job satisfaction of therapy radiographers in the uk: results of a phase i qualitative study

Radiography (2009) 15, 146e157

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Job satisfaction of therapy radiographers in the UK:Results of a phase I qualitative study

Heidi Probst a,*, Sue Griffiths b

a Sheffield Hallam University, Faculty of Health and Wellbeing, Collegiate Crescent Campus,Robert Winston Building, 11-15 Broomhall Road, Sheffield, S10 2BP, UKb Leeds Teaching Hospitals NHS Trust, UK

Received 8 February 2007; revised 7 February 2008; accepted 12 February 2008Available online 2 April 2008

KEYWORDSRadiation therapist;Job satisfaction;Grounded Theory;Vacancy;Turnover;Intention to leave

* Corresponding author. Tel.: þ44 0E-mail address: [email protected]

1078-8174/$ - see front matter ª 200doi:10.1016/j.radi.2008.02.003

Abstract Background: Department of Health (DoH) vacancy data for radiography have beenconsistently higher than other allied health professions. In radiotherapy there has been ongo-ing concern about recruitment and retention. It is therefore useful to consider what elementsof the job and the work environment influence job satisfaction and intentions to leave in ther-apy radiographers (therapists), in order to stem any future losses from the profession.Aim: To identify and explore the current and developing roles and responsibilities of therapistsand the impact of these factors on job satisfaction.Design: An interpretive study utilising unstructured interviews with qualified practitioners wasundertaken across three radiotherapy centres in England. A Grounded Theory approach wasutilised within a case study design.Setting and participants: Three radiotherapy centres were the focus of this phase I study.Centres were geographically close but with historically different vacancy rates (based onthe DoH vacancy data). A total of 18 therapists across a range of grades and experience par-ticipated in the one to one interviews.Results: From the interviews, factors which influence job satisfaction fall under three main head-ings: job design, leadership and organisational governance, and stress or burnout. A preliminarymodel is proposed to explain how job satisfaction changes with level of responsibility (which isprimarily linked to job design and opportunities for autonomy) and job-tenure. Leadership andaspects of organisational governance (such as perceived fairness in application of departmentalpolicies) and stress or burnout appear to moderate job satisfaction and leaving intentions.Conclusion: This study provides some preliminary qualitative data to help managers designretention strategies. These strategies should initially focus on job redesign, development of ap-propriate leadership qualities in those within supervisory roles and minimising opportunities forstress and burnout. This data will be tested in a wider quantitative survey phase.ª 2008 The College of Radiographers. Published by Elsevier Ltd. All rights reserved.

114 225 4359, þ44 07870213484.k (H. Probst).

8 The College of Radiographers. Published by Elsevier Ltd. All rights reserved.

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Job satisfaction of therapy radiographers in the UK 147

Background to the current vacancy problem primary aim was to identify and explore the current and

Vacancy rates for therapy radiographers (or radiation thera-pists) have long been problematical and were reported as 17%for 2004.1 Staffing radiotherapy departments have recentlybecome easier (financial constraints and job cuts may maskcurrent shortages) but a significant problem remains.

Greater numbers of staff are required to treat increasingpatient numbers with the aging population and greaterutilisation of radiotherapy for some cancers2e4 and estab-lishments have risen faster than training outputs. Overallattrition of around 3% per annum is seen.1 Policy initiativessuch as the introduction of patient centred services, newroles and blurring of professional boundaries all have thepotential to affect job satisfaction with subsequent effectson turnover and retention.5e8

The importance of accurate staffing levels for therapistswas highlighted by Griffiths in 20009 including planning fortraining related to the constantly changing technical envi-ronment and increased cognitive task load. For example,the number of cognitive checking tasks with asymmetricfields increases by 80% compared with symmetrical fields.9

The increased cognitive load per patient carries a greaterpotential for treatment error and consequently greaterstress for the radiographers involved in treatment delivery.It is essential that further knowledge is gained about thefactors that contribute to job satisfaction to reduce turn-over. A diminished workforce has substantial effects onthe ability to provide an adequate cancer service, particu-larly the ability to meet waiting time targets. Movement ofstaff between departments is a healthy way to ensuredepartments keep moving forward with the introductionof new ideas or perspectives. However, where turnover ishigh there may be substantial costs in training and develop-ment during induction and orientation periods, and loss ofsenior staff may have a significant impact on the abilityto maintain a safe service.

Hence identifying the factors that influence job satis-faction is important. Job satisfaction is a precursor toturnover and is predictive of employee behaviour. Jobdissatisfaction can lead to employee withdrawal and vol-untary exit from the establishment.10 The variable ‘propen-sity to leave’ or ‘turnover intention’ is closely associatedwith actual turnover.10 A literature review11 identified evi-dence (some from health professions) about job design, theworking environment (including the possibility of burnout)and leadership qualities that influence job satisfaction inother fields, and informed understanding of job satisfactionand turnover intentions. No published research on radiationtherapists in the UK existed until this study into job satisfac-tion which attempts to corroborate findings from similarprofessional fields. Experiences of therapists from a rangeof backgrounds and job-tenure add to the richness andapplicability of our data which managers and policy makerscan use to inform retention strategies and their own worksatisfaction surveys.

