PA P E R S
Allied health professionals’ intention to work for the National Health Service: a study of stayers, leavers and returners Crispin Coombs, John Arnold, John Loan-Clarke, Sara Bosley and Caroline Martin Business School, Loughborough University, Loughborough, UK E-mail:
[email protected]
Summary While there has been a recent squeeze on staff costs, it continues to be important to offer graduating clinical staff National Health Service (NHS) employment in order to maintain the long-term strength of the service. In addition, the experiences of the Canadian nursing profession suggest that complacency about an improving recruitment situation can lead to problems. Consequently, the objective of this study was to identify what influences allied health professionals’ (AHPs) intention to work for the NHS. A postal survey was sent to members of four Allied Health Professions equally (N ¼ 4800), targeting Stayers in, Leavers from, and Returners to, the NHS. One thousand nine hundred and thirty-nine questionnaires were returned giving an overall response rate of 40%. Stayers’ intention to remain in the NHS was influenced by continuing professional development opportunities, confidence that they can find NHS work, commitment to their profession, a sense of moral obligation and a belief that other people important to them think it is a good idea. Returners’ intention is influenced by similar factors as Stayers. Leavers are influenced by similar factors as Stayers/Returners but to a lesser extent. The study shows that perceptions of various NHS work characteristics, which lead to reasonably positive attitudes towards the NHS, do not necessarily translate into intention to work for it. The study also shows that intention to work for the NHS is not solely dependent on perceptions of NHS jobs and that career-decision-making is a social process, with the opinions of people who are important to AHPs also influencing career decisions.
Introduction The National Health Service (NHS) Plan (2000) identified labour shortages across a range of clinical professions, and envisaged an increase of 30,000 allied health professionals (AHPs) working in the NHS between 2001 and 2008.1 However, by 2005 there was governmental concern to ensure that local NHS organizations were financially viable,2 as previously high levels of funding were falling. Consequently, over the 2006/2007 financial year there was a squeeze on staff costs. Because of previous increases in training provision, combined with vacancy
Crispin Coombs PhD, Lecturer in Information Systems, Business School, Loughborough University, Loughborough LE11 3TU, UK. John Arnold PhD, Professor of Organisational Behaviour, Business School, Loughborough University, Loughborough LE11 3TU, UK. John Loan-Clarke MSc, Senior Lecturer in Organisational Development, Business School, Loughborough University, Loughborough LE11 3TU, UK. Sara Bosley PhD, Research Associate, Business School, Loughborough University, Loughborough LE11 3TU, UK. Caroline Martin MA, Research Associate, Business School, Loughborough University, Loughborough LE11 3TU, UK.
freezes, the supply of AHPs was projected to exceed the availability of NHS jobs.3 However, it is important to offer NHS employment to graduating clinical staff to ensure the long-term strength of the service.4 Evidence from the Canadian nursing profession warns that complacency about an apparently improved recruitment situation can lead to subsequent problems.5 Consequently, there is a need to continue to improve our understanding regarding what influences AHPs’ intention to work for the NHS. At the national policy level, the Improving Working Lives initiative, and Agenda for Change were both designed as part of an attempt to make the NHS a ‘model employer’ or ‘employer of choice’.6 Money has been provided by the government for specific kinds of provision – for example, workplace childcare facilities.7 However, previous research suggests that the NHS’s image as an employer is shaky,8 though many people nevertheless see significant positive features in the nature of the work.9 Limited research evidence is available concerning recruitment, retention and turnover among AHPs in the NHS. Common factors identified in respect of turnover are workload/pressure, limited career prospects, family commitments and pay10 – 12 (Johnson J, Back to Therapy Survey. Wirral: Clatterbridge Centre of Oncology, 1999,
