Download - Health Services Workforce
Health Services workforce renaissance through Information Technology Infrastructure in Health
Abstract Purpose: The purpose of this paper is to develop a plausible
model that utilizes effective implementation of information
technology as a possible revival strategy in reducing attrition.
Design/methodology/approach – This study tests the
relationship between various factors acting as antecedents in
affecting the job satisfaction, commitment and intention of a
healthcare professional to stay in the job. For this purpose
healthcare professional attrition tracking survey (HATS),
carried out on a random sample of 807 respondents consisting
of doctors, nurses, paramedics and administrators was utilized.
Basic descriptive statistics and factor analysis have been
performed.
Findings – Survey data confirm that among the many factors
that are relevant to job satisfaction, six factors are
predominant. Use of information technology has been
identified as one of the factors. A highly probable theoretical
model linking worker motivation, job satisfaction and
commitment with information technology implementation for
reducing attrition has been proposed.
Research limitations – The main limitation of the research is
that the current findings cannot be applied as a generalized
framework to all healthcare organizations since the study has
been conducted only in certain parts of the country. Also the
study has been undertaken only in those organizations where
computers are used, at least on a primitive level scale say for
patient registration, billing or preparing monthly reports etc.
Further research needs to be carried out to actually evaluate
the theoretical strategy proposed in the paper.
Practical implications - In an increasingly global scenario of
decreasing healthcare human resource due to attrition it is
imperative for organizations to look for long-term strategy to
retain the employees instead of focusing on short-term
benefits like worker efficiency and performance. Although it
is well known that monetary benefits, work environment,
effective leadership, work-life balance etc can be utilized to
achieve the purpose, the ubiquitous nature of information
technology in current healthcare domain can be availed to
provide a better enduring and stable approach to increased
patient safety and quality of patient care. Better healthcare
human resource planning and management can be achieved
using information technology implementation leading to
employee empowerment, patient retention and market
leadership. The current study can be used as a foundation to
build up a framework where IT can be used as a driver for
reducing attrition.
Originality/value – While there has been extensive studies on
job satisfaction and commitments in healthcare organizations,
most have been limited either to a particular group, region or
time frame. Also there are very few studies in Indian scenario
particularly pertaining to development of strategies for
reducing attrition. For the first time a practical approach for
reducing retention and resurgence of healthcare human
resource using information technology has been explored in
this paper.
Keywords Job satisfaction, work-life balance, healthcare
professional, healthcare information technology, attrition.
INTRODUCTION
Health care industry is a labour-intensive industry. In recent
decade due to dynamic economic fluctuations throughout the
world, there has been increase in healthcare costs, regulatory
changes and healthcare staff shortages leading to healthcare
organizations undergoing changes [1, 2]. Some of these
reforms have created a tumultuous practice environment for
healthcare professionals that are affecting their work
satisfaction and practice freedom. Furthermore, there is also
an increased performance and efficiency expectations on the
workforce which has repercussions in the form of increase in
staff turnover and absenteeism leading to attrition in
healthcare industry [3-5]. Every healthcare professional is an
important stakeholder of the healthcare system and due to
advances in medical technology and the prime demand for
personalized health care more and more skilled workforce is
required. Shortage of skilled workers in hospitals leads to
decrease in patient safety and quality of healthcare services
[6]. A study using sample of nurses revealed that nurses
working in conditions of shortage of staff and support were
likely to report low quality of health care [7,8].
The main reason of attrition among health professionals in
developing countries has been debated by many authors [9-
13]. It has been noted that while opportunities for professional
training, higher salaries, perks and better living conditions act
as “pull” factors, surplus production of health personnel,
resultant unemployment, less attractive salary, high work load,
stagnation or underemployment coupled with lack of
infrastructure act as “push” factors for the healthcare
professionals to migrate. Especially the subject of job
satisfaction is particularly relevant and of interest to healthcare
organizations due to the fact that organizational and
employees‟ health and well-being rest a great deal on job
satisfaction [14]. Any healthcare manager responsible for
making decisions regarding recruitment and retention needs to
have a thorough knowledge of factors affecting the same in
order to make appropriate decisions regarding advancement,
personal growth of employees, building a good calibre of team
for quality healthcare delivery [15]. Therefore healthcare
organizations should take necessary steps to understand
attrition and address them systematically to retain trained,
knowledgeable and experienced employees. This is
particularly important because employees in a healthcare
delivery system are expected to provide quality patient care
while working in a highly stressful environment [16]. Social,
cultural and job factors all influence employees‟ behaviour
[17] and are related to job satisfaction of the individual. There
are evidences to prove that dissatisfaction with one‟s job may
result in higher employee turnover, absenteeism, and
grievances. Improved job satisfaction, on the other hand,
results in increased productivity [18]. From the employee‟s
point of view, job satisfaction reflects the benefits they might
be looking for when they take the job and on other
expectations like the desire to use their skills and abilities to
make a meaningful contribution and to be valued. In a
healthcare setting, employee satisfaction has been found to be
positively related to quality of service and patient satisfaction
[19]. A number of studies have been into job satisfaction in
the healthcare setting [20-22]. Due to the dynamic changing
environment of healthcare scenario with its diversities in
healthcare provider settings there is still there is a need to
understand job satisfaction of healthcare providers in more
detail. Many strategies have proposed for reducing attrition
among healthcare professionals [11-13]. Besides pay
packages, career level growth and co-worker relationships
were identified as major factors. Staff turnover and attrition is
a component of any industry, but its impact on a vital service
industry like healthcare needs special consideration.