The study

This is phase I of a multi-phase investigation into the factorsthat influence job satisfaction and turnover intentions. The

developing roles and responsibilities of therapists and theimpact of these factors on job satisfaction. The secondaryaim was to determine the characteristics of the workenvironment and conditions that can be changed toenhance work satisfaction and reduce turnover. The studyalso tried to answer the following:

1. Does job satisfaction change with grade (orexperience)?

2. Do those in specialist roles experience different levelsof job satisfaction?

3. What is the impact of the working environment on ther-apist’s intentions to leave?

4. What is the impact of critical incidents on therapist’sintentions to leave their post (or the profession)?

5. What aspects of radiotherapy work are the most influ-ential for determining job satisfaction?

A model to explain some of the aspects that contributeto a therapist’s job satisfaction (and turnover intentions)was a primary outcome.

Study design and data collection

Independent scientific review of the study at SheffieldHallam University preceded NHS ethics approval. Re-search governance approval was granted by participatingcentres and all participants gave written consent beforeparticipating.

A case study design was adopted using three geograph-ically close NHS radiotherapy departments. Two of thethree departments were in a region with historically highvacancy rates according to the Department of Health (DoH)data (for example, 11.4% for 2002), compared with a muchlower regional vacancy rate for centre 3 (for example, 5.5%for 2002).12 This difference provided an opportunity toinvestigate potential differences in work design or organisa-tional differences which may be influential (recognisingthat factors other than turnover influence vacancies).

An interpretive design was adopted, using GroundedTheory13 within the Glazer tradition14 to ensure the modelproposed was grounded in the data developed from partic-ipants. Individual comments are used to further validatethe concepts proposed.

Individual one to one unstructured interviews were heldwith participants at their workplace with interview dura-tions between 30 min and 1 h. Some questions were pre-pared in advance to serve as prompts for later interviews(see Fig. 1). Following opening questions participantswere asked to reflect on a time when they felt happy atwork. The direction of the interview was determined bythe comments made by participants and evolved as theinterview progressed (the questions in Fig. 1 were not fol-lowed rigidly and subsequent questions reflected the topicsraised by individuals).

Sampling

Staff at participating centres was invited to a presentationabout the aims of the study, and information sheets were

1. Tell me about your current post, -----current grade 2. Do you mind telling me how long you have been working as a therapy radiographer?3. Can you tell me about a time when you felt satisfied working as a therapy radiographer -

can you describe why you were satisfied? 4. What were the factors that influenced your satisfaction? 5. Is there a particular incident or time when you remember being very unhappy

(unsatisfied) as a therapist? 6. Did you ever feel demoralised at work? 7. Can you describe the relationship you have with your patients? 8. Was your contact/relationship with the patients always like this? 9. What aspects of your current role do you find most challenging? 10. How did you progress through the grades? 11. Did you have a particular ambition when you qualified in terms of what you wanted to

achieve?12. Has your career developed as you had planned? If not what has hampered your career

development?13. How do you see your career or your job developing from this point onwards? 14. What aspects of your current job do you really enjoy?

Figure 1 Sample questions for initial interviews.

148 H. Probst, S. Griffiths

disseminated. Individuals interested in participating wereasked to contact the main author so that interviews couldbe arranged. For reasons of confidentiality and anonymitythe names of the institutions and the participants areomitted but basic demographic data are provided in theresults section so that the results can be contextualised.

Initially interviews across centres 1 and 2 were con-ducted purely on volunteers who contacted the leadresearcher. After these initial interviews it was apparentthat the sample was heavily weighted towards more senior(and older) therapists so it was necessary to go back tothe field and newly qualified and general grade therapists(i.e. non-specialists) were approached to participate. Atthis stage interviews included one therapist who had leftand returned, one who was in the process of leaving aswell as three therapists who had made sideways move-ments out of radiotherapy delivery into radiotherapyplanning. We therefore sought a further participant whohad previously worked at centre 1 who had left hospitalemployment altogether as well as other younger andjunior participants.

Interviews were first conducted at centres 1 and 2 thencentre 3 was used to test the themes raised by participants.In centre 3 questioning started with open questions on jobsatisfaction as the interview progressed questioningconcentrated on the main themes identified from earlierinterviews. For example, participants were asked to com-ment on the communication process they would use if theywanted to explore changes to a current technique, as wellas how information was disseminated to them, and partic-ipants were asked specifically about circumstances whenthey (or a colleague) had been involved in a radiation error.Agenda for change had been mentioned briefly in centre 1interviews and the importance of this was tested in centre 2and centre 3 where it was identified as not a main issue togeneral job satisfaction at that time. All three centres wereof similar size with new cancer referrals in the region of5000e6500 and each with between 6e7 linacs and 2e3simulators.

Therapy radiographers were eligible for inclusion in thestudy if they were in full- or part-time employment in thedepartment. Agency staff was excluded as their jobsatisfaction may be influenced by other factors. Partici-pants included those with a range of grades and experienceand in specialist and generalist roles, those who had madesideways moves into dosimetry and those intending toleave, as well as individuals who had already left theorganisations. The sampling strategy was purposive to allowaccess to a range of perspectives; so specific individualswith different levels of experience within the organisationas well as those with experience from other institutionswere actively sought to add depth and understanding to thestudy themes. Sampling continued until no new themeswere identified in the interviews (saturation). Within laterinterviews initial themes were tested to ensure validity ofthe data and the developing model.

Trustworthiness of the data

A number of strategies were implemented to enhance thequality of the research outcomes. The period of datacollection was prolonged to ensure sufficient time for readingand reflection between interviews. A third of participants(n Z 6) were sent copies of the themes developed from theirinterview to verify these themes reflected the essence of theinterview (member checking). Peer-debriefing used two ex-perienced qualitative researchers to ensure interpretationsof the data were similar across colleagues.

