Institutional commitment and aging among allied health care professionals in the British National Health Service

Abstract

Because of a perceived decline in staff morale, the UK National Health Service has begun to routinely assess the extent to which commitment to the National Health Service may aid staff retention. While a number of studies have investigated the role of employee commitment in relation to staff turnover, no research to date has empirically tested if staff commitment to the NHS could protect job satisfaction from the effects of high job demands, and if this varies according to age. Using latent variable path analysis, this novel study examined this question among a national sample of Healthcare Professionals Allied to Medicine in the National Health Service. The results indicate that the negative effects of high job demands on job satisfaction were fully mediated by commitment to the National Health Service, but age mattered. Among the over 45s and over 55s, commitment to the National Health Service acted as an effective buffer against the negative effects of job demands on job satisfaction, but this effect was not as strong among the 35–44 age group. The broader policy implications of these findings are that age sensitive policies to support NHS workforce retention are needed. Also, pro-social institutions who employ Healthcare Professionals Allied to Medicine should develop policies for inspiring commitment to that institution, as it could help them with the demands of the job, and may even encourage more skilled workers to work longer.

Keywords

age Allied Healthcare Professionals commitment to National Health Service job demands job satisfaction mediation analysis National Health Service

Introduction

Awareness has never been higher of the need for sustained efforts to retain experienced staff working in the British National Health Service (NHS). It is an ageing workforce, as there are now 1.4 million more older workers over the age of 50 today compared to 15 years ago¹ in the United Kingdom (UK). While these demographic shifts mean a large cohort of workers may be exiting because they are reaching retirement age, there is an indication that some form of disaffection is also causing a range of professions to leave the NHS earlier than this.² Understanding why skilled and experienced staff are leaving their NHS employment before retirement has become an urgent priority for healthcare managers. The British Medical Association³ has indicated that work demands, psychosocial factors and low morale may be factors hastening the departure of staff in all age groups, not just those close to retirement.⁴ This is understandable, given the background of rising unprecedented demands for care services, lack of resources, lack of flexibility and numerous fundamental structural reforms, such as the amalgamation of urgent and emergency care services.⁵ The situation is becoming more worrying as professions such as physiotherapists who are expert in keeping people active and physically fit, are reporting that the continued rise in job demands are causing them to be concerned about their own capacity to cope with their job as they age.⁶

What makes this current research relevant and important for healthcare managers is that our sample comprises of Allied Healthcare Professionals (AHPs) who are under-researched when it comes to healthcare workforce retention literature, and yet they are the third biggest job family in health and care in England which includes (not exclusively) speech and language therapists, physiotherapists, occupational therapists, art therapists, counsellors, pharmacists and psychologists. According to Barret and Robinson⁷ (p. 19) ‘nurses and to a less extent GPs, are the focus of the overwhelming majority of studies, with scant coverage of the multitude of other staff groups’.

Because of this, there is not just a paucity of research about AHPs, there is also a gap in the literature more generally about positive models that may offer insights into staff retention, because stress or deficit models have tended to dominate the wellbeing at work literature.⁸ Moreover, we have little research evidence about the how ageing is implicated with these models. What research exists indicates that older AHPs may experience high job demands adversely because they suffer more acute pain, and are more likely to change their job because of musculoskeletal disorders or injuries, and are two-and-a-half times more likely than their younger counterparts to take sick leave.⁹ Furthermore, Radford and Chapman¹⁰ found Australian older workers, compared to younger workers, were influenced by different factors connected to retention and reported that older workers were more committed compared to their younger counterparts. Added to this, a number of research studies undertaken by Merali¹¹ indicate that NHS clinical and non-clinical managers take great pride in working for the NHS and they were committed to the altruistic values of the NHS. It would appear therefore that commitment, and job satisfaction continue to be important factors that help to retain these skilled workers.^11,12

A short survey instrument did not exist prior to this study that would enable us to capture the multi-factorial determinants of staff retention in NHS. Because of this, the researchers took this opportunity to create a brief survey instrument. One of the goals of this research was consequently to create and test such an instrument that could have the potential to be employed at a later time by other researchers interested in NHS staff’s work experiences. We hope this current research adds new insights into the role of the intrinsic, satisfying components of work to existing literature and how they relate with the negative impact of high jobs demands. Given the available related research about older health care workers,¹⁰ one would expect to find stronger commitment and satisfaction among older workers, perhaps because of their longer service. This is one of the key questions we address in this current paper.

