Health Services workforce renaissance through Information Technology Infrastructure in Health

Abstract Purpose: The purpose of this paper is to develop a plausible

model that utilizes effective implementation of information

technology as a possible revival strategy in reducing attrition.

Design/methodology/approach – This study tests the

relationship between various factors acting as antecedents in

affecting the job satisfaction, commitment and intention of a

healthcare professional to stay in the job. For this purpose

healthcare professional attrition tracking survey (HATS),

carried out on a random sample of 807 respondents consisting

of doctors, nurses, paramedics and administrators was utilized.

Basic descriptive statistics and factor analysis have been

performed.

Findings – Survey data confirm that among the many factors

that are relevant to job satisfaction, six factors are

predominant. Use of information technology has been

identified as one of the factors. A highly probable theoretical

model linking worker motivation, job satisfaction and

commitment with information technology implementation for

reducing attrition has been proposed.

Research limitations – The main limitation of the research is

that the current findings cannot be applied as a generalized

framework to all healthcare organizations since the study has

been conducted only in certain parts of the country. Also the

study has been undertaken only in those organizations where

computers are used, at least on a primitive level scale say for

patient registration, billing or preparing monthly reports etc.

Further research needs to be carried out to actually evaluate

the theoretical strategy proposed in the paper.

Practical implications - In an increasingly global scenario of

decreasing healthcare human resource due to attrition it is

imperative for organizations to look for long-term strategy to

retain the employees instead of focusing on short-term

benefits like worker efficiency and performance. Although it

is well known that monetary benefits, work environment,

effective leadership, work-life balance etc can be utilized to

achieve the purpose, the ubiquitous nature of information

technology in current healthcare domain can be availed to

provide a better enduring and stable approach to increased

patient safety and quality of patient care. Better healthcare

human resource planning and management can be achieved

using information technology implementation leading to

employee empowerment, patient retention and market

leadership. The current study can be used as a foundation to

build up a framework where IT can be used as a driver for

reducing attrition.

Originality/value – While there has been extensive studies on

job satisfaction and commitments in healthcare organizations,

most have been limited either to a particular group, region or

time frame. Also there are very few studies in Indian scenario

particularly pertaining to development of strategies for

reducing attrition. For the first time a practical approach for

reducing retention and resurgence of healthcare human

resource using information technology has been explored in

this paper.

Keywords Job satisfaction, work-life balance, healthcare

professional, healthcare information technology, attrition.

INTRODUCTION

Health care industry is a labour-intensive industry. In recent

decade due to dynamic economic fluctuations throughout the

world, there has been increase in healthcare costs, regulatory

changes and healthcare staff shortages leading to healthcare

organizations undergoing changes [1, 2]. Some of these

reforms have created a tumultuous practice environment for

healthcare professionals that are affecting their work

satisfaction and practice freedom. Furthermore, there is also

an increased performance and efficiency expectations on the

workforce which has repercussions in the form of increase in

staff turnover and absenteeism leading to attrition in

healthcare industry [3-5]. Every healthcare professional is an

important stakeholder of the healthcare system and due to

advances in medical technology and the prime demand for

personalized health care more and more skilled workforce is

required. Shortage of skilled workers in hospitals leads to

decrease in patient safety and quality of healthcare services

[6]. A study using sample of nurses revealed that nurses

working in conditions of shortage of staff and support were

likely to report low quality of health care [7,8].

