Incentives for improving human resource outcomes in health care: overview of reviews

Abstract

Objectives

To review the effectiveness of financial and nonfinancial incentives for improving the benefits (recruitment, retention, job satisfaction, absenteeism, turnover, intent to leave) of human resource strategies in health care.

Methods

Overview of 33 reviews published from 2000 to 2012 summarized the effectiveness of incentives for improving human resource outcomes in health care (such as job satisfaction, turnover rates, recruitment, and retention) that met the inclusion criteria and were assessed by at least two research members using the Assessment of Multiple Systematic Reviews quality assessment tool. Of those, 13 reviews met the quality criteria and were included in the overview. Information was extracted on a description of the review, the incentives considered, and their impact on human resource outcomes. The information on the relationship between incentives and outcomes was assessed and synthesized.

Results

While financial compensation is the best-recognized approach within an incentives package, there is evidence that health care practitioners respond positively to incentives linked to the quality of the working environments including opportunities for professional development, improved work life balance, interprofessional collaboration, and professional autonomy. There is less evidence that workload factors such as job demand, restructured staffing models, re-engineered work designs, ward practices, employment status, or staff skill mix have an impact on human resource outcomes.

Conclusions

Overall, evidence of effective strategies for improving outcomes is mixed. While financial incentives play a key role in enhancing outcomes, they need to be considered as only one strategy within an incentives package. There is stronger evidence that improving the work place environment and instituting mechanisms for work-life balance need to be part of an overall strategy to improve outcomes for health care practitioners.

Keywords

workload human resources outcomes

Introduction

Discussions about human resources in health care have intensified around the globe due to shortages of some types of health care workers plus distributional imbalances by geography, sex, occupation, and institution.^1,2 These emerging trends require new strategies to attract and retain a productive and motivated health workforce to where they are most needed.³ While financial incentives such as higher wages, loans, and bonuses have been, and will continue to be, an integral component of employment contracts, nonfinancial incentives including work autonomy, clarity of roles, workload management, flexibility, work-life balance, child care, and support for career and professional development are important for improving the management of human resources.² Incentives are tools that employers can utilize to design an organizational incentives package and for planners to develop strategic plans for human resources.

There has been much discussion and research into the links between both financial and nonfinancial incentives and human resource outcomes: recruitment, retention, job satisfaction, absenteeism, turnover rates, and the intent to leave or continue practice. There has, however, been no review of this literature. Identifying and understanding the most effective strategies for improving outcomes is complex. Incentives suitable for urban communities, for instance, may not be appropriate for rural and remote communities.⁴ Incentives may need to be tailored to different generations,^5,6 work contexts and settings, and types of health care workers. Moreover, the mix and effectiveness of incentives is influenced by labor market conditions and the organization of professional groups (such as union coverage) amongst other factors. Employers and planners may also face challenges related to the availability of both human and financial resources when developing incentives.²

This overview of reviews was conducted to identify and highlight financial and nonfinancial strategies for improving health workforce outcomes to support evidence-based recruitment and retention strategies.

Methods

Search strategy

An overview of reviews (Cochrane reviews, systematic reviews, narrative reviews) of financial and nonfinancial incentives and their effectiveness to improve human resource outcomes was conducted.⁷ We developed the search terms and search parameters in consultation with a human resources manager responsible for recruitment and retention for a large health care organization and a research librarian proficient with health care databases, who executed the search strategy.