The growth of medical tourism, demand for better quality
healthcare delivery due to growing aging population, and
increase in chronic disease patient population are driving the
increased adoption of information technology (IT) solutions in
the emerging markets like India, China and Brazil. These
emerging markets are expected to surpass developed countries
in innovative healthcare delivery over the next decade [23]
due to their competitive advantage in latest innovations in
medical technology. These developments are inspiring the
hospitals and healthcare organizations to move forward
towards excellence rather than survival and to fulfil the gaps
in three key areas of people, process and technology. The
current trend is to use highly integrated information systems as
a major enabler of organizational change [24] to distribute
information within and across organisations. These systems
not only impact organisations‟ business processes, structure
and performance, they also influence individuals‟
performance, job specifications, and motivation with a variety
of outcomes and secondary side effects that may be of positive
or negative nature [25]. An important study was conducted in
UK for establishing health informatics as a recognized and
respected profession in UK National Health Services [26].
Healthcare professionals trained in health informatics are able
to work in alternative healthcare facilities like Ambulatory
care centres, Rehabilitation centres, Public Health Facilities,
Home Health Agencies, Insurance Companies etc. This
overwhelming opportunity increases the job satisfaction and
adds to the job enrichment and motivation of the employees
thereby reducing attrition. The literature is filled with
examples of importance of HIT in healthcare [27-30]. There
are evidence based cases of improved patient care, reduced
waste and inefficiency in services, reduction in adverse drug
effects and medical errors [31]. However physician job
satisfaction also has important implications for quality
healthcare delivery. Healthcare professionals those who are
satisfied with their job are inspired to provide quality patient
care [32]. Hence it is a necessity for every healthcare
organization to ascertain the effect of bringing in information
technology on the work performance and motivation of its
employees.
Indian healthcare scenario has been continuously undergoing
dramatic changes in the past few years. Reports clearly
suggest that healthcare sector is going to be one of the major
sectors that would fuel the economic growth and will
contribute to the increased revenues, along with IT Services
and Education sectors in the country. The Indian healthcare
sector is poised to reach US$ 280 billion by the year 2020,
thereby contributing an expected Gross Domestic Product
(GDP) spend at a CAGR of 17% by 2012 [33]. 75% of health
expenditure is of private health expenditure [34]. Despite
being the 2nd most populous country with 70% population in
rural areas and with Indian Medical Council churning out
nearly 31000 health care professionals (excluding ayurvedic,
homeopathic doctors, health policy analysts, ambulance
drivers and the like), the physician – to- population ratio
works out to be 50-60 per 100,000 [35] leading to a shortage
of qualified medical professionals. According to the latest
press release in India dated July 19, 2011 on a study
conducted by MyHiringClub.Com, [36] healthcare sector in
India is facing a highest attrition rate of 12% among talented
employees leading to retention as a major challenge. It has less
doctors among the BRIC Nations about 6 for every 10,000
population [37]. Medical tourism is one of the major external
drivers of growth of the Indian healthcare sector. A Google
search of “India medical tourism” turns up more than two
million results. Medical tourism in India is expected to be $2
billion industry by 2012 [38]. This is adding to the existing
burden of shortage of skilled healthcare employees.
While there are reports and literature that indicate there is
greater danger of brain drain in the area of healthcare in India
due to migration and attrition among doctors, nurses,
pharmacists [9,12,13] there are no detailed studies that
explores this thought and offers an effective retention strategy
for reducing the attrition. Some of the reasons cited for
attrition in Indian public sector hospitals are expectations of
higher salaries and professional development (higher
education) abroad, lack of infrastructure, bureaucracy, lack of
recognition etc [39]. Private sectors are also abundant with
attrition. It has been observed that healthcare professionals
leave private organizations due to lack of professional
autonomy, lack of job enrichment, less scope of academic
achievement, lack of infrastructure etc [40].
Many organizations have taken number of steps to address
challenges posed by attrition by developing appropriate
strategies. Hospitals like Fortis and Artemis offer performance
based bonus [41]. Apollo Hospitals have taken many steps like
making their nurses customer custodians, performance- linked
rewards, transparent review process, building a high-
performance work teams etc [42]. Job satisfaction, motivation,
job enrichment, attrition are complicated issues that deal with
human emotions and behaviour. They need to be dealt in
stringent manner while planning for healthcare human
resource. Most of the reports regarding the same are
journalistic in nature or interviews with management that
highlight some of the strategies employed without deeper
analysis of the problem. IT has evolved in healthcare segment
in India via hospital information management systems
(HIMS), health management, clinical information
systems(CIS), clinical decision support systems CDSS),
electronic health record (EHR) etc, both in public and private
sectors. Not only have the private organizations (hospitals)
were the pioneers to adopt HIT, they have paved way for the
government to adopt IT through public – private partnerships.
With HIT undergoing great paradigm shift through initiatives
by industry and government, it is appropriate to investigate if
IT can act as a driver in controlling attrition rate in India. The
purpose of this is to analyse the factors associated with
attrition among healthcare professionals in Northern parts of
India and explore the possibility of using information
technology implementation as a strategy to control attrition.
III. METHODOLOGY
A. Data Source and Study Design
Data for this work was collected through Healthcare Attrition
Tracking Survey (HATS) a study designed by the authors to
address the issues regarding attrition among healthcare
professionals and to determine the usability of health
information technology in hospitals and healthcare centres as a
strategy to reduce attrition in India. It was conducted among
skilled healthcare professionals such as doctors, paramedics,
administrative and managerial staff in public as well as private
hospitals covering rural and urban regions of Northern India.