Data analysis

Interviews were transcribed rapidly so that the transcriptcould be read while the essence of the interview was easilyrecalled. The narrative discussion was read several timesand open coding was used to identify incidents as theyarose in the early interviews. Through the constant com-parative method of coding, incidents were categorised

Table 2 The three main concepts identified as influentialto job satisfaction and intentions to leave

Key concept Concepts

Job characteristics Unchallenging workJob contentOpportunities for specialismOpportunities for continuingprofessional development (CPD)

Leadership andorganisationalgovernance

Empowerment (or lack of it)Being listened toRoutes of communicationLack of support fromimmediate managerInequality in the applicationof policiesWeak leadership

Stress and burnout Heavy workloadsEmotional exhaustionFearTeam support


according to their properties and were compared togenerate a theory on how therapists perceive their work.In the traditions of Glaser13 the literature on job satisfac-tion and turnover was not considered until a model hadstarted to emerge from the data. This literature was thenrelated to the emergent theory (see Ref. [11] where theliterature is discussed).

Ethical considerations

When divulging personal experiences to a third partysensitive issues can cause the emergence of emotionslong since forgotten. To ensure participants felt safe aboutdisclosing issues of personal importance the transcribedinterviews excluded names. Participants rarely becameoverly emotional and all were returned to the ‘here andnow’ at the completion of discussions.

The need to ensure a balance in power between in-terviewer and interviewee was recognised. All participantswere honest and open reflecting an appropriate level oftrust between researcher and researched. It was necessarythroughout to be aware of any potential bias associatedwith being known as a radiation therapist now working ineducation with some insider knowledge. Insider knowledgehelps understanding of key concerns, yet it was alsonecessary to be reflexive throughout to ensure personalbeliefs did not cloud themes identified.

Table 1 A breakdown of the participants by centre, gradeand job-tenure

Institution Grade Time at the institution

Centre 1 Specialist post/senior I >20 yearsSenior I e specialist 4 yearsSenior I 5 yearsSenior II 5 yearsSenior I part-time >5 years in the

process of leavingRadiographer <1 yearSuperintendent >10 years in the

process of leavingHead of department >10 years in postLeft radiotherapy 7.5 years at last job,

left approximately3 years ago

Centre 2 Superintendent >20 yearsLeft radiotherapy Sideways move into

dosimetryLeft radiotherapy Sideways move into

dosimetrySuperintendent e

specialist>20 years

Left radiotherapy Sideways move intodosimetry

Centre 3 Link grade radiographer 18 monthsSenior II 18 monthsSuperintendent e

specialist>5 years in theprocess of leaving

Link grade radiographer 8 months

Findings

A total of 18 therapists participated in the phase I study,a breakdown of these for each centre can be found in Table 1.

The sample contained all grades of therapy radiographerexcept consultant and advanced practitioner roles. How-ever, to establish the influence that specialism may have onjob satisfaction four radiographers in specialist posts wereincluded in the sample, with at least one specialistidentified at each centre. In centre 2 the sample is heavilyweighted towards individuals who had taken sidewaysmoves from the radiotherapy department into dosimetry.This may bias the results in favour of those less satisfiedwith the traditional role of a radiation therapist but mayhave advantages in identifying those aspects of the role orthe environment that led to dissatisfaction. Additionally,a total of four participants overall were in the process ofleaving (i.e. had declared notice to leave their post) or hadleft. Again this might introduce some bias as the pre-dominant themes could focus around job dissatisfaction.However, these interviews could provide substantial insightinto the key factors that may lead to turnover.

Job-tenure of participants ranged from 8 months to over20 years providing a good range of experience and knowl-edge of the job across changing roles and polices.

Key concepts

The main concepts and sub concepts that were consistentthroughout the interviews are identified in Table 2.

Job characteristics

Primarily individuals wanted work that was mentally chal-lenging, for many work had become monotonous andrepetitive as identified by the quotes from four participantsin Box 1.

Box 1. Unchallenging work

‘‘I wasn’t feeling that I was learning anything new, andI felt as though my job was becoming a bit monoto-nous, because it’s one patient after another afteranother and there’s no challenge any more and I feltlike I needed a new challenge’’ B2

‘‘It was literally like working in a factory’’ A9

‘‘. you’re not feeling particularly challenged any-more, it’s just routine, mundane .’’ A7

‘‘I wasn’t really prepared for the repetition of workingon a treatment machine and that actually didn’t reallysuit me’’ . ‘‘The job wasn’t what exactly how I’denvisaged it .. I actively sought out somewherethat did dose planning’’ B5

Box 3. Job content

‘‘I hadn’t been on Simulator since I was a student andthe boss said ‘you’re going to simulator’ and I said ‘Ohmy God’ and I got there and the first morning I justthought it was brilliant. It’s more independent thanbeing on the treatment machines; it feels like you’vegot more autonomy, although you’re being bossedaround by the doctors! Ever since, I’ve known thatthat’s where I wanted to work. I don’t like being onthe treatment sets’’ A2

‘‘It was a conscious decision to move into the clinicarea just because I became disillusioned with treat-ment. I got bored of trailing in and out of the roomall day every day and I’d always had more of a likingfor the pre-treatment side of things’’ .. ‘‘On theother side there are people that hate the pre-treat-ment side of work.’’ C3

Box 4. Job content

‘‘There’s no comparison in complexity now to what itwas even as little as five years ago e it’s got so


For some, despite their student training preparing themin part for the role they would take once qualified, someparticipants were not truly prepared for what working asa treatment radiographer would entail. The lack ofa challenge was primarily associated with repetitive work.Although, it was apparent that satisfaction with the workfluctuated with either time since qualification or time incurrent role (see Box 2). Participants commented how theirjob satisfaction had improved once they had moved upa grade where they were learning new skills and taking onchallenges they hadn’t experienced previously.