The following incentives were used as search terms : salary; wage; bursaries/scholarships; pensions; pensions; subsidies/allowance; child care; travel; loan repayment; educational loans; insurance (e.g. life and health); benefits, holiday/vacation; study leave; professional development; job security; flexible work environments; flexible scheduling arrangements, earned days off, career advancements; laddering; practice relief; recreational facilities; coaching/mentoring; leaves of absence including parental compassionate, terminal care, pressing necessity, and other leaves; paid overtime; leadership development opportunities; recognition of work; staffing models; professional autonomy; manageable workload; onsite childcare and professional supports. The outcome measures included in the search were: recruitment; retention; motivation; turnover; intent to leave; engagement; productivity; absenteeism; and satisfaction. The search was conducted to capture different contexts (demographics and workforce dynamics). Databases searched covered 2000–2012 and included MEDLINE (Ovid); Embase; CINAHL; Cochrane Database of Reviews; PsycINFO; Evidence-Based Medicine Reviews; ABI Inform Trade & Industry; and Business Source Complete. A hand search of the health systems evidence repository of the McMaster Health Forum was also conducted. The full search strategy is available online.⁸

Assessment for inclusion

The assessment process for inclusion was multistaged. In Stage 1, abstracts were downloaded into a reference database and duplicates removed. Each abstract was independently screened by three readers for eligibility according to the following criteria: identification of regulated or unregulated health care providers; English or French language; published between 2000 and 2012; reviews relating to Canada, the United States, or publicly funded health care systems similar to Canada (e.g. New Zealand, Australia, United Kingdom, Sweden, Denmark, France, Germany, Finland, and Norway); inclusion of one or more financial or nonfinancial incentive and inclusion of one or more human resource outcomes; and peer-reviewed.

Differences in agreement amongst readers about inclusion were resolved. Reviews that met the inclusion criteria were then retrieved (Stage 2) and read by two researchers to determine eligibility using the same inclusion criteria as used during the abstract screening. Reading of the full reviews led to the exclusion of a number of reviews as they did not meet criteria. Differences in agreement between researchers were resolved and the remaining reviews advanced to Stage 3 where they were rated independently by two researchers for methodological quality using the Assessment of Multiple Systematic Reviews tool.⁹ This is a validated tool composed of 11 criteria (such as if the scientific quality of the included studies was assessed and documented, was a list of included studies provided, and were potential biases evident/declared). Reviews scoring five or higher were considered of moderate or high quality and included in the overview.

Data extraction

Two reviewers sequentially extracted data from the included reviews using an extraction sheet that captured details of each review’s aim, details of the search, number, and designs of studies included in the review, countries represented, providers, settings (e.g. acute care, primary care), and conclusions. The second extractor reviewed the first extractor’s data and validated and complemented the information as needed.

Results

Incentives identified in the reviews

Figure 1 displays the number of abstracts or reviews at each stage and reasons for exclusion. A meta-analysis was not performed as not all reviews reported on quantitative findings. Table 1 displays the characteristics of the reviews relevant to workforce incentives. Often incentives were part of a larger discussion of variables that have an impact on human resource outcomes (e.g. job stress) or discussed within the wider context of workforce incentives and an array of outcomes (e.g. patient outcomes or clinical practice).^10–12

Figure 1.

Process of reviewing abstracts and reviews.

Table 1.

Characteristics of reviews.