Conceptual framework

Retention is a multi-factorial problem, and high workload or job demands, stress, work/life balance, lack of flexible working and job dissatisfaction are often cited as determinants of staff retention in NHS.⁷ Job demands broadly relate not just to the physical strains of the job, but also to psychological burden.¹³ Because professions such as physiotherapy and occupational therapy require physical effort,⁹ excessive workload, both physical and psychological, may consequently influence not only well-being of both younger and older staff, but also job satisfaction among this professional group.

Job satisfaction has been characterised as ‘a global sense of satisfaction with one’s work’.¹⁴ Jobs involving the provision of care to others such as healthcare jobs, afford particularly high intrinsic job satisfaction, something which is negatively related to leaving intentions.^15,16 Not only are those who experience high job satisfaction more likely to want to stay, but another important outcome is that job satisfaction can lead to better quality of care.¹⁷

General organisational commitment is not a new concept in NHS, as research about this topic began over 40 years ago. Porter et al.¹⁸ discovered that general organisational commitment was higher in psychiatric nurses who had no plans to leave the NHS. Later, Williams and Hazer¹⁹ investigated the relationship between general organisational commitment and job satisfaction in non-state sector health institutions and reported that general organisational commitment was more important than job satisfaction for retention, but could not find a causal link. There are also some indications that commitment to the NHS is not just a source of staff well-being, but could play a role in counteracting the negative impact of extrinsic job demands; for example, the long working days, high physical load and shortage of resources on job satisfaction, as it can bolster emotional resilience and protect against these stresses and strains, an effect found to exist among other stressful non-healthcare professions.²⁰

While there is little, if any, research evidence to date that has tested if commitment to the NHS per se has protective properties, research about staff in non-NHS healthcare organisations in India and Saudi Arabia has discovered that affective commitment or emotional attachment, could mediate or lessen the effects of perceived injustice or burnout on the turnover intentions of nurses.^21,22 Added to this comes evidence of what might build affective commitment, and the source is a study of Portuguese nurses who work in public hospitals. Freire and Azevedo²³ found that when nurses feel empowered and trusted their leaders, it strengthened their affective commitment. Furthermore, when nurses in Taiwan perceived their employer as one who demonstrated a high level of social responsibility, it also boosted their commitment towards that healthcare employer.²⁴ Commitment, unlike job satisfaction takes longer to grow, and so it is less likely to change with context.^18,19,22 Importantly, commitment to the institution such as the NHS and what it represents, may be a particularly important contributor to job satisfaction.²⁵

Further support for our conceptual model comes from outside of healthcare, and research conducted among the Norwegian teaching profession.²⁶ The study involved measuring teachers’ values and the research established that working in a profession that is trying to make a difference to society was important to them, and so value convergence or consonance (the extent to which they shared their values and norms with their schools) predicted feelings of belonging and job satisfaction. The broader implications of these findings are that commitment to any pro-social organisation, whether it be in a healthcare or an educational setting, could instill strong commitment and contribute to intrinsic job satisfaction. It has already been reported elsewhere that commitment is higher among some older workers.¹⁰ What remains untested, is if age matters in the relationship between job satisfaction, commitment and high job demands. To summarise, there is a paucity of research about AHPs in the literature, as well as our understanding of the relationship between commitment to the NHS, the psychological and physical job demands of the job and job satisfaction, and if these models differ according to age. To this end, we formulated the following hypotheses:

Research hypothesis

Hypothesis 1: NHS commitment will have a significant and positive relationship with job satisfaction for AHPs.