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unpublished). Region-specific studies identify the influence of local factors.13 – 15 In some respects the findings are conflicting. For example, Hunter and Nicol16 reviewed the literature and found little evidence that provision of continuing professional development influenced recruitment and retention of Occupational Therapists, but von Zweck17 and Wright18 argued the opposite. Johnson (Management Project on Returners. Wirral: Clatterbridge Centre for Oncology, 2000, unpublished) found a variety of factors were salient to potential returners to radiography, though financial incentives and flexible hours featured prominently. In summary, there is some evidence about what factors influence AHP staff retention and return. However, it is fragmented and often based on limited sample size. The purpose of the study reported in this paper was to identify what factors influence AHPs’ intention to work for the NHS. By sampling AHPs currently working in the NHS (those who have returned to working for it having worked elsewhere, and those who have left it), a broad understanding of influential factors could be developed. Incorporating these three groups: Stayers, Leavers and Returners in one study has not been done before. The study was informed by Ajzen’s Theory of Planned Behaviour (TPB)19 (see Figure 1). The key elements in the TPB are that behaviour can be predicted by intention to perform that behaviour and the extent to which the individual believes they have control over whether they perform the behaviour ( perceived behavioural control). Ajzen argues that intention is the direct primary antecedent to performing behaviour, so the stronger the intention to engage in behaviour, the more likely its performance by the individual. The TPB proposes that there are two further predictors of intention (in addition to perceived behavioural control). The first is an individual’s attitude towards the behaviour. The second is the perceived social pressure (e.g. from friends and family) to perform or not to perform the behaviour (subjective norm). The TPB has been successfully used in a range of applied settings associated with recruitment and retention.20,21
Method Questionnaire construction was informed by the TPB and also by a questionnaire designed for a previous project
Figure 1 A simplified representation of Ajzen’s theory of planned behaviour
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undertaken by the research team which explored perceptions of NHS work characteristics.8 Six main categories of data were collected: general perceptions of working for the NHS as a qualified AHP; attitudes towards NHS work; perceptions of the opinions of salient other people (subjective norm); perceptions of one’s confidence in finding NHS work ( perceived behavioural control); and various other opinion variables, e.g. belief in NHS principles. We included among these opinion variables one related to moral obligation to work for the NHS, as we have previously found that this can influence intention to work for the NHS among potential NHS recruits who are either currently unqualified or in clinical training.8 Finally, demographic data were collected. The questionnaire was sent to members of each of four AHP groups with targeting of likely Stayers, Leavers and Returners. Potential respondents were identified with the assistance of The British Association/College of Occupational Therapists; The Society of Radiographers; The Royal College of Speech and Language Therapists and the Chartered Society of Physiotherapy. Our sampling strategy selected randomly for Stayers, Leavers and Returners in each of the four professions. A total of 4800 questionnaires were distributed: 1200 to AHPs in each of the four professions. Data analysis was carried out in SPSS and a number of variables were combined using principal components analyses and alpha reliability measures are shown in Table 1. Multiple regression analyses were conducted in order to investigate which factors were the best predictors of overall attitude and intention regarding working for the NHS as an AHP. Table 1 Details of factors and single items used in analysis
Construct
Alpha reliability
Intention to work for the NHS 0.95 as an AHP Attitude towards working for the 0.89 NHS as an AHP Perceived NHS work characteristics Professional development 0.87 Negative work pressure 0.75 Patient care 0.73 Lifestyle 0.81 Convenience 0.60 Social contact 0.73 Low pay n/a Secure job n/a Good pension scheme n/a Opinions about the NHS Subjective norm 0.72 Moral obligation 0.71 Principles of NHS n/a Confident find/stay in NHS job n/a Plenty of job options n/a Committed to NHS n/a Committed to profession n/a
Number of items 3 3
11 5 4 3 3 2 1 1 1 3 2 1 1 1 1 1
NHS, National Health Service; AHP, allied health professional; n/a, not applicable
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Of the 4800 questionnaires distributed, 1939 were returned giving a response rate of 40%. In addition, 86 individuals completed the same questionnaire in electronic format through the research project website giving a total of 2025 responses. After data cleaning 1960 usable responses were incorporated into data analyses. Table 2 summarizes the main features of respondents broken down by profession and the three groups (Stayers, Leavers and Returners).