First author, year	Focus of review	Details of search	Description of studies	Countries represented	Description of providers in studies	Type of settings in studies	Main Results
Butler, 2011	Impact of hospital nursing staff models on patient and staff outcomes	1977–2009 databases not reported	Total studies: 15	Corresponding author: Ireland	Hospital nursing staff (RNs or equivalent, licensed practical, or equivalent, unlicensed assistive personnel or equivalent)	Hospitals (acute, nonacute, all sizes, teaching, and nonteaching, and public and private	Interventions relating to hospital nurse staffing models may improve some staff-related outcomes. In particular, primary nursing and self scheduling may reduce staff turnover.
Butler, 2011		1977–2009 databases not reported	Individual studies include: RCT (n = 8); controlled clinical trials (n = 2); controlled before/after (n = 5)	individual studies include: Australia, Netherlands, USA, Canada, England
Buykx, 2010	Retention strategies for health workers in rural/remote areas in Australia	2000–2009	Total studies: 14	Corresponding author: Australia	Doctors, nurses, multidisciplinary, hospital administrators, allied health	Rural/remote areas (not specified)	There is inconclusive evidence that financial incentives are the most important factor in the decision to remain in rural/remote areas. The authors found evidence that nonfinancial incentives such as adequate relief, autonomy, and child care/family supports influence retention. There is supporting evidence for the use of strategies that “bundle” retention incentives rather than relying on one strategy alone.
Buykx, 2010		Seven databases	Individual studies include: evaluations (n = 6), review articles (n = 8)	Individual studies include: USA, Australia, Canada, Japan, New Zealand, Africa (other countries not specified)		Rural/remote areas (not specified)
Chenoweth, 2010	Evidence-based factors supporting recruitment and retention of nurses in aged and dementia care	1990-2008	Total studies: 25	Corresponding author: Australia	Dementia and aged care nurses (registered, enrolled, licensed, practical, director of nursing, advanced practice)	Aged care settings (acute, residential, community)	Developing a family-friendly, learning environment that values its staff is important for recruiting and retaining nursing staff. Some successful nurse recruitment and retention strategies include: careful selection of student nurse clinical placements and ongoing supervision and education; training for new and existing nurses; increased autonomy; pay parity across health settings; and family friendly policies. There was less evidence that skill mix or work load impact health human resources outcomes such as absenteeism and nurse retention. It is more effective to combine different strategies rather than relying on a single incentive.
Chenoweth, 2010		12 databases	Individual studies include: not reported	Individual studies include: Australia, UK, USA, Sweden, Canada, Finland (other countries not specified)		Aged care settings (acute, residential, community)
Davey, 2009	Predictors of short-term absences of staff nurses working in hospital settings	1986–2006	Total studies: 14	Corresponding author: Canada	Nurses (registered, licensed practical, ICU, general, new)	Acute care hospitals	There is inconclusive and mixed evidence on the association between absenteeism and several workforce incentives including pay, staffing levels, work responsibilities, and role ambiguity. One exception is the significant negative influence of a part-time staffing ration and absenteeism. More research is needed on these linkages.
Davey, 2009		10 databases	Individual studies include: prospective studies (n = 7); others not reported (n = 7)	Individual studies include: USA, Canada, Netherlands, Israel (other countries not specified)	Nurses (registered, licensed practical, ICU, general, new)	Acute care hospitals
Dolea, 2010	Effectiveness of intervention strategies to attract and retain health workers in remote and rural areas	1995–2009	Total studies: 27	Corresponding author: Switzerland	Health providers	Rural/remote settings (not specified)	Rurally oriented medical education programmes, professional support and financial incentives (e.g. allowance, scholarships/loan repayment programs) positively influence the decision of graduates to practise in rural areas.
Dolea, 2010		3 databases, websites	Individual studies include: longitudinal cohort (n = 5); retrospective (n = 3); pre and post (n = 5); control (n = 1); cross-sectional observation (n = 12)	Individual studies include: Australia, Canada, Japan, New Zealand, USA, Africa, Latin America, south-eastern Asia	Health providers	Rural/remote settings (not specified)
Hodgkinson, 2011	Evaluation of nursing models in residential aged care designed to reduce negative and improve positive outcomes for residents	1989–2007	Total studies: 2	Corresponding author: Australia	Nurses (registered and enrolled), personal care attendants	Aged care settings (residential, subacute, and extended)	There is some evidence to suggest that a primary-care model is preferred by staff over team nursing; however, there were no significant improvements in staff outcomes (i.e. job satisfaction, absenteeism, and turnover).
Hodgkinson, 2011		Six databases	Individual Studies Include: Interrupted time series (n = 1), Controlled before-and-after (n = 1)	Individual studies include: Canada, Netherlands	Nurses (registered and enrolled), personal care attendants	Aged care settings (residential, subacute, and extended)