Different aspects of the job appear to motivate differentindividuals with a clear split identified between those whoenjoyed the greater variety in job content that pre-treatment roles allowed (Box 3).

The range of activities undertaken by therapists hasclearly changed with an increased emphasis on technolog-ical aspects (Box 4), with little time and emphasis (in somecentres) on patient care tasks. Technology has improvedopportunities for more targeted radiotherapy and the de-sign of the therapist’s role has been transformed as a result.Sadly for many a reduction in the patient care role isa movement away from initial desires for joining the

Box 2. Unchallenging work

‘‘I think being a different grade makes a difference toyour outlook. When you are first qualified you’re stillquite enthusiastic and think all this is wonderful,then after a few years you start to think things aren’tquite so wonderful and it gets a bit monotonous’’ A1

‘‘I think it varies in what you’re allowed to do ..they seem to let the basic radiographers, when youstart out initially, they seem to let them do a fewmore things like looking at images, but as you moveto different departments they seem to let you do dif-ferent things in different places depending on whatgrade you are.’’ C2

profession and so some misalignment may occur betweenprimary career objectives and work responsibilities leadingto dissatisfaction (Box 5). Furthermore, the need for effi-ciency and the limitations of some equipment has led tothe use of some site specialist machines where the work-load consists of primarily one or two pathologies (i.e. breastcancer treatments, for example, all being undertaken onone linac). While staff on these machines will developa level of expertise in this type of set up there is the oppor-tunity for boredom and for practitioners to feel that theirwider skill base is not being utilised (Box 5).

For some this increase in technical complexity was notalways easily justified and detracts from the time available

much more complex’’ B1

‘‘Technology seems to be leading practicality e thetails wagging the dog. We do things because we cane not because we need to but because we can’’ B1

‘‘It has become probably more technology based ..because the support networks at [names hospital] areso fantastic, I think sometimes as a radiographer youjust adapt to the role of being a technology based pro-fessional and sometimes as a result the pressures thatthere are with being so busy and there being so muchto concentrate on and deal with, that your patientskills are almost detracted from because you knowthere are support networks, which is fantastic, but Ithink there are times when you think that, becausea lot of the reasons that I went into Radiography wasto do with patient care and my interest in the technol-ogy side isn’t as great .’’ A5

Box 5. Job content

‘‘You almost felt like your skills weren’t being used,you weren’t able to do very much for the patient with-out referring them to another person, which was okfrom the patient’s perspective in one way becausethe problem was dealt with, but for you personallyyou think well, ‘I have these skills to offer, I couldhelp that person or I could do this’ but you were soconstrained by the next person has to come in .’’ A9

‘‘they seem to be more concerned about the waitinglist now with the cancer targets . which means itmakes your job harder because you’re able to spendless time with the patients and you do feel sometimesyou’re working in a factory’’ B2

‘‘Sometimes I find it just a little bit tedious, especiallynow as they’re starting to focus each machine, so onemachine might have breast patients on it all day, andafter a while you want a bit of variety in there so thatyou can keep your skills up in other areas really’’ C2

Box 6. Opportunities for specialisationor career development

‘‘Some people do get dissatisfied with the fact thatthere aren’t opportunities in those areas for them tomore permanently work in that area’’ C3

‘‘I don’t think the opportunities are there, not for usanyway, for people to sort of widen their field of expe-rience, or widen the scope of their post’’ .. ‘‘One ofthe major things is because there’s not the time to di-versify because the treatment machines, the demandson the staff that are working on them it’s horrendous,absolutely horrendous, in terms of volume.’’ B1

‘‘I reached a point of thinking ‘where do I go fromhere?’ I seriously considered leaving’’ B5

‘‘I control it basically [workload], so I suppose I man-age my own and I’ve got total say over what I doeach day .. which I suppose you get a lot of satisfac-tion out of’’ B3

Talking about being in a specialist post

‘‘I have had more autonomy to do as I want, and I’vehelped develop things as well, you don’t feel you’rejust part of the system, you are given the opportunityto think things through’’ A1


for some patient care aspects traditionally associated withthe role. This is due in part to time and waiting listpressures requiring departments to instigate efficient sys-tems so that linac activity is not delayed by patients gettingundressed or discussing problems with side effects. Tradi-tionally staff used the time to take patients into the roomas a time to orientate themselves with the patient’s currentsituation, assess side effects, and build rapport. Theseactivities have been minimised within the linac vicinity andpatients are often required to undress before entering thetreatment room and others within the multi-disciplinaryteam are employed to advise patients about eating plans,and side effects. This has a substantial effect on maintain-ing efficiency and even providing a quality patient careservice for the user, but it is at a cost to the job satisfactionof the radiation therapist. For some the drive for efficiencyhas meant reducing the work almost to a ‘conveyor belt’ ofpatients in and out of the linac room that has resulted insome deskilling of radiographers.