As the first stage a pilot survey was performed among 40
healthcare professionals from different parts of the country in
management role. This was done to get a perspective of the
employee turnover among healthcare professionals.
Following this two types of methods were utilized for data
collection.
1. Cross Sectional Survey: Parameters regarding job
satisfaction, motivation, work commitment, attrition in
healthcare sector were analysed through literature and were
utilized to develop a survey questionnaire to collect data
regarding attrition among healthcare workforce. Initially,
many healthcare organizations both public and private were
invited to participate in the survey. Among those who
responded, based on ease of convenience and accessibility, 40
hospitals were randomly selected with an equal distribution of
public/ private and rural/ urban categorization. The complete
details of the sample target and list of hospitals included for
the survey are presented elsewhere [43].
The questionnaire tool was developed by the authors,
reviewed by the experts in the field and then utilized for the
HATS. The questionnaire had 60 questions, divided into three
parts: 1) Demographic profile which included their age,
gender, education, marital status, tenure, experience and
annual income, 2) Overall perception of the work which
included their level of satisfaction, motivation, involvement
and work compatibility, and 3) Existing awareness in
information technology, attitude towards utilizing it, its
current usage and perception towards future utilization. There
were both multiple-choice and open-ended questions. This
was a self-administered questionnaire in which, after a brief
explanation of how the questionnaire was arranged,
respondents were asked to complete it based on their
interpretation.
A pre-test study was conducted on 30 respondents in a leading
100 bedded Private Hospital in New Delhi, India to test the
validity and reliability of the tool. The Reliability Test
(Cronbach alpha) on Data was 0.75%. Kaiser-Meyer-Olkin
(KMO) test was done to measure the homogeneity of variables
and Bartlett's test of sphericity was done to test for the
correlation among the variables used. The KMO value was
greater than 0.85 which is a acceptable value. The Bartlett‟s
test showed significant results for all the parts and hence the
instrument was accepted for further study. On getting quite
meritorious results of the validity, the instrument was floated
for data collection.
A convenient sample method was utilized for selecting
respondents (sample size = 2000). Doctors, paramedics,
administrative and managerial staff were interviewed. Due to
the sampling technique adopted, respondents diverged from
every age group, gender, education, marital status etc. but
were restricted only to low and middle level employees, where
the attrition is highest. Prior to providing a questionnaire to be
filled each participant was screened to determine survey
eligibility based on the following criteria:
Criteria 1 (origin): Health care professionals who are not of
Indian origin or Non–Resident Indians but undergoing special
training in India were not included as the prime focus to study
attrition among respondents trained solely in India.
Criteria 2 (Completion of Training): Respondents who have
not yet completed their training or not yet licensed or
temporarily licensed were excluded. Proxy respondents were
not permitted.
Criteria 3 (Job Satisfaction): The survey was constructed
from the following question: “Taking into consideration your
future career plans in medicine/ healthcare, would you say that
you are currently: satisfied, very much satisfied, somewhat
satisfied, dissatisfied, very much dissatisfied, neither satisfied
nor dissatisfied”. Participants who responded “don‟t know” or
“refuse to answer” were excluded from the HATS survey.
This allowed examination of potential differences in the
attitudes of the respondents towards identifying reasons for
attrition.
Finally after screening 1000 respondents were included for the
survey. The respondents were asked to indicate their response
on a five-point Likert scale from 1 (strongly agree) to 5
(strongly disagree) for the multiple choice questions. A
hospital administrator or chief medical manager was chosen as
the facilitator for the self-administered questionnaires.
The above measures allowed the investigators to examine the
factors affecting attrition, type of HIT utilized by the
respondents and to determine if adoption of HIT would help in
reducing attrition.
2. Focus Group Study: Two focus group studies, one in a
private urban hospital and another in a rural government
hospital were conducted. Each lasted for one hour with 15
professionals participating from private hospital and 9 from
public hospital. Questions regarding the reasons for staff
turnover in their organization, broad estimates of attrition rates
among doctors, nurses and administrators in their hospital,
methods used to minimize attrition, perceived barriers to
employee retention, benefits and use of information
technology in healthcare especially in their work were
included in the discussions and responses elicited. The results
were qualitatively analysed and utilized while interpreting the
quantitative data collected through survey.
During the pre-test survey it was observed that the Senior
Consultants showed a bit of enthusiasm for participating in
HATS while the junior staffs were reluctant to fill
questionnaire. Also few respondents especially the
experienced healthcare professionals did not like to mention
their salaries while the new physicians & nurses were keen to
fill the survey form. As initially some of the respondents were
reluctant to fill the form due to reasons like transparency,
being odd man out in expressing their view, not being taken
seriously, data privacy etc. in-formal discussions were
conducted by the authors and managerial staff confidence
sought before the actual HATS implementation. The major
challenge faced was to take permission from the HR
authorities to conduct the survey due to issues of transparency
of the system and its HR policies.
B. Data Analysis
Finally only 807 completely filled in questionnaires were
obtained giving a response rate of 40% out of the initial 2000
respondents selected. The data from the tool was coded and
entered into SPSS16.0 package. A random 5% sample of
responses was checked for coding errors. Wherever the data
was left uncompleted and unclear the respondents were
approached individually to recollect the data (less than 1%).
Data were analysed by means of Factor Analysis on Rotated
Factor Matrix using Principal Components Analysis (PCA) in
SPSS 16.0 package to determine the relationships between
factors influencing attrition. Descriptive statistics included
percentage rates for categorical variables, means and standard
deviations. The categorical variables considered were
demographic i.e., gender, marital status, age, education, work
nature, work experience and income.