Results The results of the regression analyses shown in Table 3 provide important insights about what affects Attitude and Intention towards working as an AHP for the NHS. Although Attitude is an important component of the TPB it can seem no more than a ‘black box’ in that research participants can express a positive Attitude but researchers do not understand what influences that positive Attitude. Therefore, our analyses concentrated on understanding what influenced respondents’ Attitude, as this is more important for formulating employment policies. The first observation is that various perceptions of NHS work are influential in explaining Attitude. Professional development, negative work pressure and patient care were all associated with Attitude among the Stayers and Leavers. Professional development was consistently the most strongly related of the three to Attitude, and was the only one of the three significantly related to Attitude among Returners. So AHPs’ Attitude towards working for the NHS was positively associated with the extent to which they felt NHS work allowed them to use and develop their professional skills and careers, and positively associated with the extent to which they believed NHS work offers the chance to provide high-quality
patient care. Attitude was negatively associated with the extent to which they felt that NHS work involved understaffing and pressure. Both these last two findings are particularly the case for the Leavers, but not for the Returners. The only other variables to be consistently associated with Attitude towards working for the NHS were subjective norm and the respondent’s commitment to his or her AHP. Surprisingly, the variable ‘Belief in NHS Principles’ was not associated with Attitude. Predictors of Intention are noticeably different from, and weaker than, those of Attitude. The only work characteristic to be consistently associated with Intention to work for the NHS is professional development. These associations are the strongest among the Returners. Perceptions of NHS work as offering good opportunities for patient care are associated with Intention for the Leavers only. This might well mean that this issue is important for Leavers, and persuading them that working for the NHS will allow them to provide high-quality patient care may well be a significant factor in attracting them back. Perhaps even more notable is the role of subjective norm, for all groups, but especially for the Returners. Subjective norm seems to matter for both Attitude and Intention. This emphasizes the socially embedded nature of job/career choices. Commitment to the AHP is also strongly associated with Intention to work for the NHS, especially among the Stayers and Returners. Confidence in finding NHS work was also quite a strong independent predictor of Intention for Stayers and Leavers, but not Returners (who had already demonstrated they could find it!). This factor represents the perceived behavioural control component of TPB. There are also two other opinion variables associated with Intention. Neither of them predicts Attitude towards working for the NHS. The first is moral obligation.
Table 2 Description of respondents broken down by profession
General information Number of respondents Stayers Leavers Returners % male % BME % married or living with partner % with childcare responsibilities % with elder or other care responsibilities Mean age Age range % working full time % working part-time Mean years since qualification Mean number of full time years’ work as AHP Mean number of part-time years’ work as AHP
Total sample
OT
Physiotherapist
Diagnostic radiographer
Therapeutic radiographer
SLT
2025 907 735 318 15 5 77 43 9 39.3 21–67 58 32 16 9.5
533 199 238 78 9 2 78 46 13 41.4 22– 65 56 37 17 10.1
455 192 174 73 16 7 80 53 9 38.4 22–66 46 33 17 9.0
421 153 186 71 22 6 79 37 11 41.9 21–67 67 31 21 13.0
58 33 12 11 16 9 54 19 5 34.8 21– 63 78 16 14 10.5
558 330 125 85 13 4 75 39 5 36.3 22– 63 59 30 11 6.5
4.5
3.5
4.4
0.9
2.1
3.5
OT, occupational therapist; SLT, speech and language therapist; BME, black and minority ethnic; AHP, allied health professional
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Table 3 Results of multiple regression analyses predicting Attitude and Intention for whole sample and each group
Perceptions of NHS work Professional development Negative work pressure Patient care Lifestyle Convenience Social contact Working for low pay Having a secure job Opportunity to be in good pension scheme Opinions re-working for NHS Subjective norm Moral obligation Belief in NHS principles Confidence in finding NHS work Options other than NHS Strongly committed to AHP Demographic variables Having childcare responsibilities Having other care responsibilities Being White Living in London or South-East England Age Being married/living with partner Being male Statistical control variables Being a Leaver Being an occupational therapist Being a physiotherapist Being a diagnostic radiographer Being a therapeutic radiographer
Total sample
Stayers
Att
Att
Int
0.35 20.13 0.16
0.15
Int
0.31 20.09 0.08
20.05
0.10 20.08
0.05
0.06
0.21
0.06
0.22 0.20 0.18 20.11 0.16
Leavers Att
0.18
Int
0.33 20.26 0.25
0.19 0.06
0.14 0.20
0.11
0.25 20.15 0.29
Total adjusted R 2
N/A
0.57
0.46
0.26
0.20
0.26 0.13
0.10
0.31
0.12
0.17
0.13 0.39 0.21 20.07 0.08
20.06 0.07
20.23
0.14
20.07
20.09
20.11
N/A
N/A
N/A
N/A
N/A
0.07 0.08
0.07 0.59
0.12
Int
0.09
20.06 20.27
Att
0.10
0.05
20.10
Returners
0.49
0.47
0.57
0.43
0.56
0.43
Notes: Figures shown are beta weights. These represent the extent to which each variable makes a net contribution to explaining Attitude or Intention, independent of all the other predictor variables. Positive beta weights mean higher scores on a predictor predict higher scores on Attitude or Intention, and vice versa. Only those that are both statistically significant at P , 0.05 and greater than þ or 20.05 in magnitude are shown. The further the beta weight is from zero, the greater the change in Attitude or Intention that is associated with a unit change in the predictor. All predictor variables were entered into regression equation simultaneously. Total adjusted R 2 represents the proportion of the variance in Attitude or Intention that is explained by all the predictors together. Among the statistical control variables, one profession has to be omitted because the information would be redundant: if a respondent is in none of the professions shown, he or she must be a speech and language therapist
This is a notable predictor of Intention for all three groups. It is at its strongest for Leavers. It seems, then, that the extent to which these AHPs perceive a duty to contribute to the NHS, and guilt if they do not, may well affect their Intention, though not their Attitude. Finally, in the sample as a whole, being a Leaver is associated with lower Intention to work for the NHS than being a Stayer or Returner. This is not surprising, but again note that it is true even after allowing for their generally more negative perceptions of the NHS. Having made investments in some other arena of work and/or life, there are naturally barriers to be overcome before Leavers will contemplate returning. There are relatively few differences between professions, as shown in Table 4. Nevertheless, it is possible to discern some trends. First, there are some signs that Health Services Management Research
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Occupational Therapists’ Attitude and Intention is related to their perceptions of the opportunities for highquality Patient Care that they perceive the NHS offers. Second, for Physiotherapists and speech and language therapists, having childcare responsibilities was associated with stronger Intention to work for the NHS. Bearing in mind that this finding is not confined to Leavers, it suggests that the NHS tends to be seen as a good employer by people with such responsibilities.