For some participants there wasn’t an opportunity tomake a choice about whether they wanted to specialise inpre-treatment or any other aspect of radiotherapy delivery,and this appears to cause some frustration (Box 6). The op-portunity for autonomy in the role also had some influenceon job satisfaction, with those in specialist roles identifyinggreater autonomy and subsequently greater job satisfac-tion. The opportunity for career development (or lack ofopportunity) led some to consider leaving (Box 6).

However, for many the issue was not so much careerstagnation but professional plateau that concerned andfrustrated them. For example, it was not an issue of beingstuck on a particular pay scale, or staying on a particulargrade, but more about the opportunity to continue todevelop skills in line with developing technology or newpractices. In some cases frustration centred round time forCPD activities. This was partly due to a need for mentalchallenge, continuing to learn new techniques and the need

to maintain individual marketability; with some dissatis-faction stemming from a lack of perceived time for CPDactivities. This may reflect that in the departments studiedat the time there were no clearly defined advancedpractitioners or consultants. Roles were based on tradi-tional hierarchical promotion through radiographer andsenior grades to management appointments. This linearcareer structure does not allow for individual diversificationor specialisation and there was no clear career planning tohelp individuals identify a career path, and this wasconsistent across all three centres.

Some teams could see a clear organisational vision andwere effective at making time for professional develop-ment activities. Others seemed frustrated by a lack of timeprovided for their development. These differences wereconsistent within departments so a clear cultural differ-ence seemed to exist across the centres studied. Thepositive comments in Box 7 are from different individualsfrom the same centre demonstrating a clear appreciationin this centre that the responsibility for organising timefor CPD fell to the individual. All participants from thiscentre were happy with this approach but this was not con-sistent across centres.

Opportunities for personal development seemed key tolevels of job satisfaction. The opportunity to extendknowledge and maintain mental challenge had clear re-wards in terms of job satisfaction. Participants were alsosensitive to the need to maintain their own marketabilityand where there was a lack of opportunity to utilise skillsthis was of concern, affecting satisfaction.

Box 7. Opportunities for CPD

‘‘We don’t get any study time, we don’t get any CPDtime because there isn’t enough staff. So I’ve found Ieither have to do it in the evenings or I have takenannual leave to study’’ A4

‘‘so staff development I think, certainly in my expe-rience within radiotherapy is very much self-driven.So I think people are often appointed and have todevelop within a role but aren’t given the correcthelp’’ A9

Positive experiences of CPD

‘‘You’re also encouraged to try and be on some sort ofcommittee that has to do with professional develop-ment, whether it be directly to do with patient care orrunning the department’’ .. ‘‘At the moment youhave to be a little pro-active yourself and try and lookat the weeks schedule and see when there might be anappropriate time for you to leave the set’’ C1

‘‘We’ve got a designated sheet on each machine andyou should get an hour a week off to go off set to doCPD time and then if you are involved in any groupsyou should get the time off the set to be able to go tothe meetings and things like that’’ C2

Talking about dissatisfaction withinprevious role

‘‘I felt like I was lagging behind with the informationand updating myself’’ B2

In new job

‘‘I’ve done two MSc modules now so it’s changeda huge amount and I feel as though it’s my personallearning curve. It’s definitely improved my job satis-faction’’ B2

Box 8. Empowerment

‘‘you just get to a point where you think there’s nopoint trying to say anything nothing ever gets done’’.. ‘‘if it’s something like one of your great interestsregarding whatever, that if it’s a good idea then some-times other people adopt it and it’s taken out of yourhands and it’s very difficult to get involved in thingsthat you really are passionate about .’’ A5

‘‘So if you build up a frustration or a lack of communi-cation with a person and that’s your only route of com-munication that’s quite difficult’’ A9

‘‘I still feel nothing’s changed, nothing got any bet-ter.’’ A4

Talking about feeding back concerns to the linemanager

‘‘To be perfectly honest, it doesn’t seem to havea huge effect, simply because historically we’ve beenunderstaffed. It’s just a vicious circle really, you getpee’d off, you go and have a whinge, you get a littlepat on the shoulder and things will get better bla blaso you go back and things do improve for a while, andthen you have another couple of people go off sick andthe whole circle starts again.’’ B1

Box 9. Being listened to

Interviewer e ‘‘do you feel listened to?’’

‘‘Listened to at the time, but I think nothing everchanges’’ A4

‘‘there were other frustrations, I think that everybodyfeels with management that the department had notbeen listened to.’’ A9

Examples of good engagement with staff:

‘‘It depends on the topic and issue but I’ve never feltas if nobody listens to you’’ C1


Leadership and organisational governance

In some centres participants appeared powerless to enactany change and it appeared that many had resignedthemselves to the fact that their work experience wascontrolled by those in management or issues beyond theirimmediate control (Box 8).

Participants varied in their perceived levels of empow-erment. In some centres participants were aware ofmeetings where they could raise issues that were impor-tant to them but for some there was a clear lack ofinvolvement in decision-making processes and this wasoften accompanied by feelings of ‘not being listened to’(Boxes 8 and 9).

In some centres communication streams were eitherunclear or untested so participants used terms such as

‘‘probably’’ and ‘‘maybe’’. In other centres individualsseemed to have a definite understanding of the route totake and phrases were more often ‘‘I can raise it with .(Box 10)’’.