IV RESULTS
An overall response rate of 40% was achieved in this
study with a total of 2000 questionnaires distributed and 807
responses. The following illustrates the descriptive statistics of
the various parameters considered for the HATS.
TABLE I
DEMOGRAPHIC CHARACTERISTICS OF THE RESPONDENTS
N= 807
Gender
Male 57.6% ( 461 )
Female 43.2% ( 346 )
Marital Status
Married 62.4% ( 499 )
Unmarried 38.4% ( 307 )
Practice
< 1 year 76.1% ( 609 )
> 1 year 24.7% ( 198 )
Age
17-25 18.7% ( 150 )
26-35 52.1% ( 417 )
36+ 30% ( 240 )
Education
undergraduate 11.6% ( 93 )
graduate 54.7% ( 438 )
postgraduate 34.5% ( 276 )
Nature of Work
Doctors 38.9% ( 311 )
Nurses &
paramedics 37.1% ( 297 )
Administrators 24.7% ( 198 )
Income
upto 10,000 20.5% ( 164 )
10,000-20,000 18.9% ( 151 )
20,000-30,000 26.6% ( 213 )
30,000-40,000 16.6% ( 133 )
>40,000 17.9% ( 143 )
The sample was predominantly male and the
proportion ranged 57.6 ± 0.5%. The respondents were mostly
middle-aged (52.1%) in the range 26 to 35 years and mostly
married (62.4%) living with family. Nearly 20% of the
married respondents especially male were living alone with
their family in their respective home towns. Almost two-thirds
of the participants were doctors, paramedics, nurses,
administrators who had less than a year of practice in the
current organization and also middle-aged. 54.7% of the
participants were graduates while the postgraduates were
34.5%. Undergraduates were few (11.6%). Approximately nearly equal number of doctors and nurses, paramedics
participated while the administrators were less. There was not
much difference in the number of participants based on their
income.
One of the main criteria for the respondents to be eligible to
participate in the survey was to indicate their job satisfaction
level. Based on the response to this query, the overall
satisfaction level of the respondents was analysed (Fig 1). It
could be seen that though greater percentage of respondents
were satisfied with their job equally same number of
respondents were not highly satisfied.
Further the distribution of the respondents who were
dissatisfied based on the nature of their work group,
experience, nature of the organization and its location were
determined (Table II).
% OF RESPONDENTS DISSATISFIED WITH CURRENT JOB
% Dissatisfied
Doctors 62
Nurses & Paramedics 19
Administrators 18
< 1 year Experience 78
> 1 year Experience 22
Public 43
Private 57
Urban 65
Rural 35
In order to identify and evaluate the factors behind attrition,
factor analysis was done. The Kaiser rule for number of
factors to extract was applied. Initially 10 factors were
extracted. Based on the factor loadings of the individual items
and the number of items contributing to a factor, the initial 10
factors were reduced to 6 factors. The following table
illustrates the factors that have been extracted using factor
analysis. Each question (item) in the questionnaire has been
designed to indicate a job characteristic that has been known
to contribute to job satisfaction.
TABLE III
Factor Job Item Factor
Loading Factor Name
1
Salary and financial
benefits 0.6814 Compensation
and Perks Non Financial
Incentives 0.6482
2
Policies related to
Employees 0.6699 Work Life
Balance Facilities for
Employee comfort 0.6796
Work Facilitation 0.6586
3
Sense of
Accomplishment 0.7341 Sense of
Accomplishme
nt Self Esteem 0.7186
Freedom on Job 0.6187
4
Work Overload 0.8540 Work Load
Leading to
Exhaustion
Exhaustion from Work 0.6086
Work Stress 0.6145
5
Innovation through
Automation 0.8383 Automation
and
Technology
Improvement
Information
Technology
Requirement 0.6815
Technical Support of
IT 0.7904
6
Interesting and
Motivating 0.9062 Break
Monotony of
the Work Challenge 0.6788
Skill Variety 0.7142
Based on the factor loadings, only those items
contributing to a particular factor with a factor loading of 0.6
and above have been grouped together. No one item
contributes to more than one factor. Based on the groupings of
the items for a factor, each individual factor has been named.
Percentage variance of each factor and the correlation between
each factor were also determined. Generally, the first two or
three components are expected to extract at least 50% of the
variance as a rule of thumb [44]. For the six factors identified
60% and above variance were obtained. Table IV illustrates
the variance obtained for one factor, sense of accomplishment
as an example. TABLE IV
Initial Eigen values
Component Total % of
Variance
Cumulative
%
1 2.59 59.50 59.50
2 0.93 21.44 80.94
3 0.83 19.06 100
Extraction Method: Principal Component Analysis.
Correlations within a factor were positive and greater than 0.5
indicating a cohesive relationship between the items in the
questionnaire and the particular factor. The next step involved
in analysing the effect of each independent variable on all the
factors. . For this purpose, t-statistics and Duncan‟s mean test
were utilized. In this work, the results of those variables that
had an effect on the factors are illustrated.
TABLE V
COMPARISON OF FACTORS OF ATTRITION BETWEEN MALE
AND FEMALE RESPONDENTS
Factors of
Attrition
Male ( N=
462)
Female ( N=
345)
t -
value
Mean SD Mean SD
Compensation
and Perks
3.31 1.16 3.27 1.03 0.35
NS
Work life
balance
3.32 1.15 3.08 0.98 2.24 **
Sense of
accomplishmen
t
3.03 0.92 2.94 0.83 0.97
NS
Work load
leading to
exhaustion
3.21 1.01 3.06 0.82 1.56
NS
Need for
Automation
and technology
improvement
2.71 1.43 2.46 1.16 1.84
NS
Break
Monotony of
Work
2.94 1.10 2.63 0.88 3.07 **
NS : Not Significant * Significant at 0.05 level ** Significant at
0.01 level
Comparison of the six factors of attrition (Table V) between
male and female respondents yielded significant contribution
to the two forces of attrition namely work- life balance and
break monotony of work.
