciences University Research and Ethics Committee, Sefako Makgatho Health Sciences University. The patients/participants provided their written informed consent to participate in this study.

LC contributed to the conceptualization of the study, the intellectual content, analyses, interpretation of data, drafting and revising of the paper, and final approval. AW contributed to the intellectual content in the manuscript, analyses, interpretation of data, revising of the paper, and final approval. EB and AG contributed to the intellectual content in the manuscript, revising of the paper, and final approval. RK contributed to the conceptualization of the study, analyses, interpretation of data, revising of the paper, and final approval. All authors contributed to the article and approved the submitted version.

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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