The main reason of attrition among health professionals in

developing countries has been debated by many authors [9-

13]. It has been noted that while opportunities for professional

training, higher salaries, perks and better living conditions act

as “pull” factors, surplus production of health personnel,

resultant unemployment, less attractive salary, high work load,

stagnation or underemployment coupled with lack of

infrastructure act as “push” factors for the healthcare

professionals to migrate. Especially the subject of job

satisfaction is particularly relevant and of interest to healthcare

organizations due to the fact that organizational and

employees‟ health and well-being rest a great deal on job

satisfaction [14]. Any healthcare manager responsible for

making decisions regarding recruitment and retention needs to

have a thorough knowledge of factors affecting the same in

order to make appropriate decisions regarding advancement,

personal growth of employees, building a good calibre of team

for quality healthcare delivery [15]. Therefore healthcare

organizations should take necessary steps to understand

attrition and address them systematically to retain trained,

knowledgeable and experienced employees. This is

particularly important because employees in a healthcare

delivery system are expected to provide quality patient care

while working in a highly stressful environment [16]. Social,

cultural and job factors all influence employees‟ behaviour

[17] and are related to job satisfaction of the individual. There

are evidences to prove that dissatisfaction with one‟s job may

result in higher employee turnover, absenteeism, and

grievances. Improved job satisfaction, on the other hand,

results in increased productivity [18]. From the employee‟s

point of view, job satisfaction reflects the benefits they might

be looking for when they take the job and on other

expectations like the desire to use their skills and abilities to

make a meaningful contribution and to be valued. In a

healthcare setting, employee satisfaction has been found to be

positively related to quality of service and patient satisfaction

[19]. A number of studies have been into job satisfaction in

the healthcare setting [20-22]. Due to the dynamic changing

environment of healthcare scenario with its diversities in

healthcare provider settings there is still there is a need to

understand job satisfaction of healthcare providers in more

detail. Many strategies have proposed for reducing attrition

among healthcare professionals [11-13]. Besides pay

packages, career level growth and co-worker relationships

were identified as major factors. Staff turnover and attrition is

a component of any industry, but its impact on a vital service

industry like healthcare needs special consideration.

The growth of medical tourism, demand for better quality

healthcare delivery due to growing aging population, and

increase in chronic disease patient population are driving the

increased adoption of information technology (IT) solutions in

the emerging markets like India, China and Brazil. These

emerging markets are expected to surpass developed countries

in innovative healthcare delivery over the next decade [23]

due to their competitive advantage in latest innovations in

medical technology. These developments are inspiring the

hospitals and healthcare organizations to move forward

towards excellence rather than survival and to fulfil the gaps

in three key areas of people, process and technology. The

current trend is to use highly integrated information systems as

a major enabler of organizational change [24] to distribute

information within and across organisations. These systems

not only impact organisations‟ business processes, structure

and performance, they also influence individuals‟

performance, job specifications, and motivation with a variety

of outcomes and secondary side effects that may be of positive

or negative nature [25]. An important study was conducted in

UK for establishing health informatics as a recognized and

respected profession in UK National Health Services [26].

Healthcare professionals trained in health informatics are able

to work in alternative healthcare facilities like Ambulatory

care centres, Rehabilitation centres, Public Health Facilities,

Home Health Agencies, Insurance Companies etc. This

overwhelming opportunity increases the job satisfaction and

adds to the job enrichment and motivation of the employees

thereby reducing attrition. The literature is filled with

examples of importance of HIT in healthcare [27-30]. There

are evidence based cases of improved patient care, reduced

waste and inefficiency in services, reduction in adverse drug

effects and medical errors [31]. However physician job

satisfaction also has important implications for quality

healthcare delivery. Healthcare professionals those who are

satisfied with their job are inspired to provide quality patient

care [32]. Hence it is a necessity for every healthcare

organization to ascertain the effect of bringing in information

technology on the work performance and motivation of its

employees.

Indian healthcare scenario has been continuously undergoing

dramatic changes in the past few years. Reports clearly

suggest that healthcare sector is going to be one of the major

sectors that would fuel the economic growth and will

contribute to the increased revenues, along with IT Services

and Education sectors in the country. The Indian healthcare

sector is poised to reach US$ 280 billion by the year 2020,

thereby contributing an expected Gross Domestic Product

(GDP) spend at a CAGR of 17% by 2012 [33]. 75% of health

expenditure is of private health expenditure [34]. Despite

being the 2nd most populous country with 70% population in

rural areas and with Indian Medical Council churning out

nearly 31000 health care professionals (excluding ayurvedic,

homeopathic doctors, health policy analysts, ambulance

drivers and the like), the physician – to- population ratio

works out to be 50-60 per 100,000 [35] leading to a shortage

of qualified medical professionals. According to the latest

press release in India dated July 19, 2011 on a study

conducted by MyHiringClub.Com, [36] healthcare sector in

India is facing a highest attrition rate of 12% among talented

employees leading to retention as a major challenge. It has less

doctors among the BRIC Nations about 6 for every 10,000

population [37]. Medical tourism is one of the major external

drivers of growth of the Indian healthcare sector. A Google

search of “India medical tourism” turns up more than two

million results. Medical tourism in India is expected to be $2

billion industry by 2012 [38]. This is adding to the existing

burden of shortage of skilled healthcare employees.