A perceived lack of support by immediate managers hadthe potential to lead to dissatisfaction from lack ofencouragement, or feedback (Box 11).

Strong leadership and transparency in the execution ofpolicies are key to good organisational governance. Frus-tration and dissatisfaction were raised in relation to whatappeared to be inequality in promotion and CPD opportu-nities further affecting job satisfaction (Box 12).

Box 10. Routes of communication

‘‘I think I know there are systems in place for you to dothat, there are plenty of forums for you to voice yourconcerns, plenty of staff meetings .’’ A5

‘‘So if you build up a frustration or a lack of communi-cation with a person and that’s your only route of com-munication that’s quite difficult’’ A9

Examples of good communication systems:

‘‘The superintendent meeting minutes are alwayspublished so everyone in the department has accessto what has been discussed.’’ C1

‘‘We try to make sure that everybody knows exactlywhat’s happening development wise and where we aregoing, so that everyone can play a part and feed-back.’’ B3

Box 12. Inequality in the application ofpolicies

‘‘They let me put my application in and everything andI was waiting for an interview date and I got called tothe managers office to say that I couldn’t be inter-viewed because I hadn’t been qualified long enough,even though when the criteria came out I mentionedthat fact, I said ‘I haven’t been qualified long enough,does it matter?’ and they said ‘no apply anyway’ .. Iwas really upset and really angry. I felt I’d been reallybadly treated’’ A4

‘‘It always seemed to be that other people would begoing to the courses or the meetings or whatever andI felt really dissatisfied’’ B2

‘‘I think one of the problems is that if people aren’tgiving you cut and dried rules and there seems to bea rule for person A and a rule for person B, you dotend to have a bit of a problem’’ A1

Talking about the opportunity for roleextension

‘‘Rather than it being specific people it should be opento whoever’s interested in that, but I don’t think it wasreally’’ B2

Box 13. Weak leadership

‘‘You do try and see it from their perspective e theyhaven’t got an easy job, it’s not a job I’d relish, butat the end of the day we’re the ones that have to treatthe patients and we’re the ones that have to cope inthose situations. It is difficult and you do try to seetheir perspective but sometimes you get cross and


Managerial style or leadership ability was also men-tioned as having an influence on individual job satisfaction.In many cases participants acknowledged that the man-agers or leader (such as clinical superintendents) roles werenot an easy one understanding that a balancing act wasrequired to maintain equilibrium between pressures anddirectives from higher management levels and the needs ofstaff. Despite this understanding there was an element offrustration, in that it was their (management’s) responsi-bility despite the difficulties to manage difficult situations(Box 13).

Stress and burnout

Working in any service profession has the potential forstressful situations and opportunities for staff burnout;here stress was primarily related to perceived heavyworkloads (Box 14) and the absence of appropriate support.

Box 11. Lack of support

‘‘you just don’t feel supported .. I think it’s thestructure above senior I level where sometimes youdo feel unsupported, decisions are made and thingsare brought up in the department that make youthink ‘why am I bothering? Why am I trying sohard?’’’ A4

‘‘I think it’s also times when you can almost have somekind of feedback really so you know you’re doinga good job, or that your role as part of a team is work-ing’’ A9

‘‘Well that’s the problem in that my manager supportsme to my face but when we’re all together in a meet-ing or in that kind of situation things are not whatwe’ve discussed’’ A7

frustrated and think they’re not bothered, they’venot sorted it out, they’ve not made it better and that’stheir job to do that .. I feel that radiographers don’tnecessarily make good managers’’ A4

‘‘I think it’s hard for managers because they’ve alwaysgot targets to meet’’ B2

‘‘Managers are appointed with no real tangible mana-gerial skills . some managerial people that I had dif-ficulties with I think needed a lot of skills developmentto be managers’’ A9

Talking about the Superintendent team

‘‘it’s a very inexperienced team at a very difficult timewith waiting lists and high numbers of referrals andthings like that so it’s difficult to manage. That’s fine ifwe have clear direction from our management but I’mnot sure we do to be honest’’ A7

Box 14. Workload pressures

‘‘I think that’s why I left because I was stressed’’ B2

‘‘You can’t keep it up forever because it gets you a bitfed up after a while, constantly battling againsta heavy workload and not enough staff’’ A6

Box 16. Fear of making a mistake

Talking about working after an error had beenidentified:

‘‘I find the thought of having to go and work on a linacagain terrifies me’’ A5

‘‘Any mistakes that are made the pressure is muchhigher as well and because of that the staff workdifferently they feel under a lot more pressure’’ A7

‘‘I felt like I was going on to a machine which I wasworking on which I hadn’t had the right training. Ilearnt off someone else and if they were doing itwrong and you learnt off them then that starts thewhole thing’’ B2

Talking about how an error affected them

‘‘it affected me a lot. You start to doubt whetheryou’re still fit professionally to carry on’’ C1

Talking about seeing a friend going throughthe process after making an error:

‘‘It made me feel like you don’t get enough money forwhat we do! And it certainly made me think, ifsomething does go wrong that would probably dissuademe from staying in the profession’’ C2

Box 17. Team support

‘‘it was quite hectic, but you felt like you were needed


Those who seemed to cope in the heavy workload situationsmentioned the importance of good team support whereteam goals were unified. For some who had made sidewaysmoves it was apparent that stressful situations had in someway influenced the desire to leave.

For some individuals there were clear signs of burnoutand for one this had precipitated a break from the pro-fession (Box 15).