Hypothesis 2: Job demands will have a significant negative and direct relationship with job satisfaction for AHPs.

Hypothesis 3: NHS commitment will lessen the negative impact of job demands on job satisfaction for AHP’s.

Hypothesis 4: NHS commitment may be stronger among older AHPs.

Method

This was a cross-sectional study as measurements were taken at one point in time. The data was collected between March 2016 and October 2016. Full ethical approval was obtained from the University of Leicester (Ref: gp171-912f) and the University of Bath Ethics Committees (Ref: 14/123). As the research project involved NHS staff only, no NHS ethics approval was required. As well as attracting national respondents from England and Scotland, the sub-sample (n = 1115) included AHP staff from six NHS organisations (Trusts) providing care in community and acute care settings, who had been participating in a larger four-year project funded by the Medical Research Council (UK) entitled ‘Extending working Lives in the NHS’. Data were generated from a short web-based survey, designed using Bristol Online Survey software. The short survey contained a set of structured demographic questions on job role, job band (grade), NHS tenure, patterns of working, plans to work in NHS in the future, and whether or not the respondent managed staff.

A number of cognitive interviews had previously taken place with healthcare staff, as a preliminary pilot test of the content validity of the items, the selection of which had been already informed by established instruments (see Supplementary File for full details). The respondents in the pilot had found the questions clear and easy to understand. The agreed final set of 33 attitude statements corresponded to work and environmental conditions, such as satisfaction with the job, lack of resources, time pressures, autonomy and commitment to the NHS. The responses comprised of scores on a 5-point Likert scale, from strongly disagree (1) to strongly agree (5). An informed consent procedure was an integrated part of the web-based survey management system.

Measures

Control variables

Participants provided their job band or grade (ranging from 1 to 10), and indicated how long they had worked in the NHS, whether or not they managed staff (no (0) yes (1)), the amount of unpaid and paid overtime they normally worked in a week, gender, length of service. Any statistically significant differences found with effect sizes less than 0.01 were treated as non-noteworthy. Levene’s tests of equality of error variances in any assessment of power, suggests that partial η² values of 0.01 are considered small, 0.06 medium and 0.14 high. Initial inspection of the data and testing of means differences in the main study variables revealed only significant differences according to job banding, and this became a control variable in the main analysis.

Job satisfaction

Existing job satisfaction scales informed the choice of statements (see supplementary file). The statements aimed to tap intrinsic components of satisfaction and the characteristics of the job that were important to NHS staff. Respondents were asked: ‘I enjoy the actual work I do’; ‘I find it satisfying to care for and treat patients’; I find my job fulfilling’ and ‘I look forward to going into work’. Participants responded using a 5-point Likert scale, with anchors of strongly disagree (1) to strongly agree (5).

Job demands

Potential impacts of the psychological and physiological demands of the job informed statements about attitudes towards work rates, resources; time pressures, flexibility, role ambiguity and psychological stress. As existing scales were long, and the authors wanted to avoid a lengthy survey, 25 items were included from previous scales (see supplementary file). For example; ‘My job often leaves me psychologically stressed; there is often too much to do in the time available; my shifts are too long; ‘there are insufficient resources to do my job’, and so on. Participants responded using a 5-point Likert scale, with anchors of strongly disagree (1) to strongly agree (5).

Commitment to the NHS

Commitment to the NHS was probed through the inclusion of items reflecting the self-categorisation and belonging components of commitment to the NHS. The formulated statements were as follows: ‘I think the NHS is where I belong’; ‘I would never want to work outside the NHS’; ‘I would recommend working for the NHS to others’; if I could afford to (financially), I would leave the NHS tomorrow (reverse coded). They were asked to indicate their agreement using a 5-point Likert scale, with anchors of strongly disagree (1) to strongly agree (5).