Hunter, 2002	The influence of continuing professional development on enhancing the recruitment and retention of occupational therapists	1990–1999	Total studies: 13	Corresponding author: not reported	Occupational therapists, clinical specialists	Hospitals, not reported	Recruitment and retention of occupational therapists is influenced by a combination of personal and professional factors (e.g. autonomy, opportunities to develop skills, and salary). There is insufficient evidence to conclude that continuing professional development alone increases recruitment and retention.
Hunter, 2002		3 databases, 1 bulletin	Individual studies include: not reported	Individual Studies Include: USA, UK	Occupational therapists, clinical specialists	Hospitals, not reported
Lee, 2008	The determinants of front line nurse managers’ job satisfaction	1990–2006	Total studies: 14	Corresponding author: Canada	Frontline nurse managers (nurses in leadership roles responsible for managing a nursing unit or team, and having direct supervision of staff nurses in a healthcare organization)	Healthcare organizations	Strategies that address autonomy, workload, increasing organizational support for managers, and empowering managers to participate in decision-making improve job satisfaction for nurse managers.
Lee, 2008		10 databases, 4 journals, 7 websites	Individual studies include: quantitative (n = 12); mixed methods (n = 1); qualitative (n = 1)	Individual studies include: USA, Canada, Hong Kong , UK		Healthcare organizations
Patterson, 2010	The relationship between human resource management (HRM) and individual and organizational outcomes	1996–2006	Total studies: 10	Corresponding author: United Kingdom	Health professionals	Not reported	Human resource management methods can be used to support organizational change. Work design practices that enhance employee autonomy and control positively influenced job satisfaction, absence, and health. Involving employees in the design/implementation of changes that affect their work is an effective strategy for enhancing HHR outcomes including job satisfaction. Incorporating training to support implementing change was emphasized.
Patterson, 2010		20 databases	Individual studies Include: experimental (n = 2); prospective (n = 8)	Individual studies include: UK, USA, Denmark, Sweden, the Netherlands	Health professionals	Not reported
Salt 2008	Organization retention strategies for new graduate nurses	1979–2006	Total studies: 16	Corresponding Author: Canada	NGNs, registered nurse residents, registered nurse interns, registered nurse externship, preceptors, managers, patient care directors, experienced nurses	Hospitals	Four types of retention strategies were implemented to increase retention rates for NGN. Implementing a retention strategy is effective for increasing retention rates of NGNs. The most successful retention rates were linked to a preceptor program model with an NGN focus and a program length of 3 to 6 months, while strategies implemented for less than 3 months were least successful.
Salt 2008	Organization retention strategies for new graduate nurses	11 databases, 8 research web sites, reference lists of key selected articles	Individual studies include: one-time experimental case study design (n = 9); one-group pretest-posttest design (n = 3); nonrandomized control group pretest-posttest design (n = 3); static group comparison design (n = 1)	Individual studies include: USA		Hospitals
Van Ham 2006	The factors that influence job satisfaction of general practitioners	1990–2006	Total studies: 24	Corresponding author: not reported	General practitioners	Not reported	Job satisfaction for general practitioners is increased by work diversity, relations and contact with colleagues, and being involved in teaching medical students. The main factors that decrease job satisfaction include low income, too many working hours, high workloads, and lack of recognition.
Van Ham 2006		Four databases, reference lists	Individual studies include: not reported	Individual studies include: not specified	General practitioners	Not reported
van Wyk 2010	The effects of preventative staff-support interventions for health workers	1983–2008	Total studies: 10	Corresponding author: South Africa	Nurses of various ranks (from nurse managers to nursing aides) , mixture of health professionals, healthcare team as a unit	Tertiary, secondary, various settings including tertiary, secondary, residential, community, referral	There is strong evidence to support the effectiveness of an intensive, long-term stress management training intervention on reducing job stress and risk of burnout among a wide range of health workers in various settings. However, insufficient evidence was found to conclude that stress management training interventions positively affected job satisfaction and absenteeism over the short and medium term.
van Wyk 2010		Seven databases	Individual studies include: RCTs	Individual studies include: USA, Canada, Taiwan, Japan (other countries not specified)
Zangaro, 2007	The relationship between autonomy, job stress, and nurse-physician collaboration on job-satisfaction among registered nurses	1991–2003	Total studies: 31	Corresponding author: USA	Staff nurses	Hospitals, specialty facility, multiple sites	There is supportive evidence that good collaboration between nurses and physicians and fostering autonomy in improves job satisfaction for nurses.
Zangaro, 2007		Seven databases	Individual studies include: not reported	Individual studies include: England, USA, Canada, Australia, Taiwan, Sweden, Israel, Hong Kong, Scotland, United Kingdom	Staff nurses	Hospitals, specialty facility, multiple sites