While there are reports and literature that indicate there is

greater danger of brain drain in the area of healthcare in India

due to migration and attrition among doctors, nurses,

pharmacists [9,12,13] there are no detailed studies that

explores this thought and offers an effective retention strategy

for reducing the attrition. Some of the reasons cited for

attrition in Indian public sector hospitals are expectations of

higher salaries and professional development (higher

education) abroad, lack of infrastructure, bureaucracy, lack of

recognition etc [39]. Private sectors are also abundant with

attrition. It has been observed that healthcare professionals

leave private organizations due to lack of professional

autonomy, lack of job enrichment, less scope of academic

achievement, lack of infrastructure etc [40].

Many organizations have taken number of steps to address

challenges posed by attrition by developing appropriate

strategies. Hospitals like Fortis and Artemis offer performance

based bonus [41]. Apollo Hospitals have taken many steps like

making their nurses customer custodians, performance- linked

rewards, transparent review process, building a high-

performance work teams etc [42]. Job satisfaction, motivation,

job enrichment, attrition are complicated issues that deal with

human emotions and behaviour. They need to be dealt in

stringent manner while planning for healthcare human

resource. Most of the reports regarding the same are

journalistic in nature or interviews with management that

highlight some of the strategies employed without deeper

analysis of the problem. IT has evolved in healthcare segment

in India via hospital information management systems

(HIMS), health management, clinical information

systems(CIS), clinical decision support systems CDSS),

electronic health record (EHR) etc, both in public and private

sectors. Not only have the private organizations (hospitals)

were the pioneers to adopt HIT, they have paved way for the

government to adopt IT through public – private partnerships.

With HIT undergoing great paradigm shift through initiatives

by industry and government, it is appropriate to investigate if

IT can act as a driver in controlling attrition rate in India. The

purpose of this is to analyse the factors associated with

attrition among healthcare professionals in Northern parts of

India and explore the possibility of using information

technology implementation as a strategy to control attrition.

III. METHODOLOGY

A. Data Source and Study Design

Data for this work was collected through Healthcare Attrition

Tracking Survey (HATS) a study designed by the authors to

address the issues regarding attrition among healthcare

professionals and to determine the usability of health

information technology in hospitals and healthcare centres as a

strategy to reduce attrition in India. It was conducted among

skilled healthcare professionals such as doctors, paramedics,

administrative and managerial staff in public as well as private

hospitals covering rural and urban regions of Northern India.

As the first stage a pilot survey was performed among 40

healthcare professionals from different parts of the country in

management role. This was done to get a perspective of the

employee turnover among healthcare professionals.

Following this two types of methods were utilized for data

collection.

1. Cross Sectional Survey: Parameters regarding job

satisfaction, motivation, work commitment, attrition in

healthcare sector were analysed through literature and were

utilized to develop a survey questionnaire to collect data

regarding attrition among healthcare workforce. Initially,

many healthcare organizations both public and private were

invited to participate in the survey. Among those who

responded, based on ease of convenience and accessibility, 40

hospitals were randomly selected with an equal distribution of

public/ private and rural/ urban categorization. The complete

details of the sample target and list of hospitals included for

the survey are presented elsewhere [43].

The questionnaire tool was developed by the authors,

reviewed by the experts in the field and then utilized for the

HATS. The questionnaire had 60 questions, divided into three

parts: 1) Demographic profile which included their age,

gender, education, marital status, tenure, experience and

annual income, 2) Overall perception of the work which

included their level of satisfaction, motivation, involvement

and work compatibility, and 3) Existing awareness in

information technology, attitude towards utilizing it, its

current usage and perception towards future utilization. There

were both multiple-choice and open-ended questions. This

was a self-administered questionnaire in which, after a brief

explanation of how the questionnaire was arranged,

respondents were asked to complete it based on their

interpretation.

A pre-test study was conducted on 30 respondents in a leading

100 bedded Private Hospital in New Delhi, India to test the

validity and reliability of the tool. The Reliability Test

(Cronbach alpha) on Data was 0.75%. Kaiser-Meyer-Olkin

(KMO) test was done to measure the homogeneity of variables

and Bartlett's test of sphericity was done to test for the

correlation among the variables used. The KMO value was

greater than 0.85 which is a acceptable value. The Bartlett‟s

test showed significant results for all the parts and hence the

instrument was accepted for further study. On getting quite

meritorious results of the validity, the instrument was floated

for data collection.