Data analysis methodology

The authors used a random selection of 50% of cases (sample one) from the main data file to test for a suitable factor solution (a full breakdown of the exploratory factor analysis and descriptive statistics are available in the supplementary file). Having found the best solution, the remaining data provided a second data file, which was used to perform a confirmatory factor analysis see Figure 1 (CFA).

Figure 1.

Latent path analysis model.

Having confirmed that the data fitted the model adequately, the structural equation modelling command in STATA 14 was used to perform a latent variable mediation analysis. The purpose of the main analysis was two-fold: to test Hypotheses 1, 2 and 3, and also to determine how these effects may differ among age groups.

The sample was 85% female (mean age 47) and 15% male (mean age 48). The authors categorised the age variable with three groups, under 45 (0), 45–54 (1) and 55 and over.² Those who did not know about their future working intentions (n = 207) were not included in the main analysis. The CFA (measurement model) was combined with the structural models for ‘under 45s’, ‘over 45s’ and ‘55's and over’ age groups. In this current analysis, 95% confidence intervals of indirect effects were obtained with 1000 bootstrapped samples. If direct effects are found to be non-significant, this is an indication of total mediation. A path analysis provided total, indirect and direct effects in the mediation model while controlling for job banding. A goodness of fit test using the χ2 ratio, was used to yield fit indices including the comparative fit index (CFI). The root mean square error of approximation (RMSEA) was used to test how well the model fitted the population.

Results

An examination of the overall fit indices indicated the model fitted the data well, the maximum least squares estimate χ2 value associated with the model was equal to 466.580 (df, 171), p < 0.001), and null model χ2 was 6424.188 (df, 210), p < 0.001. Using these two χ2 indices, the goodness of fit values were TLI = 0.94; CFI = 0.95, RMSEA = 0.04 and SRMR = 0.05. The following section examines the results of the path analyses separately for the three age groups.

Statistical mediation was established and the total, direct and indirect effects results are in Table 1. As hypothesised, commitment to the NHS significantly and positively predicted job satisfaction, supporting H1; in under 45s (b = 0.459, p < 0.001), over 45s (b = 0.605, p < 0.001) and over 55s (b = 0.546, p < 0.001) (see Table 1). In support of H2, job demands significantly and negatively predicted commitment to the NHS in under 45s (b = −0.516, p < 0.001), over 45s (b = −0.439, p < 0.001) and over 55s (b = −0.687, p < 0.001). Also, in support of H3, the total effects of job demands on job satisfaction were mediated by commitment to NHS by 38% in under 45s (calculated by dividing indirect effect by total effect (237/0.626), by 86% in over 45s (0.265/0.308) and by 81% in the over 55s age group (0.375/0.462). This suggests that commitment to the NHS is less effective in acting as a buffer against high job demands among the under 45s age group, and most effective for the 45–54 age group (also we found the strongest relationship between commitment to NHS and job satisfaction in this age group). Lack of flexibility significantly and negatively predicted commitment in under 45s (b = −0.220, p < 0.05 and lack of flexibility effects on job satisfaction were mediated by commitment to the NHS in under 45s by 58%. Lack of resources was the most significant and negative predictor of job satisfaction among the under 45s age group.

Table 1.

Results of Mediation Analysis showing Total, Direct and Indirect effects of Job Demands on Job Satisfaction among the three Age Groups.

