IMPLICATIONS OF MASLOW’S HIERARCHY OF NEEDS THEORY ON HEALTHCARE EMPLOYEES’ PERFORMANCE*1

Abstract The purpose of this study is to provide a new perspective of the motivation-performance link, and the infl uence of satisfying each basic human needs, described by Maslow’s hierarchy of needs, on employees’ professional performance. We assumed that the positive relationship between each dimension of motivation and professional performance is mediated by work satisfaction. The proposed conceptual model was operationalized by seven latent constructs (the fi ve dimensions of motivation, inspired by the Maslow’s hierarchy of needs, job satisfaction and the professional performance), each of them measured by several observed indicators. The survey conducted for this occasion, was fi lled in by 824 employees from Romanian health organizations. Based on the research results, we can state that the Romanian health system employees are mostly motivated by meeting the needs of higher level, especially the need of self-actualization, and to a lesser extent by meeting the lower level ones. Those fi ndings may serve as useful insights for health system policy makers and managerial practices in designing and implementing the most effective motivational strategies, able to generate increased professional performance.


Introduction
Nowadays, the healthcare sector is facing stiff competition and increasing needs and expectations from the patients (Hee and Kamaludin, 2016). To meet these challenges, healthcare organizations must develop and expand continuously to be able to provide high quality health care as their ultimate objective. Health sector policy makers and health facilities managers must recognize the importance of work motivation in reaching sector and organizational goals, and they must understand the links between their current policies and worker motivation (Van Lerberghe et al., 2002).
Health workers' motivation can potentially impact the health services delivery (Mbilinyi, Daniel and Lie, 2011) and it is therefore important to make workforce development one of the priorities of health policy and consider it an essential public health function (Dussault and Dubois, 2003).  e motivation of healthcare workers will undoubtedly refl ect in their performance and, of course, in job satisfaction, which in turn impacts the quality of health services, their equity, effi ciency, effi cacy, accessibility and viability (Bennet and Franco, 2000;Dussault and Dubois, 2003).
However, despite the increased a ention grounded in motivation and its individual and organizational implications, there are still some underling aspects which are not well understood, one of the reasons being the lack of an appropriate instrument for measuring motivation (Borghi et al., 2018;Lohmann et al., 2017). Even if motivation and job satisfaction have been both mentioned as critical determinants of health workers performance and retention, they are abstract concepts which cannot be directly measured (Mbindyo et al., 2009).
Moreover, although there are studies suggesting clear links between motivation and job performance (Alhassan et al., 2016;Grant, 2008;Kuvaas, 2006;Sato et al., 2017), other studies which established a relationship between job satisfaction and job performance (Pe y, McGee and Cavender, 1984), and others which indicated a relationship between motivation and job satisfaction (Oguz et al., 2016), a clear connection between all the three terms mentioned above was not yet found.
 is study aims to investigate the motivation level of employees in the Romanian healthcare system, based on the fi ve levels of motivation, according to the Maslow's hierarchy of needs (1943): physiological needs, safety, love and belonging, esteem and self-actualization.  e study also a empts to evaluate the impact of satisfying each of these needs on performance and job satisfaction.  e novelty and relevance of the paper stem from the creation of a model that highlights the intimate mechanism explaining the relationship motivation-satisfaction-performance and providing empirical evidences to support it.  e paper also off ers a new perspective on the motivation-performance relationship, taking into account every basic human need described by the Maslow hierarchy, and assumes that the relationship between each dimension of motivation and performance is mediated by professional satisfaction. At the same time, the novelty of the paper is also supported by the study of the above described relations within a domain with distinct features, that of health services, which is also considered to be of major interest.
Based on the review of the relevant literature (section 2), a conceptual model and fi ve research hypotheses were developed.  e methodological section (3) provides the overall study design, research instrument and the main methods of data analysis.  e main results, which include also the validation of research hypotheses, are comprehensively presented and discussed in section 4 of the paper. In the conclusions part, limitations and future lines of research are outlined.