TABLE VI
COMPARISON OF FACTORS OF ATTRITION BETWEEN
MARRIED AND UNMARRIED RESPONDENTS
Factors of
Attrition
Married (
N= 500)
Unmarried (
N= 307)
t - value
Mean SD Mean SD
Compensation
and Perks
3.37 1.05 3.16 1.18 1.72 NS
Work life
balance
3.33 1.08 3.03 1.07 2.71 NS
Sense of
accomplishment
3.05 0.92 2.90 0.82 1.75 NS
Work load
leading to
exhaustion
3.24 0.98 2.99 0.83 2.69 **
Need for
Automation and
technology
improvement
2.66 1.41 2.51 1.17 1.17 NS
Break Monotony
of Work
2.87 1.09 2.69 0.91 1.74 NS
NS : Not Significant * Significant at 0.05 level ** Significant at 0.01
level
The marital status of the respondents affected the workload
leading to exhaustion (Table VI). Married but divorced
respondents were not considered as a separate entity. They
were considered as a part of unmarried status.
TABLE VII
COMPARISON OF FACTORS OF ATTRITION BASED ON TENURE
OF THE RESPONDENTS IN THE ORGANIZATION
Factors of
Attrition
Upto 1 year
( N= 609 )
>1 year
( N=198 )
t
value Mean SD Mean SD
Compensation
and Perks
3.35 1.12 3.11 1.05 1.88
NS
Work life
balance
3.28 1.09 3.01 1.07 2.09*
Sense of
accomplishment
3.01 0.88 2.93 0.91 0.75
NS
Work load
leading to
exhaustion
3.13 0.96 3.19 0.86 -0.61
NS
Need for
Automation and
technology
improvement
3.12 0.98 2.77 0.77 3.62**
Break Monotony
of Work
2.87 1.07 2.61 0.86 2.33*
NS: Not Significant * Significant at 0.05 level ** Significant at 0.01
level
When the duration of time spent by the respondents in the
organization were considered (Table VII), it was found that
need for technology implementation was significant at 0.01
level while work life balance and break monotony of work
were significant at 0.05 level.
Age of the respondent and education background did not seem
to matter much when the factors of attrition were considered
except for work load (Not shown here).
Nature of the work group of the respondents (Table VIII)
considered seems to throw significant contributions to
attrition. Nearly 4 out of the 6 factors were affected. All the
four factors namely, Compensation and Perks, Work -Life
balance, Sense of accomplishment and Need for Automation
and Technology all were significant at 0.01 level.
Table VIII
COMPARISON OF FACTORS – STUDIES AMONG RESPONDENTS OF NATURE OF WORK GROUPS
( W1 = MEDICAL PROFESSIONALS , W2 = NURSING AND PARAMEDICS , W 3 = ADMINISTRATION) - DUNCAN’S MEAN TEST
Factors of
Attrition
W1
( N = 312 )
W2
( N=297)
W3
( N=198 )
F- Value
Mean SD Mean SD Mean SD
Compensation and
Perks
2.88 .84 3.03 .71 2.53 .80 11.52**
Work life balance 2.65 .78 2.80 .55 2.44 .70 7.77**
Sense of
accomplishment
2.67 .49 2.77 .49 2.6 .55 3.39**
Work load leading
to exhaustion
2.88 .81 2.94 .74 2.9 .84 .24 NS
Need for
Automation and
technology
improvement
2.17 .73 2.40 .72 2.17 .69 4.24**
Break Monotony
of Work
2.94 .83 2.92 .51 2.92 .62 .03 NS
NS : Not Significant * Significant at 0.05 level ** Significant at 0.01 level
Irrespective of the salary package (Table IX) five out of the six factors of attrition identified were significantly found to
contribute to attrition.