Discussion Having outlined the key findings we now consider them in the context of NHS recruitment and retention policy, and the TPB. We will concentrate on factors that influence
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Table 4 Results of multiple regression analyses predicting Attitude and Intention for each of four professions
Perceptions of NHS work Professional development Negative work pressure Patient care Lifestyle Convenience Social contact Working for low pay Having a secure job Opportunity to be in good pension scheme Opinions re-working for NHS Subjective norm Moral obligation Belief in NHS principles Confidence in finding NHS work Options other than NHS Strongly committed to AHP Demographic variables Having childcare responsibilities Having other care responsibilities Being White Living in London or South-East England Age Being married/living with partner Being male Statistical control variable Being a Leaver Total adjusted R
2
Occupational therapy
Physiotherapists
Diagnostic radiographer
Speech and language therapy
Att
Att
Att
Att
0.37 20.12 0.22
Int
0.15 0.13
Int
0.37 20.21 0.14
0.15
Int
0.35 20.14
0.30
Int
0.27 20.12 0.17
0.10 0.10 0.07
20.10
0.18
0.19 0.20 0.16 20.17 0.13
0.16
0.11
0.16 0.16
0.19
0.29 0.17
0.14 20.10 0.28
0.25
0.17 0.10
0.14
0.10 0.19 0.19 0.23 20.11 0.21 0.10
20.06 20.08
20.16
20.27
20.12
20.33
20.10
20.32
20.08
20.16
0.66
0.61
0.49
0.53
0.52
0.56
0.59
0.58
Notes: Figures shown are beta weights. These represent the extent to which each variable makes a net contribution to explaining Attitude or Intention, independent of all the other predictor variables. Positive beta weights mean higher scores on a predictor predict higher scores on Attitude or Intention, and vice versa. Only those that are both statistically significant at P , 0.05 and greater than þ or 20.05 in magnitude are shown. The further the beta weight is from zero, the greater the change in Attitude or intention that is associated with a unit change in the predictor. All predictor variables were entered into regression equation simultaneously. Total adjusted R 2 represents the proportion of the variance in Attitude or Intention that is explained by all the predictors together
intended behaviour, i.e. to work for the NHS, as this component of the model is closest to actual behaviour. For both Stayers and Returners commitment to one’s AHP is the strongest single predictor of Intention to work for the NHS. This was a surprising finding in one sense as the questionnaire item was worded to reflect commitment to work in their AHP in any organization, not just the NHS. This item’s relationship with intention to work in the NHS may reflect two things. Firstly, AHPs may feel that they have relatively little choice of organization in which they can practice their work, with the NHS being the obvious employer for their skills. Secondly, when responding to this question, respondents may be interpreting the organization to be the total NHS rather than the individual Trust they work in. Given that they can conduct their work for many Trusts in the NHS they intend to work for the NHS, as a national organization, wherever that may be. Of course, this geographical spread of the NHS gives AHPs ( potentially) plenty of scope for employment if they need/wish to move around
the country. The relationship between commitment to AHP and intention to work in the NHS was weaker, but still significant, for Leavers. This suggests that Leavers think more broadly about possible employment contexts for their skills, e.g. private health care; self-employment, agency work. This seems to be reinforced by the fact that the more Leavers considered there to be other employment options than the NHS, the weaker their intention to work for the NHS. Professional development was the most important perception of NHS employment that influenced intention to work in the NHS. This factor reflected three key things: availability of appropriate training/development, career progression prospects and scope for professional autonomy. These features of the NHS were particularly influential for Returners and were likely to have been key reasons for attracting them back to NHS employment. Leavers were less influenced by this factor but it may be worthwhile for the NHS to emphasize professional development opportunities in its recruitment activity as some Leavers Health Services Management Research