Literature review
Motivation is a process that infl uences and directs behavior in order to satisfy a need. Maslow (1943) developed a theory of how all dimensions of motivation are interrelated, based on the idea that human behavior is determined by a limited number of developing fundamental needs which emerge and operate in a sequential order (Sengupta, 2011). He called his theory a 'need hierarchy'. Maslow's hierarchy of needs consists of fi ve levels/dimensions of motivation: physiological needs, safety, love and belonging, esteem and need for self-actualization. When a lower level need is met or overtaken by a higher level one, people tend to be no longer motivated by satisfying that need (Suyono and Mudjanarko, 2017). Furthermore, people will try to meet the needs of the next level. Maslow's theoretical tenet indicate that it is necessary for prepotent needs to be satisfi ed before the next level need emerges and the person becomes concerned by satisfying it (Taormina and Gao, 2013). Maslow's model was studied in various disciplines: in social sciences, psychology, sociology and education (including adult learning) and was used as a model to understand the individuals' needs, while in business it was approached as a model to explain employees' motivation (Benson and Dundis, 2003). Since it was fi rst formulated, Maslow's theory was further developed by Maslow itself or by other researchers -i.e. Alderfer (1969) ERG theory.  e theory was also subjected to empirical testing and criticism (Berl, Williamson and Powell, 1984;Hall and Nougaim, 1968;Lawler III and Su le, 1972;Soper, Milford and Rosenthal, 1995) that contested its empirical basis and applicability within an organizational context. In sum, Maslow's theory highly infl uenced the way of thinking and subsequent research (Alderfer, 1969) and became the most well-known theory that a empted to explain the mechanisms of human motivation.
Human resources motivation is primordial in all sectors of activity, especially in the healthcare system, where the need for high quality services is in a continuous grow, because it has become an essential condition in creating and maintaining high performance, both in terms of each employee and overall organizational performance. In the healthcare system, motivational factors can be diff erentiated into many categories. For instance, in a study conducted in Pakistan, motivating factors were intrinsic and social cultural factors, like serving people, respect and career growth were also important (Malik et al., 2010).
As it is stated by Da (2010) motivation can lead to behaviors refl ecting high performance within an organization, therefore, it is the manager's responsibility to de-sign the right combination of motivational tools and incentives able to simultaneously satisfy employees need and encourage high performance. In terms of job performance, in most hospitals are used various performance evaluation methods as a means of monitoring and evaluating the individual and organizational objectives. Motivation is considered a strong predictor to job performance (Hee and Kamaludin, 2016, p. 343).
Previous studies addressed the issues of motivation-performance relationship, providing theoretical and empirical arguments to support a positive infl uence of motivation on professional performance. Studies suggested both a direct eff ect (Alhassan et al., 2016;Sato et al., 2017), but also a mediating role of motivation for other determinant factors of performance (Deci, Olafsen and Ryan, 2017;Rowe et al., 2005;Taghipour and Dejban, 2013).
 e results of several studies indicate a correlation between motivation and job performance (Grant, 2008;Van Knippenberg, 2000). Other studies further demonstrated that employees with higher levels of motivation potentially have be er professional performance (Kuvaas, 2006). Looking at the connection between motivation and performance, one may see that it is a relationship of mutual conditioning since, when the individual expectations and organizational demands overlap, there are high chances of fostering professional performance.  erefore, in the work process, motivation is the driving factor of performance and links the individual and organizational interests (Gîlmeanu, 2015, p. 70). Taghipour and Dejban (2013) state that employees' motivation is one of the most eff ective managers' strategies to enhance eff ective workers job performance within their organizations.
Job satisfaction should be considered an important factor in healthcare se ings. Atefi et al., (2014) identifi ed three main factors infl uencing nurses' job satisfaction: (1) work environment factors (benefi t and rewards, working conditions, team cohesion, available medical resources, responsibilities, patient and doctor perceptions, leadership skills), (2) spiritual feeling (involvement in patient care and help giving), and (3) motivation (task requirement, clinical autonomy and professional development).
Even motivation and job satisfaction are two independent concepts, they are also interrelated to each other (Oguz et al., 2016), involving cognitive, aff ective, and behavioral processes ( Mutale et al., 2013).  us, Oguz et al. (2016) reported a strong positive correlation between job satisfaction levels, motivation and organizational commitment of healthcare professionals who work in the public healthcare sector in Turkey. As a result of the analysis, it was found that both job satisfaction and motivation had a signifi cant eff ect on organizational commitment.  ese two factors can signifi cantly infl uence labor productivity, labor fl uctuation or absenteeism, or in a word, performance (Le er et al., 2012, p. 129).
 ere are also strong empirical evidences supporting a causal relationship between job satisfaction, quality of health care and patient safety (Alhassan et al., 2013;Berenson and Rice, 2015). In the healthcare system, the job satisfaction of physicians is in the interest of the entire healthcare context (DeVoe et al., 2002) and has important eff ects on physician productivity, the quality of medical care, and the supply of physicians available to meet the medical care needs of population (Malik et al., 2010). Conversely, a lower healthcare staff job satisfaction will lead to increased brain drain, poor work performance and lower healthcare outcomes (Wang et al., 2017).
However, the job satisfaction -job performance relationship was perhaps one of the most controversial topics of research on employee behavior (Pe y et al., 1984). Following an extensive literature review regarding the extent to which high employees' satisfaction leads to enhanced performance, Kim (2002) found mixed results, ranging from no relationship to a strong and positive impact.  us, in spite of considerable eff orts, the controversy on satisfaction-performance relationship remained unsolved (Pe y et al., 1984).