	Age groups
	Under 45s			45–54			55 and over
Variables	Total effects	Direct effects	Indirect effects	Total effects	Direct effects	Indirect effects	Total effects	Direct effects	Indirect effects
Job demands – commitment to NHS [H1 and H2]	–0.516***	–0.516***	No path	–0.439***	–0.439***	No path	–0.687***	–0.687***	No path
Job demands – Job satisfaction [H3]	–0.626***	–0.390**	–0.237***	–0.308***	–0.042	–0.265***	–0.462***	–0.087	–0.375***
Lack of resources – job satisfaction	0.371**	0.298**	0.073	–0.050	0.072	–0.121	0.304*	0.227	0.077
Lack of resources – commitment to NHS	0.160	0.160	No path	–0.201	–0.201	No path	0.141	0.141	No path
Commitment to NHS – job satisfaction	0.459***	0.459	No path	0.605***	0.605	No path	0.546***	0.546	No path
Lack of flexibility – job satisfaction	–0.188*	–0.087	–0.101*	–0.268**	–0.173*	–0.095	–0.106	–0.007	–0.099
Lack of flexibility – commitment to NHS	–0.220*	–0.220*	No path	–0.158	–0.158	No path	–0.182	–0.182	No path
Job band – job demands	0.105**	0.105**	No path	0.115**	0.115**	No path	0.148**	0.148**	No path
Job band – job satisfaction	0.011	–0.058	0.069*	–0.009	–0.065	0.056	0.009	–0.058	0.067
Job band – resources	0.269***	0.269***	No path	0.284***	0.284***	No path	0.311***	0.311***	No
Job band – commitment to NHS	0.029	–0.001	0.030	0.008	0.083	0.075*	0.014	0.031	–0.017
Job band – lack of flexibility	–0.186***	–0.186***	No path	–0.205***	–0.205***	No path	–0.224***	–0.224***	No path
Job Band – Job demands	0.105**			0.115**			0.148**

*<0.05; **<0.01; ***<0.001.

Our final hypothesis was that commitment to the NHS would be stronger among oldest AHPs in line with previous related research,²⁷ however the over 55s were no more committed to the NHS than the younger age groups, as no noteworthy differences in commitment to the NHS mean scores were detected. The negative effects of job demands, however, had the most negative influence on commitment to NHS among the over 55s age group. Furthermore, among all age groups, there was a significant positive relationship between job band and lack of resources, and also with job demands, and these effects grew as age increased. It appears that with seniority, comes the experience of an increasing lack of available resources and higher job demands. The effects of lack of flexibility on job satisfaction were mediated by commitment to the NHS among the under 45s and 45–54 age groups. Surprisingly, no significant relationship was found between lack of flexibility and level of commitment to NHS among the over 55s age group. Finally, a lack of flexibility had the most negative impact on commitment to NHS among the under 45s, and commitment to the NHS was the least effective as a mediator of job demands on job satisfaction among this younger group (38%).

Summary

Among AHPs, an exploratory and a confirmatory factor analysis yielded a 5-factor model with acceptable fit indices which the authors used to build a structural equation model (Figure 2). The findings revealed a positive, significant and direct relationship between AHPs’ commitment to the NHS and job satisfaction. Moreover, commitment mediated and therefore significantly lessened the negative effects of job demands on job satisfaction for all AHPs, and this was most effective among the over 45s and over 55s age groups. As job demands increased, commitment to the NHS reduced significantly in all groups, but more so among the over 55s. A lack of flexible working opportunities was not a significant predictor of commitment to the NHS, nor of job satisfaction among the over 55s.

Figure 2.

Confirmatory Factor Analysis of the Theoretical Model.

Discussion

Working in the NHS can bring with it high intrinsic job satisfaction, but it can also embody high job demands. Commitment to the NHS reduced the negative impact of job demands on job satisfaction and this worked best among the older workers and less well among the under 45s age group. These findings suggest that commitment to the NHS among AHPs, like affective commitment in non-NHS nurses¹⁸; can provide an important buffer against high job demands, and age matters. Commitment was more effective in buffering job satisfaction among the under 45s from a lack of resources, and lack of flexible working. It would seem intuitive therefore to suggest different retention strategies will be needed for different age groups.