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may consider NHS provision of this to be better than other employers. Perhaps surprisingly, given media coverage of the NHS, negative work pressure appears not to be a significant influence on intention. Thus, various components of this factor, e.g. workload, staffing levels, bureaucracy, do not affect intention over and above other factors. This seems to imply a widespread understanding/acceptance by AHPs within and outside the NHS that negative work pressures are part and parcel of NHS working life and that AHPs take those pressures into account when considering intention to work for the NHS. A sense of moral obligation to contribute to the NHS was significantly associated with intention to work for it for Stayers, Returners and, particularly, Leavers. However, the mean scores for this factor were never above the midpoint of the scale. This means that AHPs, in general, do not experience a strong sense of obligation to contribute to the NHS, nor guilt if they do not. However, the more that they do so the more it affects their stated intention to work for the NHS. Therefore, it is likely that a sense of moral obligation may bring people back to the NHS (or keep them in it), but it does not necessarily make them feel positive about NHS employment as they are acting from a sense of duty, e.g. working for the public, rather than private sector, or perhaps repaying investments in training made on their behalf by the NHS. This can be contrasted with the higher mean scores regarding commitment to their AHP, which reflect much more a sense of vocational calling.22 The influence of subjective norm on Intention, across Stayers, Leavers and, particularly, Returners was also noticeable. This means that individuals who perceive that significant others, e.g. family and friends, support them in working for the NHS, are more likely to intend to do so. It emphasizes the partly social nature of employment-decision-making by AHPs and suggests that factors influencing the opinions of people who are important to the AHP may also be significant. Previous work has shown that the media image of the NHS has a strong influence on people’s opinions of what it is like to work for it.9 Consequently, it would appear that the more ‘good press’ the NHS generates, the more positive the people who are important to the AHP are likely to be about the individual continuing or returning to work for the NHS. Overall, our findings suggest that, while there are a number of factors that are common to Stayers, Leavers and Returners in influencing their intention to work for the NHS, they differ in their magnitude across the three groups. In addition to those factors already discussed, specific to Leavers was the existence of childcare responsibilities. This suggests that Leavers may consider the NHS to be reasonably flexible enough in its work arrangements to consider working for it, although the link with intention was not especially strong. Finally, Leavers were also influenced by the scope for providing good quality patient care. Emphasis by Trusts of positive assessments of their clinical care, e.g. through external monitoring of performance standards, could be useful in recruitment. Health Services Management Research
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It is important to recognize that confidence that one can find an NHS job, moral obligation and subjective norm all explain a lot of variance in intention to work as an AHP for the NHS. Furthermore, they explain a lot of variance not explained by perceptions of the characteristics of NHS jobs. This is an important finding as it indicates that intentions to work for the NHS depend a lot on factors other than perceptions of what NHS jobs are like. Previous research of ours9 has emphasized that potential employees wish to see realistic job/organizational information in recruitment campaigns and the findings of this study indicate that current and potential employees recognize the realities of working life in the NHS and that it does not adversely affect the likelihood or working for it. Emphasizing professional development opportunities in recruitment would seem important, and generally attempting to influence positive public perceptions of the NHS seems important given the influence of significant others on AHPs’ intentions. However, excessive emphasis on sense of duty to work for the NHS may not be a desirable recruitment strategy overall, as it emphasizes obligations rather than positive aspects of the NHS.
Acknowledgements We thank the four professional bodies for assisting us in contacting their members, and to the Department of Health for financial and other support.
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14 Noh S, Beggs CE. Job turnover and regional attrition among physiotherapists in Northern Ontario. Physiother Can 1993;45:239–44 15 Mills A, Millsteed J. Retention: an unresolved workforce issue affecting rural Occupational Therapy services. Aust Occup Ther J 2002;49:170– 81 16 Hunter E, Nicol M. Systematic review: evidence of the value of continuing professional development to enhance recruitment and retention of Occupational Therapists in mental health. Br J Occup Ther 2002;65:207– 15 17 Von Zweck C. Becoming an employer of choice: a workplace solution to recruiting and retaining Occupational Therapists. Occup Ther Now 2003;5:12–15
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