Conceptual model and hypotheses
In the fi rst step, the conceptual model was set-up, based on the theoretical approach of motivation-satisfaction-performance relationships presented above. Motivation was conceptualized as a multidimensional construct, made-up by fi ve dimensions inspired by Maslow's theory of needs (Maslow, 1943): physiological needs, safety, love and belonging, esteem and self-actualization. However, no relationship or hierarchy was assumed between the fi ve dimensions, as in Maslow's theory. Since we intended not only to measure the motivation level of healthcare professionals, but also to investigate the impact of each dimensions on work satisfaction and professional performance, the conceptual model included two additional latent constructs.  e conceptual model is presented in Figure 1, alongside with the research hypotheses, denoted by H1-H5: • Hypothesis 1 (H1):  ere is an underling construct of motivation, made up of fi ve dimensions inspired by the Maslow's hierarchy of needs: physiological needs, safety, love and belonging, esteem and self-actualization; • Hypothesis 2 (H2): Motivation of employees in the health system by meeting the higher-level needs (esteem and self-actualization) according to Maslow's hierarchy of needs is positively associated with professional performance; • Hypothesis 3 (H3): Motivation of employees in the health system by meeting the lower level needs (physiological needs, safety, love and belonging) according to Maslow's hierarchy of needs is not associated with professional performance; • Hypothesis 4 (H4):  e relationships between each dimension of motivation and professional performance of healthcare employees is mediated by work satisfaction; and • Hypothesis 5 (H5):  ere are diff erences between private and public health organization in terms of the intensity of mediation of satisfaction on the relationship between motivation dimensions and performance.

Overall research design
Considering that the present study a empts to evaluate the motivation level of employees in the healthcare system, based on the theoretical support of the Maslow's pyramid of needs (Maslow, 1943) and the impact of satisfying each of these needs on employees' performance, the survey was addressed by employees within the Romanian health system (inclusion criteria). Since we were interested in motivation primarily as an organizational process, in the study population (and consequently, in the sample) we did not include dentists and family doctors, healthcare professional which work mostly in their own private practice, rather than within an organization (exclusion criteria). To ensure both a satisfactory response rate, and access to a suffi ciently large geographical area, the questionnaire was distributed and completed, both on paper and online format, using the snowball sampling procedure.
 e research was approved by the Research and Innovation Management Department of the Bucharest University of Economic Studies (approval no. 1420/29.11.2016).  e respondents were informed of the objectives of the study and that the data resulted will be used only for this purpose. Moreover, no personal data was collected through the survey, the respondents' participation being strictly anonymous; the respondents were also informed that their participation is voluntary, having the opportunity to withdraw at any time.
 e fi nal sample of the study included 824 respondents, employees within Romanian healthcare organizations, who completed and returned valid questionnaires measuring work motivation, work satisfaction and professional performance.  e best represented development region was the Bucharest-Ilfov region (27.55%), while fewer respondents came from West (10.92%). According to the property of health organizations, 68.81% of respondents come from public institutions, while 31.19% were employed in private healthcare organizations. Chi-square goodness to fi t tests revealed no statistically signifi cant diff erences between the shares of two key characteristics within the total population (National Institute of Statistics, 2018) and the sample: geographical distribution (χ 2 (5) = 10.738, ns) and property (χ 2 (2) = 0.923, ns), thus supporting the sample representativeness.
Considering the individual characteristics, most of the respondents were women (77.31%), with an average age of 36.87 years. Since we assumed diff erences in motivation, within the sample were nurses (37.86%), physicians (27.31%), pharmacists (14.44%), but also auxiliary medical staff (9.71%), as well as non-medical staff (10.68%), most of them (79.98%) were in non-managerial positions. With respect to the health organizations they are employed, more than half of the respondents (55.83%) came from hospitals, but also from pharmacies (19.82%), specialized medical care centers (12.86%) and emergency units (11.89%). In terms of the organization size, since hospitals employees were best represented in our survey, it was expected that the respondents coming from organizations with more than 250 employees to represent a similar share (58.62%).  Maslow, 1943;Porter, 1961), asking the respondents how motivated they are in their professional activity by: ( 1) salary, other material benefi ts and work schedule -corresponding to the physiological needs dimension; (2) working conditions, organization staff policy, workplace safety and health and pension insurance -corresponding to the safety dimension; (3) relations with colleagues and teamwork -corresponding to the love and belonging dimension; (4) possibility to assume responsibilities, performance recognition by colleagues and performance recognition by superiors -corresponding to the esteem dimension, and (5) possibilities to value skills, the possibilities to always learn new things and career development possibilities -corresponding to self-actualization. A 5-point Likert scale, ranging from 1 (not at all) to 5 (to a very large extent) was used for measurement.  ree items were designed to measure professional performance (Ștefan, Popa and Dobrin, 2016), asking the respondents to asses (on a 5-point scale, where 1 = much worse, 5 = much be er) their professional performances compared with the objectives set, with those of colleagues and with their own performance from fi ve years ago.