A convenient sample method was utilized for selecting

respondents (sample size = 2000). Doctors, paramedics,

administrative and managerial staff were interviewed. Due to

the sampling technique adopted, respondents diverged from

every age group, gender, education, marital status etc. but

were restricted only to low and middle level employees, where

the attrition is highest. Prior to providing a questionnaire to be

filled each participant was screened to determine survey

eligibility based on the following criteria:

Criteria 1 (origin): Health care professionals who are not of

Indian origin or Non–Resident Indians but undergoing special

training in India were not included as the prime focus to study

attrition among respondents trained solely in India.

Criteria 2 (Completion of Training): Respondents who have

not yet completed their training or not yet licensed or

temporarily licensed were excluded. Proxy respondents were

not permitted.

Criteria 3 (Job Satisfaction): The survey was constructed

from the following question: “Taking into consideration your

future career plans in medicine/ healthcare, would you say that

you are currently: satisfied, very much satisfied, somewhat

satisfied, dissatisfied, very much dissatisfied, neither satisfied

nor dissatisfied”. Participants who responded “don‟t know” or

“refuse to answer” were excluded from the HATS survey.

This allowed examination of potential differences in the

attitudes of the respondents towards identifying reasons for

attrition.

Finally after screening 1000 respondents were included for the

survey. The respondents were asked to indicate their response

on a five-point Likert scale from 1 (strongly agree) to 5

(strongly disagree) for the multiple choice questions. A

hospital administrator or chief medical manager was chosen as

the facilitator for the self-administered questionnaires.

The above measures allowed the investigators to examine the

factors affecting attrition, type of HIT utilized by the

respondents and to determine if adoption of HIT would help in

reducing attrition.

2. Focus Group Study: Two focus group studies, one in a

private urban hospital and another in a rural government

hospital were conducted. Each lasted for one hour with 15

professionals participating from private hospital and 9 from

public hospital. Questions regarding the reasons for staff

turnover in their organization, broad estimates of attrition rates

among doctors, nurses and administrators in their hospital,

methods used to minimize attrition, perceived barriers to

employee retention, benefits and use of information

technology in healthcare especially in their work were

included in the discussions and responses elicited. The results

were qualitatively analysed and utilized while interpreting the

quantitative data collected through survey.

During the pre-test survey it was observed that the Senior

Consultants showed a bit of enthusiasm for participating in

HATS while the junior staffs were reluctant to fill

questionnaire. Also few respondents especially the

experienced healthcare professionals did not like to mention

their salaries while the new physicians & nurses were keen to

fill the survey form. As initially some of the respondents were

reluctant to fill the form due to reasons like transparency,

being odd man out in expressing their view, not being taken

seriously, data privacy etc. in-formal discussions were

conducted by the authors and managerial staff confidence

sought before the actual HATS implementation. The major

challenge faced was to take permission from the HR

authorities to conduct the survey due to issues of transparency

of the system and its HR policies.

B. Data Analysis

Finally only 807 completely filled in questionnaires were

obtained giving a response rate of 40% out of the initial 2000

respondents selected. The data from the tool was coded and

entered into SPSS16.0 package. A random 5% sample of

responses was checked for coding errors. Wherever the data

was left uncompleted and unclear the respondents were

approached individually to recollect the data (less than 1%).

Data were analysed by means of Factor Analysis on Rotated

Factor Matrix using Principal Components Analysis (PCA) in

SPSS 16.0 package to determine the relationships between

factors influencing attrition. Descriptive statistics included

percentage rates for categorical variables, means and standard

deviations. The categorical variables considered were

demographic i.e., gender, marital status, age, education, work

nature, work experience and income.

IV RESULTS

An overall response rate of 40% was achieved in this

study with a total of 2000 questionnaires distributed and 807

responses. The following illustrates the descriptive statistics of

the various parameters considered for the HATS.

TABLE I

DEMOGRAPHIC CHARACTERISTICS OF THE RESPONDENTS

N= 807

Gender

Male 57.6% ( 461 )

Female 43.2% ( 346 )

Marital Status

Married 62.4% ( 499 )

Unmarried 38.4% ( 307 )

Practice

< 1 year 76.1% ( 609 )

> 1 year 24.7% ( 198 )

Age

17-25 18.7% ( 150 )

26-35 52.1% ( 417 )

36+ 30% ( 240 )

Education

undergraduate 11.6% ( 93 )

graduate 54.7% ( 438 )

postgraduate 34.5% ( 276 )

Nature of Work

Doctors 38.9% ( 311 )

Nurses &

paramedics 37.1% ( 297 )

Administrators 24.7% ( 198 )

Income

upto 10,000 20.5% ( 164 )