Of particular concern to some therapists was theexperience or risk of making an error. The consequencesof radiation incidents can be catastrophic and many ofthose interviewed had either experienced an incident ofsome kind or had watched a colleague go through theexperience of making an error and trying to recover fromthe emotional distress that this had caused (Box 16).

The importance of team support under stressful situa-tions cannot be underestimated. Box 17 highlights howgood team support helped them cope through stressfulperiods.

A multi-dimensional model

Considering the issues and comments identified above andhow differences in environmental factors (for example,communication routes, and leadership styles) appeared toinfluence job satisfaction across the different centresa model is proposed to explain job satisfaction and pro-pensity to leave among radiation therapists. Fig. 2 showshow satisfaction changes with time in post. Job-tenure isimportant since the opportunity for career progressionallows the relevant job changes that enhance professionaldevelopment. For example, learning new skills and takingon new responsibilities with a new grade providing thenecessary mental challenge that individuals need to retainsatisfaction in their work. Throughout this life cycle other

Box 15. Emotional exhaustion

‘‘when I got to the end of my placement there Ithought if another whinging woman whinges at meagain either I’m going to burst into tears or I’m goingto hit somebody it was that intense .. I felt asthough I’d run out of compassion almost. I could putthe smile on my face and I could do it but in my heartit wasn’t what I wanted to do.’’ A2

‘‘When you’re in it you just think this can’t happen,you can’t do it forever .. It’s almost as though youdon’t see the light at the end of the tunnel.’’ A9

job stressors and environmental factors influence levelsof satisfaction (with subsequent potential for increasingturnover intentions). The concepts outlined in the preced-ing discussing are highlighted to demonstrate the interplay

as a member of the team to be there’’ C2

Talking about how they cope through difficultperiods:

‘‘having a good team, because at that time I was onthe machine and everyone got on very well.’’ A6

‘‘There’s not a day when I don’t want to come to work.. I really enjoy my job and I think it’s the support ofmy colleagues around me’’ B2

‘‘I think a lot of moaning goes on in the rest room, butthat goes with what I was saying e everybody’s herefor the same reason e and the rest room is an areawhere you can let off steam’’ B4

Code

Job Characteristics

Leadership and Organisational Governance

Stress and burnout

Leadership style

Inequality in theapplication of policies

Lack ofcontrol

over work

Heavy workload

Limited ability to useskills

Burnout

nth

Life Cycle2nd

Life Cycle1st

Life Cycle

Qualify as therapist

Time

EnthusiasticLearning new techniques/complexitiesof the job/ taking onnew responsibility

Rotation through the department, to gain experience on all equipment

No new knowledgeobtained, job becomesmonotonous

Limited timefor patient

care

Error orincident

Promotion to senior post

Enthusiastic

Job satisfaction decreases

No new knowledgeobtained, job becomesmonotonous

Job satisfaction decreases

Specialist Post

Enthusiastic

Learning newtechniques/complexitiesof the job/ taking onnew responsibility,greater recognition,control over work

Support/perceivedlack of support

from management

Lack of trainingor lack of time

for CPD

Learning new

of the job/ taking onnew responsibility

techniques/complexities

Figure 2 A multi-dimensional model of the factors influencing job satisfaction and propensity to leave.


between the concepts and the traditional life cycle ofa therapist.

Discussion

Job characteristics

The way that roles are designed is important for em-ployee satisfaction and the need for mental challenge wasraised a number of times by participants. Hackman andOldham describe five core characteristics that contributeto the mental challenge of work activities: task identity(the extent to which an individual can see their workfrom beginning to end), task significance (the degree towhich the work is seen as important), skill variety (howmuch the role allows individuals to undertake a varietyof tasks and use their skills), autonomy (how much indi-viduals can make decisions about how to do their job),and feedback (how much the job itself provides informa-tion about how well the work has been completed).15 Inradiotherapy the need to keep waiting lists down duringa shortage of therapists has led to developments inwork flow that have potential effects on therapists’ jobsatisfaction. For example, using assistants to undertakemany administrative duties may enhance efficiency, butat a cost to the therapist in terms of the range of activ-ities undertaken. Formalised protocols can minimise treat-ment errors but may limit the opportunity for autonomouspractice. Leaving advice giving about diet and skin care to

nurses and others potentially reduces the skill base of thetherapist, reducing motivation and satisfaction. Our par-ticipants identified a reluctant acceptance of the changein their role from someone with knowledge about patientcare issues to one of a technology-based practitioner.Furthermore, operational approaches to enhance effi-ciency and drive down waiting lists such as centralisedappointment booking removes control from the workforceover their workload levels. Changes such as introducingsite-specific treatment machines (i.e. machines that pri-marily treat patients with breast cancer or patients withprostate cancer) have the potential to further reducejob satisfaction. Participants also commented on theflow of work and the ‘factory like’ conditions added tolevels of dissatisfaction.