Research instrument and variables
 e fi rst form of the conceptual model and the items included in the questionnaire for each of the seven constructs were reviewed both by management researchers and by healthcare managers. Because we assumed that diff erent individual and organizational characteristics can potentially infl uence the motivation level of healthcare employees, a set of such questions has been included in the questionnaire. As recommended (Borghi et al., 2018;Lohmann et al., 2017), in the case of developing a new (or modifi ed) measurement scale, the measuring instrument has been pretested.

Data analysis
Statistical and econometric analyses included descriptive statistics, t-tests, ANO-VA, factor analysis (FA) and structural equation modeling (SEM).  e main method of confi rmatory factor analysis (CFA), measurement and structural model' validation and testing the hypothetical relationships among latent constructs, was SEM. SEM is a combination of statistical techniques including FA, path analysis and regression. Due to its distinct ability to estimate error variations from complicated measurement components and their structures, SEM is the ideal solution for development and testing a theory, as a whole (Wang et al., 2015).  e procedure followed a tree step scenario: (1) preliminary examination of data; (2) construction of the measurement model, which allowed to test the fi rst research hypothesis, and (3) construction of the structural model, which enabled the mediation and moderated mediation analyses and testing hypotheses 2 to 5. For the purpose of data analysis, we created a database which was exploited by means of IBM SPSS Statistics so ware package, version 25.0 (IBM Corp., 2017) and IBM SPSS Amos, version 25.0 (Arbuckle, 2017).

Preliminary examination of data
Since survey-based studies are commonly associated with biases (Jakobsen and Jensen, 2015), which potentially aff ect the accuracy of their results, we considered the appropriate methods able to diminish as much as possible their eff ects. To control for the common method bias and non-response bias, along with procedural measures, we performed a Harman's single factor test for all the 19 observed variables and independent sample t-tests for each variable, comparing the means obtained in the fi rst wave with the second one (Armstrong and Overton, 1977). In both cases, no evidence of such biases was found.
Missing data is another element that could potentially cause diffi culties in data analysis (i.e., some SEM options are only available for a complete dataset) or could have a considerable impact on research results (Hair et al., 2010).  e nonsignifi cant value of Li le's MCAR test (χ 2 = 46.510, df = 36, p = 0.113) suggests that the process of estimating and replacing missing values in this research should consider the Expectation-Maximization (EM) algorithm.
 e normality of data distribution and univariate and multivariate outliers were assessed for this dataset. Since no absolute value of skewness greater than 1.0 was found, we concluded that all variables are normally distributed. As concern the outliers, a few cases presented univariate or multivariate outliers (Mahalanobis distance greater than the critical value). However, for datasets larger than 200 and normally distributed, it is suggested that there is no necessity to examine Mahalanobis Distance.