TABLE IX
COMPARISON OF FACTORS – STUDIES AMONG RESPONDENTS OF INCOME GROUPS
(I1 = UPTO RS.10,000/- , I2 = RS.11 – 20,000/- , I 3 = RS21 – 30,000/-, I 4 = RS.31 – 40,000/-, I 5 = MORE THAN RS.40,000/- ) - DUNCAN’S MEAN TEST
Factors of Attrition
I1 ( N = 165 )
I2 ( N=152) I3 ( N= 213) I4 ( N=132) I5 ( N= 144) F -
Value
Mean SD Mean SD Mean SD Mean SD Mean SD
Compensation and
Perks
3.00 .69 2.87 .88 2.61 .85 2.99 .77 2.9 .73 3.45**
Work life balance 2.73 .47 2.66 .68 2.57 .80 2.79 .75 2.57 .67 1.49 NS
Sense of
accomplishment
2.81 .51 2.68 .50 2.65 .56 2.83 .49 2.50 .38 4.93**
Work load leading to
exhaustion
3.01 .69 2.95 .77 2.74 .72 2.95 .82 2.95 .97 1.57**
Need for Automation
and technology
improvement
2.47 .78 2.39 .63 2.18 .75 2.24 .69 1.98 .65 5.29**
Break Monotony of
Work
3.02 .43 3.02 .63 2.97 .75 2.73 .73 2.85 .76 2.33**
NS : Not Significant * Significant at 0.05 level ** Significant at 0.01 level
Similarly when the six factors were analysed with respect to the location of the organization being rural or urban it was found
that five factors namely compensation and perks, work – life balance, sense of accomplishment, work load leading to
exhaustion, need for automation and technology improvement were affected in different extent. Similarly, two factors, namely
work load leading to exhaustion, need for automation and technology improvement were affected whether the organization is a
private or public. TABLE X
COMPARISON OF FACTORS – STUDIES AMONG RESPONDENTS BASED ON TYPE AND LOCATION OF ORGANIZATION
Factors of Attrition Urban (N=
586)
Rural
(N=221)
t - value Public (N=
318)
Private
(N=489)
t - value
Mean Mean Mean Mean
Compensation and Perks 2.98 3.60 3.82* 0.72 0.85 0.91 NS
Work life balance 2.95 3.90 2.82** 0.66 0.71 0.7 NS
Sense of accomplishment 2.85 3.38 3.06* 0.5 0.52 0.3 NS
Work load leading to
exhaustion
3.11 3.22 1.16** 0.86 0.74 2.98**
Need for Automation and
technology improvement
2.44 3.03 3.62** 1.10 0.88 3.07 **
Break Monotony of Work 2.67 3.16 0.97 NS 0.67 0.69 0.07 NS
NS : Not Significant * Significant at 0.05 level ** Significant at 0.01 level
Further the knowledge existing awareness in IT related to
healthcare, attitude of the healthcare professionals towards
utilizing it, current usage and their perception towards using
IT in future were also analysed. The following figures and
tables illustrate the results. Among the 807 respondents,
81.7% doctors, 76.8% nurses and 71.2% administrative staff
had awareness of computers out of which 68% of doctors,
51% of nurses and 60 % of administrators used computers for
their work. The percentage of healthcare professionals using
the computers was more among the males (80%), compared to
their female (73%) counter parts. Among the professionals
who were using IT for their work there was no difference
based on their education, experience or marital status.
Percentage of IT usage was higher amongst age bracket of 26
– 35 years than other age groups.
Fig 2 Percentage of Respondents using IT (Age wise distribution)
When the details regarding usage of computers was analyzed
it was seen that while greatest use of IT was adopted for
official administrative purposes, communication between
professionals and for knowledge gathering (guideline)
compared to use of hospital and health management
systems.More than 40% usage was identified for providing
prescriptions to the patients (Fig 3).
The respondents were queried regarding the importance of
implementing HIT for betterment of their work and also
probed to summarise their interest in undergoing training
regarding the same. While 60% of the respondents felt the
need of implementing technology 83% were keen on
undergoing training for the same (Fig. 4).
V. DISCUSSION AND CONCLUSION
The findings of this study have limited generalizability as it
covers only the northern part of India and the sample response
is only 40% of respondents approached. However, confirming
to the views of earlier articles that it is difficult to obtain
desired response rates from medical professionals, and it is
common to achieve lower rates in such studies, the current
findings are directly compared with some of the earlier
reports. Results from this survey demonstrated that 24% of the
respondents were dissatisfied with their job. This was less
than what has been reported in literature by many authors.
Based on the focus group discussions and on the responses to
the open ended questions provided in the questionnaire it was
understood that many healthcare professionals though not
happy with their job were not clear in their level of
dissatisfaction. When their responses to shifting jobs in near
future if opportunity arises is combined with their satisfaction
level, then the calculated proportion of respondents
dissatisfied with their job increased to that of 49%. The
doctors were more dissatisfied than nurses and administrators.
Manjunath et al [45] had conducted a study earlier among
doctors, nurses and administrators where they determined the
attrition rates to be less among doctors compared to nurses.
The difference in the current study compared to that might be
due to the difference in the type of the sample considered for
study. It has been identified in the current study that doctors
were satisfied with certain aspects of their work and
dissatisfied with other aspects. Overall, however, doctors in
the private sector were more dissatisfied (37%) than public
(nearly 20%). Since there are evidences that doctor
satisfaction may be positively correlated with their
performance [46, 47] and is an important determinant of
where they intended to work [48], these findings have
important implications for the provision, costs and quality of
health services of health care organizations. Considering the
job satisfaction among nurses and administrators, the current
findings indicate a dis-satisfaction among both nurses and
administrators. Nurse and other health care employees‟
satisfaction have been found to have several impacts on the
quality of care delivered which ultimately influences the level
of patient satisfaction [49].
Overall participants reported low satisfaction with salaries, not
being involved in decision making, doing a lot of non-clinical
tasks and not having sufficient work-life balance. Morrison, et
al. [50] outlined several ways in which the lack of engagement
and high turnover rates impact health care organizations.
Some of these factors include turnover costs, which according
to Waldman & Kelly [51] range between 3.4% and 5.8% of
their operating budget. When employees feel unsatisfied and
unappreciated they leave the organization and this puts higher
workloads and stress levels on those who remain and
ultimately further drives down satisfaction for both employees
and patients [52]. Employees‟ needs and motivators vary so it
is important to understand what motivates them to perform.
Hence it is imperative to analyse the factors that influence job
satisfaction which in turn affects attrition. Based on the factor
analysis of the responses recorded by the respondents, initially
10 factors were identified. They were further reduced into 6
major factors on the basis of the inter-correlation between the
items.