One explanation why commitment to the NHS predicts and protects intrinsic job satisfaction could be due to value consonance, something found in non-healthcare research.²⁶ Consonance exists when employees value and believe in what they do (e.g. patient care) and work for an institution that also promotes such values. The NHS stands for a set of benevolent values, and these very values may converge with the values of those who work there. In fact, some evidence exists already that some NHS professions have a strong affinity with altruistic values.¹¹ Believing in what you are doing provides a buffer against stressful experiences, something found in research reported elsewhere.²⁰ While job satisfaction and job demands have been thoroughly researched,^9,12 there has been no explicit account reported on the nature of the relationship between job satisfaction and commitment to the NHS and job demands. Moreover, a gap exists in the literature about AHPs work experiences in general, and a short survey tool had not previously been available that can be used to test these relationships about NHS healthcare professional, until now. The survey tool yielded good data and supported the subsequent testing of our research hypotheses. Furthermore, among AHPs, not only are these three variables statistically significantly and positively related, but commitment to the NHS appears to have a special role in bolstering job satisfaction, something important when work demands are high.

Limitations

There are a number of limitations to the research. First, this was a cross-sectional study and measures taken at one point in time. Because of this, while the analysis demonstrated statistical mediation, cause and effect relationships can only be inferred. Second, the authors employed short, self-reported attitude measures and not objective behaviour measures. Third, as a convenience sample, the survey was only available to members of professional bodies and Trade Unions, and while nationally distributed, not all AHPs are members may have had access to the survey. Further studies may perform stratified sampling to ensure any new samples more fully represent the composition of AHP staff in the NHS in terms of age, job banding and gender.

Implications for practice

These findings represent new additions to the small, but growing literature about what may help to retain experienced AHPs working in the NHS. As job demand levels rose, it had the most negative impact on commitment to the NHS among the older staff. Maintaining and building commitment is important for all age groups, but efforts to reduce heavy workload experienced by the older AHPs may be most important and relevant in efforts to retain older staff. Human Resource strategies should address the lack of resources and develop better flexible working policies for the young age groups, to ensure they plan a longer career in the NHS. Reasons for leaving the NHS are complex, but by unpacking the nature of the relationship between job demands and these retaining factors, we have demonstrated that with higher commitment to the NHS, comes better protection of job satisfaction against high work demands, and age matters.

If we consider the new evidence in this paper, and the findings from research about Norwegian teachers and the nurses in Saudi Arabia, Taiwan and Portugal, we can put forward a tentative but legitimate case that employer behaviour impacts on staff commitment. Commitment can be enhanced if employees hold values congruent with their organisation; perceive their employers as being trustworthy and morally responsible, working to benefit their organisation, as well and society at large. One way, NHS organisations, the professional bodies and trade unions representing AHPs can achieve this is, is through the adoption of the recommendations of the King’s Fund, a large think tank in the UK, to champion more commitment and engagement through the clear communication of organisational values such as honesty, fairness and compassion. To do nothing may result in more AHPs making the decision to leave the NHS, taking many years of accumulated skills, experience and wisdom with them.

Supplemental Material

sj-pdf-1-hsm-10.1177_0951484820918513 - Supplemental material for Institutional commitment and aging among allied health care professionals in the British National Health Service

Supplemental material, sj-pdf-1-hsm-10.1177_0951484820918513 for Institutional commitment and aging among allied health care professionals in the British National Health Service by Deborah Roy, Andrew Keith Weyman, Reka Plugor and Peter Nolan in Health Services Management Research

Supplemental Material

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Supplemental material, sj-pdf-2-hsm-10.1177_0951484820918513 for Institutional commitment and aging among allied health care professionals in the British National Health Service by Deborah Roy, Andrew Keith Weyman, Reka Plugor and Peter Nolan in Health Services Management Research

Footnotes

Acknowledgements

We wish to thank the Medical Research Council for funding this study (Project MR/L006634/1). We gratefully acknowledge the contribution of all the respondents and employees of the participating Trusts who gave up their time to inform this study. We would particularly acknowledge the support of the UK professional bodies of Allied Healthcare Professionals who assisted us with the survey.

Data accessibility

The data set is held in a secure repository at the University of Leicester and can be accessed by contacting Professor Peter Nolan (pn54@leicester.ac.uk).

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Deborah Roy

Supplemental material

Supplemental material for this article is available online.

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