Exploratory factor analysis (EFA)
Construction of a new scale, or adapting an existing one to a new context, assumes that researchers seek to identify meaningful dimensions and assign the observed variables to those dimensions based on their intercorrelations. Hence, EFA was performed on the 15 observed variables measuring motivation and three variables of professional performance to give us a fi rst impression of how they are grouped together. Since we assumed that motivation dimensions are related (Borghi et al., 2018), Principal Axis Factoring extraction method and Promax rotation (which allows the factors to be correlated) were selected. Following the above procedure, from the 15 observed variables measuring motivation, fi ve factors were extracted, which account for 56.07% of their variance, while from the three variables measuring professional performance we extracted only one factor.  e analysis revealed that the items of the two scales reached good convergent and construct validity and construct and internal consistency reliability (see Table no. 1).  Table 1 also presents a brief descriptive statistic on the fi ve dimensions of motivation resulting from the exploratory phase of analysis, as well as for work satisfaction and professional performance (to be included in the structural model). As one can see, the Romanian health system employees are mostly motivated by meeting the needs of higher level, especially the need of self-actualization (M = 3.873, SD = 0.780), and to a lesser extent the satisfaction of safety (M = 3.655, SD = 0.775) and especially physiological ones (M = 3.100, SD = 0.927).

Confi rmatory Factor Analysis -Testing hypotheses H1
Once the theoretical approach was strengthened by the results of EFA, and we had a strong assumption on the dimensionality of the scales and the relationships among variables, the next logical step was the CFA.  e main method of CFA, was SEM, performed using the graphical interface of AMOS 25.0 (Arbuckle, 2017).
To validate the measurement model, it was assessed in term of fi t indices, unidimensionality, validity and reliability.  e structural validity analyses aimed to confi rm that the scale measures the motivation dimensions as intended (Lohmann et al., 2017). A er the fi rst iteration, examining the modifi cation index (MI), two error terms of the same factor (physiological needs) were allowed to covariate. Moreover, one of the variables of factor 2 (safety) with exhibited insuffi cient loading was dropped out. Consequently, the fi t indices reached satisfactory levels, meaning the measurement model fi t the data well:  ree criteria were used to assess the convergent validity of the measurement model: standardized loadings between each observed variable and its factor, composite reliability (CR) and Cronbach's alpha values for each construct and average variance extracted (AVE). As one can see in Table 1 and 2, except for the AVE of safety, all values meet the recommended thresholds, supporting the convergent validity of the constructs (Hair et al., 2010;Kline, 2015;Nunnaly and Bernstein, 1994). To assess the discriminant validity, we checked (1) if the square root of AVE is larger than the inter-construct correlation for each construct and (2) if each variable loads higher on the factor which it was intended to measure than every other factor (Barcley,  ompson and Higgins, 1995;Hair et al., 2010;Kline, 2015).  e data presented in Table 1 and 2 also support the discriminant validity.  e fi rst research hypothesis assumed that there is an underling construct of motivation, made up by fi ve dimensions inspired by Maslow's hierarchy of needs (Maslow, 1943): physiological needs, safety, love and belonging, esteem and self-actualization.
 e fi ve dimensions of motivation were operationalized by fi ve latent constructs, while the intercorrelations among them were evaluated through a CFA.  e fi nal form of the measurement model was assessed in term of fi t indices, unidimensionality, validity and reliability and the results presented above were all in acceptable intervals, thus giving support for the fi rst hypothesis.

The structural model
A fi rst SEM was implemented to account for the relationships among latent variables representing the fi ve levels of motivation according to Maslow's hierarchy of needs and professional performance (model 1). Moreover, into a second model (model 2) a supplementary observed variable (measuring work satisfaction) was introduced to assess the mediating role of satisfaction on the motivation-performance relationship; as presented in Table 3, all fi t indices were found to be in acceptable range for both models.