Factor 1 (Compensation and perks) refers to the providing
incentives and extra income to the doctors in terms of
benefits. There are reports that provide such examples where
the use of provider incentives and enablers has known to
increase the performance under certain conditions [53]. Such
financial incentives usually take the form of bonuses paid over
and above the physician‟s base income from fee-for-service
payments, capitation, or salary. There are difficulties
involved, since paying incentives to reduce attrition might
increase indicators of activity to be measured, crafting proper
incentives and monitoring issues. Effect of pay structure on
job satisfaction is a complicated aspect to be dealt with. In the
current study in comparable with others [54] both „salary‟ or
„salary and fringe benefits‟, are considered as one which
enhances comparability of findings. This factor was affected
by difference in the work group (Table VIII) and based on
the location of organization (Table X). This reflects the pay
disparities available among the doctors, nurses and
administrators. Even though the salary bands are higher in
urban areas compared to rural locations, the cost of living in
cities is greater and this leads to greater salary expectation in
the urban areas. In terms of practical contribution, the findings
of this study may be used as guidelines by healthcare
organizations to improve the design of pay structure. Many
factors need to be taken into consideration while doing this.
The level of pay needs to be increased equal with employees‟
contributions to their organizations, national cost of living and
in-line with industry standard.. This will help high performers
and/or employees who have family responsibilities to fulfil
necessity needs, improve standard of living and upgrade status
in society. When employees feel that their structures of pay
are adequately allocated, it may lead to higher job satisfaction,
organizational commitment and thus reduce attrition.
Factor 2 (Work life balance) is about helping employees
better manage their work and personal (non-work) time. This
refers to family friendly work arrangements and alternative
work arrangement [55]. This depends on the nature of the
work, type of the workplace and issues in the workplace.
Without proper balance between work and family life, work-
family conflict can create series of unfavorable issues,
including decreased employee performance, reduced job
satisfaction, high absenteeism, and high attrition [56]. Hectic
nature of the healthcare industry can create work-family
conflict for the healthcare workers. As a result, high turnover
rate is one of the most common problems for healthcare
facility.Introducing strategies like flexible work options,
specialized leave policies, paid maternal leave, paternal leave;
home tele-commuting subsidized exercise for fitness centre
etc. can increase the satisfaction level of the healthcare
professionals.. In a research conducted in Thailand [57]
among healthcare staff, factors like workloads, work
flexibility, and family role conflict were found to affect work
–family conflict. It was observed that personal factors like
gender, age, work position, marital status and personal income
did not affect work –family conflict. In the current study work
life balance has been identified as one of the major factors
leading to attrition. This factor does not differentiate the male
and female respondents but seem to play an important role
especially when the type of work of the respondents is
considered. Doctors and administrators who spend greater
time of the day in the hospital are affected by work life
balance issues. Any strategy to be designed should take into
consideration the different working environment of the
healthcare professionals.
Factor 3(Sense of accomplishment) is about job satisfaction
felt by the healthcare workers. This does not depend upon the
monetary issues and it deals with the sense of achievement
and fulfilment felt by the employees. Employees feel sense of
accomplishment when they feel oneness with the organization.
This happens when the organization delivery systems share
the same mission, vision, goals, objectives and strategies. A
key to build such a culture is by involving the medical staff
members to make collaborative decisions in clinical and
operational issues
[58]. Medical staff thus involved is
philosophically and economically aligned with the
organization, feel a sense of accomplishment and are likely to
make decisions that benefit the organization, thereby
benefiting the patients served by the organization. In accord
with past research [59, 60], perceived clinical freedom was
also found to be strong and positive predictor of this
dimension of job satisfaction. This reiterates the importance of
professional autonomy in practice and suggests that
restrictions to one of the core aspirations of knowledge
workers can result in adverse outcomes in a health context.
Factor 4 (Work load leading to exhaustion) and Factor 6
(Break monotony of Work) refers to the overworked health
care professionals. A negative relationship between stress and
job satisfaction (p< 0.01) was also reported as having an
important influence on turnover in the meta-analysis of
nursing turnover conducted by Yin and Yang [61]. Stress was
indicated as one of 12 variables related to turnover from the
factors included in studies undertaken in Taiwan. Though
there has been inconsistency in ranking stress as an important
factor, it has been identified as one of the factor affecting
employee turnover and hence attrition. The current findings
are somewhat similar to these. In the current findings, though
stress was not identified as a major problem in urban
hospitals, it was more prominent in the rural areas. In the
urban hospitals, though the workload is expected to be heavy
due to a greater number of patients, these hospitals are mostly
equipped with newer medical technologies which greatly
reduce the workflow for the nurses and doctors. Also there is
an availability of greater resource in terms of nurses and
doctors. As hospitals in underserved rural areas often have
higher workloads, cover large geographic areas, have lower
access to specialists, encounter problems in recruiting and
retaining clinical staff, and treat a broad array of complex
patients. The Indian public health system has a shortage of
medical and paramedical personnel. Government estimates
(based on vacancies in sanctioned posts) indicate that 18% of
primary health centres are without a doctor, about 38% are
without a laboratory technician, and 16% are without a
pharmacist. This increases the work load which further causes
exhaustion and stress. This specifies the need to improve
working conditions and the professional interface with other
health professionals and society in the rural areas.