The degree of mental challenge that practitionersexperience is influenced by the design and the extentof their responsibilities. Career progression allows thetaking on of new responsibilities and initially extendsmental challenge. Those who have been in the sameposition for a number of years may feel they have limitedopportunity for skill expansion. Janssen et al.16 indicatethat turnover intention is primarily influenced by unmetcareer expectations, and to a lesser extent by the qualityof job content. Some individuals had lacked opportunityto use higher order skills and so felt that they were get-ting left behind professionally. Those who perceive theircareer has reached a plateau are more likely to reportlower levels of job satisfaction, with links to turnoverintentions.17


Leadership and organisational governance

Empowerment means to enable and in the context of thisstudy some participants felt unable to enact any changeand did not feel part of the decision-making process thataffected their immediate work environment. Empower-ment often relates to four psychological functions of theindividual: meaning, competence, choice and impact.These four cognitions act together to develop a pro-active,positive and self-confident approach to the individualswork.18 Hence, a lack of empowerment may have a detri-mental effect on an individual’s job satisfaction and subse-quent turnover intentions.

Well-organised and clear routes of communicationappeared to enhance levels of job satisfaction in one ofthe centres studied (poor communication adding to dissat-isfaction in two centres) and this is supported by evidencein the literature.19 It is possible that positive (two-way)communication between workers and managers enhancesthe trust between both parties strengthening organisationalcommitment and subsequently job satisfaction.20,21

Organisational governance is considered important toemployee satisfaction and strong leadership and trans-parency in the execution of policies are key to goodorganisational governance.22 Fairness in promotion ordepartmental policies and strong leadership were acknowl-edged as influential factors in an individual’s propensity toleave in our study.

Themes identified from satisfied staff in a qualitativestudy of nurses in the US (n Z 30) included working ina ‘wholesome’ and ‘pleasant’ environment, with dissatis-faction created by: lack of fairness; politics and policiesbeing applied inequitably.22 Within diagnostic radiogra-phy Makanjee et al. (2006)23 found that perceived lead-ership ability correlated with staff commitment to theorganisation with subsequent effects on job satisfactionor intentions to leave.23 Kleinman (2004)24 investigatedleadership characteristics and staff turnover in nurses(n Z 75). In those who had not considered leaving therewas a greater frequency of the following: intellectualstimulation, inspirational motivation, extra effort, andeffectiveness.24

Stress and burnout

Radiation therapy is an emotionally trying profession. Thecombination of complex technology, patients with lifethreatening diseases and the use of high doses of radiationcan lead to a highly stressful work environment. The criticalnature of the treatments means that small errors can havecatastrophic life threatening effects; recent publicityhighlighted a series of radiotherapy errors and the links tostaff shortages and increasing service demands.

‘‘Over 200 hurt or killed by botched radiation’’ TheSunday Times April 30th 2006.25

The impact of radiation errors on therapist satisfaction,confidence in their professional expertise and how workloadrelates to stress or error rate is unknown; but interviews inthis study highlighted the anxiety associated with the risk ofmaking a radiation error. Moral distress has been identified

in 50% of nurses who had experienced an adverse clinicalevent.26 Our study identified elements of stress that had ledindividuals to take either sideways moves into dosimetry orhad led them to leave the profession.

Janssen et al.16 found that mental work overload washighly correlated with emotional exhaustion that in turncorrelated with turnover intention. Within the unique ra-diotherapy environment increasing technological demands,task complexity and task load may influence levels of emo-tional exhaustion and subsequent turnover.27,28

Burnout has been studied in both Canadian and UStherapists. In the US study (n Z 1200) levels of emotionalexhaustion were significantly higher than the Maslach Burn-out Inventory (MBI) norms29 with indication that burnoutwas influenced by workload. In a Canadian study theselevels were lower than the US findings but still higherthan the MBI norms.30 Our data indicated that some staffwere concerned about workload levels and emotional ex-haustion was apparent in at least two of the participantsstudied. It is unclear at this time how widespread burnoutis in UK therapists and there is a need for further study inthis area.

Conclusions and recommendations

Retention strategies should initially concentrate around thethree main areas identified:

1. Job characteristics,2. Leadership style and organisational governance,3. Job stressors.

From the interview data strategies to enhance jobsatisfaction (and hence reduce turnover intentions) shouldfocus on:

� Career planning: coordinating individual aspirationswith CPD opportunities. Reducing professional plateaupotential by providing adequate job rotation.� An organisational culture that supports CPD: provision

of infrastructure to support continual learning. Visibil-ity of individuals who engage with CPD as role modelsand regular CPD road shows from educational partnersmay also influence cultural change.� Inclusive policies for development work: ensuring all

staff have the opportunity to participate in a workingparty to improve an element of service delivery canencourage organisational commitment with natural cor-ollaries on job satisfaction.� Job redesign: considered moves to provide a more bal-

anced approach to efficiency initiatives may be neededto broaden opportunities for skill use in patient care forthose staff who enjoy this element of the work.� Leadership skills: clinical supervisors and those in first

line management positions need to have appropriatemanagerial and leadership training: in some cases theseskills were perceived as lacking.� Communication strategies: transparency and two-way

communication are essential for staff to feel supportedand to ensure a trusting relationship between managersand staff. In some centres there was a lack of clarity


around lines of communication or the best ways to raiseideas or concerns. Supplementary web based communi-cation allows staff to access information at a convenienttime or raise questions without long periods away fromtheir work to attend meetings. It may be appropriate insome circumstances to introduce an advocacy system torebalance power between departmental managers andother members of the staff group. Efforts to improvetrust between managers and workers should also beconsidered.� Burnout: levels of burnout in UK therapists are unknown

and further work is required.

Follow on work will attempt to test the model proposedand assess the importance of the main issues identified.

Conflict of interest

The authors have no conflict of interest.

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job satisfaction of therapy radiographers in the uk: results of a phase i qualitative study

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