Testing hypotheses H2 and H3
 e structural models were also evaluated in terms of squared multiple correlations coeffi cients (R 2 ), as they account for the variability of all the independent variables explained by the dependent construct (professional performance). Overall R 2 = 0.36 indicates that all fi ve latent constructs representing dimensions of motivation (physiological needs, safety, love and belonging, esteem and self-actualization) are able to explain 36% of the variation of professional performance.
It was assumed that professional performance of employees in the health system is positively associated with motivation by meeting the higher-level needs according to Maslow's hierarchy (esteem and self-actualization) -H2, and not associated with lower levels of Maslow's hierarchy -H3. In Table 4 we reported all standardized path coeffi cients (β) between the fi ve explanatory latent constructs and performance, alongside with their standard errors, p-values and 95% confi dence intervals obtained through a percentile bootstrap method.  e results suggest that esteem and self-actualization are positively and signifi cantly associated with professional performance (β = 0.206, p < 0.05; β . = 0.377, p < 0.001), thus giving support for hypothesis 2. Moreover, the nonsignifi cant path coeffi cients between the latent constructs representing the lower motivation dimensions and professional performance ( β = 0.056, ns; β = 0.046, ns; β = 0.013, ns) support hypothesis 3.  e Maslow's Needs-Hierarchy  eory has been used as a basis for one study of motivation of health care employees (Benson and Dundis, 2003); in the aforementioned study we remark the idea that only if an individual's basic needs have been met, the higher levels of pyramid become relevant, as physiological needs are the most basic human component. By comparison, the current study brings a wider vision, by studying not only the motivation of the healthcare system, but also by providing a new perspective of the motivation-performance relationship and emphasizing the infl uence of satisfying each basic human needs, described by Maslow's hierarchy of needs, on employees' professional performance and emphasizing the positive infl uence of meeting higher-order needs (esteem and self-actualization).

Mediation -Testing hypothesis H4
In the context of mediation analysis, a mediator is an intermediate variable that helps explain the relationship between an independent variable and the dependent one (Gunzler et al., 2013). In this case, it was assumed that the relationships between each dimension of motivation and professional performance of healthcare employees are mediated by work satisfaction (H4).  erefore, to test this hypothesis, starting from model 1, a new model (model 2) was estimated by introducing a new variable as a mediator and the bias-corrected bootstrapping method (available in AMOS program) was employed to produce 95% confi dence interval for the indirect eff ects.
 is time, the research results obtained were not entirely as expected and the fourth hypothesis was partially validated (see Table 5): -As far as the relationship between physiological needs and love and belonging and performance is concerned, mediation cannot take place since the direct relationship (in the absence of the mediator) was not statistically signifi cant (β = 0.056, ns; β = 0.013, ns) (Cheung and Lau, 2008). - e bootstrapping procedure provided also evidences for the full mediation of satisfaction on the relationship between esteem and performance, since the indirect eff ect is statistically signifi cant (β = 0.087, CI 95% [0.049, 0.142]), while the direct eff ect is not (β = 0.119, ns). Furthermore, the signifi cant direct (β = 0.149, p < 0.001), and indirect (β = 0.047, CI 95% [0.019, 0.088]), eff ects of satisfaction on the relationship between self-actualization and performance support its partial mediation.  at means that esteem and self-actualization, as motivational factors, have a positive impact on satisfaction, which, in turn, has a positive infl uence on performance. However, in the presence of a mediator, only self-actualization has a direct eff ect on professional performance.

Moderated mediation -Testing hypotheses H5
Further, we were interested (hypothesis 5) whether or not the mediation eff ect of satisfaction remains the same (constant) across two groups of respondents, defi ned by the property of their employer (private or public).
 e moderated mediation eff ect or conditional indirect eff ect was identifi ed by Preacher, Rucker and Hayes (2007) when the strength of the indirect eff ect depends on the respondents belonging to one or another of the defi ned groups. To validate the fi  h research hypothesis, we employed the multigroup approach, which involved the specifi cation and estimation of multiple models, accordingly to the number of categories of variables considered as moderator (Ryu and Cheong, 2017), in this case: group 1 -respondents employed in private health organizations and group 2 -respondents employed in public health organizations. According to Fairchild and MacKinnon (2009), if the indirect estimates are statistically diff erent from one another across groups, the moderation of the indirect eff ect is signifi cant, and the mediated eff ect is moderated by group membership.  erefore, we applied heterogeneity tests with z-statistics for each indirect eff ect across the two groups.
As shown in Table 6, for the fi rst relationship, the indirect unstandardized estimates (B Private = 0.066, SE = 0.037, p < 0.05; B Public = -0.016, SE = 0.013, ns) are statistically diff erent across groups (z = 2.091, p < 0.05).  us, there were evidences for the moderated mediation eff ect, while for the other four relationships the eff ect could not be observed.  at means that the property of the health organization in which the respondents are employed moderates only the mediation eff ect of satisfaction on the physiological needs -performance relationship, respectively the mediation eff ect can only be shown for the group of respondents employed in private health organizations. Considering above, the fi  h hypothesis was partially supported.