HGNs: new graduate nurses.

The incentives were separated into financial and nonfinancial. Nonfinancial incentives were categorized as: positive work environments; supports for career and professional development (e.g. promotional opportunities, clinical supervision, and education programs); and work design (e.g. staffing models, employment status, and collaboration). While a range of human resource outcomes was included in the search strategy, the following are those that were discussed within the included reviews.

Effectiveness of financial incentives

There were mixed results from the use of financial incentives. Financial incentives may have a positive influence on job satisfaction and recruitment of health care providers but may not be as relevant for retention.^11–13 Higher wages appear to have a positive influence on job satisfaction and potentially aid in the recruitment and the initial stages of retention.^12,14 However, there is evidence that the effectiveness of financial incentives on employee retention declines after five years.¹⁵ Moreover, financial compensation is not necessarily the most effective strategy for retaining nurses compared to other factors such as a positive work environment.¹⁶

One important relationship is the linkage between financial compensation, scholarship schemes, benefits and loan repayments, and recruitment among health care providers in rural and remote areas.^13,15 In particular, these factors are important elements within an incentives package for recruiting medical students and physicians to rural or remote communities.¹⁵ However, there is less evidence that financial incentives are an important factor in their retention.¹³

Effectiveness of nonfinancial incentives

Work environment

The work environment includes components such as workload, level of professional autonomy, the availability of clinical and social supports, and work-life balance. The most promising strategies for improving job satisfaction and retention are related to professional autonomy and work-life balance. The latter improves retention and decreases turnover rates.^14,17 Self-scheduling reduces turnover rates¹⁷ while flexibility in work schedules, family friendly policies, child care facilities, social hours, and work-life balance improve retention rates.^14,16 Workplace supports, including adequate time away from the community, are particularly effective for minimizing burnout and job dissatisfaction among rural and remote health care providers.¹³ Several reviews found that promoting professional autonomy was also an important strategy for improving retention and job satisfaction.^11,14,16,18 However, one review found that autonomy did not have a significant relationship with absenteeism for staff nurses.¹¹

There is mixed evidence for the effects of clinical and social support on outcomes.^12,19 One review found little evidence that connects stress management courses with improved outcomes, such as a risk of burnout.²⁰ Likewise, there is only modest evidence of a significant relationship between workload and related factors such as job demand, role overload, task complexity, work variety, and work responsibilities with job satisfaction, retention, and absenteeism.^11,12,21 There is, however, some evidence that increased workload and work hours decreased job satisfaction for general practitioners while variation in tasks increased their job satisfaction.²¹

Supports for career and professional development

Overall, the reviews confirm a positive relationship between various supports for career and professional development, educational programs, clinical supervision, and outcomes;^11,16,19,20 having avenues available for opportunities of promotion reduces absenteeism;¹¹ good clinical supervision positively influences rates of recruitment and retention for nurses and occupational therapists, particularly when a good supervisor–mentee relationship is fostered;^14,16 opportunities for professional education and training, such as leadership training, have a positive influence on recruitment and retention of health care providers;^14,16,19 access to mentoring programs, clinical placements, preceptor-guided clinical experiences during orientation, needs-based orientation, externship programmes, and specialty training are important for recruiting and retaining new graduate nurse;²² and rural curriculum, rural clinical rotations, a rurally located medical school, and multifaceted education are effective for attracting new medical graduates to rural and remote programs.¹⁵