Factor 5 (Need for Automation and Technology
Improvement) implies the requirement of HIT implementation
in the health care industry. The supply of good support,
education and training is a key approach to attracting and
retaining allied health practitioners, especially in rural
locations [62,63]. HIT enables health care professionals to
confidently access, interpret, and apply organisational
knowledge, patient care procedures, professional workforce
competencies, best practice knowledge and other skills
information in a manner that improves patient satisfaction,
achieves positive clinical outcomes, and maximises cost
savings for the organisation [64, 65]. The middle aged
healthcare professionals were more aware of computers than
the senior people. This reflects the changing times where
computer literacy is a part of medical curriculum and also to
the fact that current digital era where computers are prevalent
in every walk of life. The distribution of computer awareness
among the respondents is in line with earlier studies[66]. In
this present study irrespective of gender, age & education the
importance of implementing HIT was stressed by almost all
respondents. The nature of work done by respondents seems
to play a significant role in assigning the need for automation
and technology as a major factor of attrition. This observation
is compounded by the data collected regarding the information
technology usage statistics (Table V). The doctors seemed to
be the preferred users of computers, then healthcare
administrators and then the nurses and paramedics. Also the
difference in the salary does not seem to detract the fact that
implementation of HIT was seen as a basic requirement of
healthcare professionals. More than three-fifths of respondents
said their level of computer literacy level was "just
conversant," with nearly 30 percent "well conversant." The
fact that more than 80 % have some level of computer
knowledge is comparable to the 98 percent of physicians at
the University of Pennsylvania Medical School [67]. While
most respondents had some computer knowledge, more than
80% had no formal computer training. A 2004 study by
Banga and Padda [68] found that more than 95 percent of
health professionals surveyed desired formal training.
Maximum usage was found for teaching or learning purposes
and official work compared to utilization for healthcare
delivery inline with earlier such study. This highlights the fact
that while healthcare organizations are implementing
technology for competitive advantage, increased patient safety
and other related perceived benefits, proper focus is not
provided for training the healthcare professionals to use the
same,
Based on the above discussions we propose a theoretical
strategy where IT implementation and training can be used as
a part of the strategy to reduce attrition. Implementing IT
technology through EHR, HMIS etc and training the
professionals to use them helps to reduce work load of the
medical professionals. It also helps to create standardized
automated processes that help to reduce medical errors. By
learning new skills and gaining knowledge, burnout due to
monotonous work load is reduced. This also provides job
enrichment which further provides sense of accomplishment
to the employees. Through networking using technology and
using it to gain latest knowledge in their area, the employees
are empowered to perform well in the job. Such a learning
environment in the organization increases their commitment
towards their work and the organization leading to a reduced
attrition.
Employee Expectations
Organization Inputs
Start of Job
Compensation and perks
(Industry Standard &
work based)
IT(Proper training and usage, new
technologies)
Job Enrichment(new skill
training, job rotation)
Work Load and Stress
(Proper distribution
of work)
Self Accomplishment
(autonomy,
collaborative decisions)
Work-Life Balance
(Flexi time, leave benefits)
Net Impact of
Factors
R
E
D
U
C
E
D
A
T
T
R
I
T
I
O
N
Fig 5. Theoretical Framework for reducing attrition using HIT
In the current study, variables such as the opportunity to
develop, responsibility, patient care and staff relations were
seen to have a significant influence on job satisfaction. This is
not surprising, in that these findings are in line with the two-
factor theory proposed by Herzberg and Mausner [69], which
lists the following factors as motivators resulting in
satisfaction: responsibility, achievement, recognition and
opportunities to develop. A surprising factor that was
perceived by the respondents to increase their job satisfaction
was the implementation of information technology in their
work in the form of healthcare information technology. This
involves healthcare organizations and professionals using
hospital information systems, lab information systems,
Electronic Health Records etc. Reasons for dissatisfaction in
this study were also found to be in line with the factors
responsible for job dissatisfaction, which include salaries,
quality of supervision and working conditions. The factors
that have been identified through statistical analyses provide a
deeper understanding of the relationships between forces that
influence attrition rate. The results also provide evidence to
demonstrate that economic motivation as a factor for changing
jobs is not an independent, stand-alone factor in itself, but
rather a component of broader factors that takes into
consideration the yearning to improvise both developments in
both professional and personal front. This finding is a
departure from previous studies that indicate the intention of
healthcare professionals to frequently change jobs and
migration to foreign countries is mainly dependent on
remuneration. This may be partly because those studies did
not take into account the deeper analysis of relationships
between factors [70,71]. The supply of good support,
education and training is a key approach to attracting and
retaining allied health practitioners especially in the rural
locations. This enables health care professionals to confidently
access, interpret, and apply organisational knowledge, patient
care procedures, professional workforce competencies, best
practice knowledge and other skills information in a manner
that improves patient satisfaction, achieves positive clinical
outcomes, and maximises cost savings for the organisation
[72]. Most importantly, to address India‟s crisis in human
public health resources, increased emphasis on recruiting
candidates from rural areas, training them and enabling them
to work in these areas would be very beneficial. As it is
difficult and in many instances difficult to train each health
worker individually, the education and training of these
professionals can be done through information technology
using teleconferencing, virtual reality, chat forums and many
other technology advancements. It is high time to bring this as
a part of employee recruitment process to gain a meaningful
use. A potential solution to bridge acute shortage of healthcare
workers and reduce attrition rate is through providing
accessibility to online healthcare, which has emerged as very
important tool for offering healthcare services that can be
accessed by patients across boundaries. Online healthcare
connects patients and doctors via internet services. Online
health portals can reduce workload and streamline processes
for consultations, booking appointments, maintaining patient
health records, getting second opinions, among various other
services offered.
The main limitation of this work is that it has taken into
consideration only those organizations where at least basic
computer facilities are available. The second major limitation
is that the proposed strategy has not been supported by
evaluating information technology implementation with
attrition rate. Further work in this area is under progress.
ACKNOWLEDGEMENT
The authors acknowledge all the respondents and
administrative staff in over 40 hospitals for allowing
conducting the survey.
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