Conclusions
 e link between motivation and the professional performance of healthcare employees was one of the most debated topics of research in the last decades.  erefore, the goal of this study was to investigate and depict the mechanism beyond this relationship, in order to provide theoretical and empirical evidences able to support managerial policies and practices able to balance the most eff ective motivational interventions with the limited available resources. Considering the aim of the study and based on theoretical approach, past empirical evidences and own experience, a conceptual model was developed, and fi ve research hypotheses were formulated and validated through appropriate methods. A summary of validation of the research hypotheses is presented in Table 7.  e main results of the research fully supported validation for tree research hypotheses and partial validation for the other two.  e fi rst hypothesis (H1) assumed that there is an underling construct of motivation, made up by fi ve dimensions inspired by the Maslow's hierarchy of needs.  e measurement model was assessed in term of fi t indices, unidimensionality, validity and reliability, their results providing support in the fully validation of hypothesis H1.
Hypothesis H2 assumed that professional performance of employees in the health system is positively associated with motivation by meeting the higher-level needs according to Maslow's hierarchy (esteem and self-actualization), and hypothesis H3 assumed that it is not associated with lower levels of Maslow's hierarchy (physiological needs, safety and love and belonging). Within the structural model, the path analysis results provided support for hypotheses 2 and 3, suggesting that high levels of health workers' professional performance could be associated only with the fulfi lment of their higher-level need (i.e., esteem and self-actualization).
Mediation analysis provided support for the partially validation of hypotheses 5.  e hypothesis assumed that the relationships between each dimension of motivation and professional performance of healthcare employees is mediated by work satisfaction.  e mediation analysis suggested not only that satisfaction fully or partially mediate the relationships between the fulfi llment of higher-order needs and performance, but, furthermore, an indirect eff ect of satisfaction on the safety-performance relationship could be noticed. It should be mentioned that (among the fi ve dimensions) only self-actualization is directly associated with performance.  e results suggest that, except for self-actualization, the fulfi lment of all the other category of needs has a positive eff ect on professional performance only if the employees are satisfi ed with their jobs, thus supporting the essential role of satisfaction in the motivationperformance relationship.
H5 assumed that there are diff erences between private and public health organization in terms of the intensity of mediation of satisfaction on the relationship between motivation dimensions and performance.  e moderated mediation (multigroup analysis) results revealed statistically signifi cant diff erences only for the indirect eff ect of satisfaction on the relationship between physiological needs and performance (i.e., positive indirect eff ect in the model including respondents employed in private healthcare organizations and negative indirect eff ect in the model including respondents employed in public sector).
 e real practice of the medical health system can use the results of the research in order to improve the work processes and professional performances. By admi ing there is an underlying construct of motivation, made up of fi ve dimensions inspired by Maslow's hierarchy of needs, the research suggests that higher-order motivational factors (self-esteem and self-actualization) should be integrated into the specifi c healthcare policies. Moreover, eff ective means of enhancing healthcare professionals' work satisfaction should be further considered, since the research results suggest its positive mediating eff ect on the motivation-performance relationship.
 e present study represents an important step forward in understanding how diff erent dimensions of motivation are related to job satisfaction and professional per-formance and found empirical evidences for the mediating role of work satisfaction in three of those relationships. Moreover, in view of the increasing number of private medical centers in Romania, as well as eff orts to modernize the public sector (including human resources management) the diff erences in the mechanism described above between the respondents employed in the two types of health organizations were also investigated.  ose fi ndings may also serve as useful insights for health system policy makers and managerial practices in designing and operationalizing the most eff ective means of action able to generate increased professional performance.
Even the above results may provide important theoretical and practical implications, certain limitations should be also addressed. First, despite the eff ort deployed to design a sampling procedure able to support the representativeness, not all conditions were met (i.e., the random selection of respondents).  us, the results may not be generalized. Second, since the motivation and performance scores were self-reported, it raises the issue of social-desirability bias (Donaldson and Grant-Vallone, 2002).  ird, our conceptual model did not consider other possible mediating factors of the motivation-performance relationship, nor other moderators. Finally, the research had a trans-sectional character which meant that data on which both the independent and dependent variables were defi ned was collected simultaneously. Addressing those limitations may shape some interesting future research directions.