Work design

Evidence is mixed on the effectiveness that restructuring staffing models and re-engineering work and ward practices on improving turnover rates and absenteeism.^13,20 There is no conclusive evidence that changes to staffing models improve human resource outcomes. For instance, one review found that changes to staffing models and re-engineered work are positively related with job satisfaction,¹⁶ while in another review, staffing models did not have any influence on job satisfaction or absenteeism.¹⁰

There is also no conclusive evidence of a relationship between staff mix and outcomes. For instance, in one review, there was no evidence that having the right staff mix is effective in retaining health care providers,¹⁶ whereas in another review, there is evidence that collaboration between nurses and doctors significantly improves job satisfaction for the nurses.¹⁸ Multiprofessional team work also improves job satisfaction for occupational therapists.¹⁴

Discussion

Main findings

Financial incentives, including direct compensation through salaries or indirect payment through benefits packages, are often the first incentives considered. The findings suggest that higher salaries and indirect financial compensation through bonuses and scholarships continue to be popular though there is conflicting evidence of their effectiveness on several key outcomes. Nevertheless, there is evidence that financial incentives may be effective for recruiting, but not necessarily retaining, health care providers in rural and remote communities.

Financial compensation as a term was seldom defined in the reviews, and therefore, it is difficult to discern whether the authors were referring to direct or indirect compensation. Also, the studies did not disclose the magnitude of the incentives, a factor likely to influence their effectiveness. Overall, a strategy that combines financial compensation with nonfinancial incentives, such as high-quality working environments and opportunities for professional growth, may be more effective for improving human resource outcomes than financial incentives alone.

While the evidence overall on the effectiveness of nonfinancial incentives is mixed, strategies such as providing opportunities for collaboration and incentives that emphasize work-life balance (e.g. child care) improve job satisfaction and staff retention.^20,22,23 However, although child care supports, social hours, and family supports seem to be effective incentives, they are not always well defined in the reviews. Similarly, although making adjustments to workload is one of the commonest incentives used, their impact on job satisfaction, staff retention, and absenteeism is unclear.

Limitations

First, the quality of the evidence in the reviews varied. Some of the reviews only included randomized controlled trials, while others included qualitative studies and reports that had not been peer-reviewed. Few reviews report the statistical significance of the effect of the incentive on the outcome. Therefore, statements made about relationships between incentives and outcomes are tentative, and the results of this overview should be considered with caution.

Second, the search strategy and inclusion criteria may have resulted in relevant reviews being missed. The reviews yielded by the literature search discussed fewer than half the incentives included in the search parameters. Third, several of the reviews report on studies conducted in the 1980s and 1990s, which may not be relevant to today’s context. Fourth, while overviews of reviews are valuable for summarizing evidence, recent studies could be missed. The reviews did not provide data on effect size, nor did the majority of reviews provide a clear description of the incentives or outcomes reported. It was impossible to discern the magnitude of the incentives (e.g. the amount of the financial package and number of education days), which limits our ability to link specific incentives with outcomes.

Implications for policy and research

While the evidence on effective financial and nonfinancial incentives is mixed, some strategies show more promise than others. Financial incentives are likely to assist with recruiting health care providers to rural and remote areas. The effectiveness of some nonfinancial incentives, such as opportunities for professional development and for collaboration, is emerged as effective mechanisms for improving human resource outcomes and requires further examination.

Other areas for further exploration include the relationship between incentives and outcomes as there is a lack of well-designed studies (e.g. controlled trials) on effective and largely untested interventions for underserved and rural areas.^4,23 Moreover, there was little discussion within the reviews of the costs associated with various incentives and the feasibility of targeted incentives packages that recognize the specific needs and expectations of different professional groups, staff demographics, and health care and employment contexts. In addition, despite including all health care professions in the search terms, many of the reviews focused on nurses, with few reporting on other health care practitioners. Finally, the settings captured in the reviews relate to either acute care or continuing care, while none explored incentives for primary care or community care.

Footnotes

Funding

This study was funded by the Institute of Health Economics at the University of Alberta, Canada.

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