10,000-20,000 18.9% ( 151 )

20,000-30,000 26.6% ( 213 )

30,000-40,000 16.6% ( 133 )

>40,000 17.9% ( 143 )

The sample was predominantly male and the

proportion ranged 57.6 ± 0.5%. The respondents were mostly

middle-aged (52.1%) in the range 26 to 35 years and mostly

married (62.4%) living with family. Nearly 20% of the

married respondents especially male were living alone with

their family in their respective home towns. Almost two-thirds

of the participants were doctors, paramedics, nurses,

administrators who had less than a year of practice in the

current organization and also middle-aged. 54.7% of the

participants were graduates while the postgraduates were

34.5%. Undergraduates were few (11.6%). Approximately nearly equal number of doctors and nurses, paramedics

participated while the administrators were less. There was not

much difference in the number of participants based on their

income.

One of the main criteria for the respondents to be eligible to

participate in the survey was to indicate their job satisfaction

level. Based on the response to this query, the overall

satisfaction level of the respondents was analysed (Fig 1). It

could be seen that though greater percentage of respondents

were satisfied with their job equally same number of

respondents were not highly satisfied.

Further the distribution of the respondents who were

dissatisfied based on the nature of their work group,

experience, nature of the organization and its location were

determined (Table II).

% OF RESPONDENTS DISSATISFIED WITH CURRENT JOB

% Dissatisfied

Doctors 62

Nurses & Paramedics 19

Administrators 18

< 1 year Experience 78

> 1 year Experience 22

Public 43

Private 57

Urban 65

Rural 35

In order to identify and evaluate the factors behind attrition,

factor analysis was done. The Kaiser rule for number of

factors to extract was applied. Initially 10 factors were

extracted. Based on the factor loadings of the individual items

and the number of items contributing to a factor, the initial 10

factors were reduced to 6 factors. The following table

illustrates the factors that have been extracted using factor

analysis. Each question (item) in the questionnaire has been

designed to indicate a job characteristic that has been known

to contribute to job satisfaction.

TABLE III

Factor Job Item Factor

Loading Factor Name

1

Salary and financial

benefits 0.6814 Compensation

and Perks Non Financial

Incentives 0.6482

2

Policies related to

Employees 0.6699 Work Life

Balance Facilities for

Employee comfort 0.6796

Work Facilitation 0.6586

3

Sense of

Accomplishment 0.7341 Sense of

Accomplishme

nt Self Esteem 0.7186

Freedom on Job 0.6187

4

Work Overload 0.8540 Work Load

Leading to

Exhaustion

Exhaustion from Work 0.6086

Work Stress 0.6145

5

Innovation through

Automation 0.8383 Automation

and

Technology

Improvement

Information

Technology

Requirement 0.6815

Technical Support of

IT 0.7904

6

Interesting and

Motivating 0.9062 Break

Monotony of

the Work Challenge 0.6788

Skill Variety 0.7142

Based on the factor loadings, only those items

contributing to a particular factor with a factor loading of 0.6

and above have been grouped together. No one item

contributes to more than one factor. Based on the groupings of

the items for a factor, each individual factor has been named.

Percentage variance of each factor and the correlation between

each factor were also determined. Generally, the first two or

three components are expected to extract at least 50% of the

variance as a rule of thumb [44]. For the six factors identified

60% and above variance were obtained. Table IV illustrates

the variance obtained for one factor, sense of accomplishment

as an example. TABLE IV

Initial Eigen values

Component Total % of

Variance

Cumulative

%

1 2.59 59.50 59.50

2 0.93 21.44 80.94

3 0.83 19.06 100

Extraction Method: Principal Component Analysis.

Correlations within a factor were positive and greater than 0.5

indicating a cohesive relationship between the items in the

questionnaire and the particular factor. The next step involved

in analysing the effect of each independent variable on all the

factors. . For this purpose, t-statistics and Duncan‟s mean test

were utilized. In this work, the results of those variables that

had an effect on the factors are illustrated.

TABLE V

COMPARISON OF FACTORS OF ATTRITION BETWEEN MALE

AND FEMALE RESPONDENTS

Factors of

Attrition

Male ( N=

462)

Female ( N=

345)

t -

value

Mean SD Mean SD

Compensation

and Perks

3.31 1.16 3.27 1.03 0.35

NS

Work life

balance

3.32 1.15 3.08 0.98 2.24 **

Sense of

accomplishmen

t

3.03 0.92 2.94 0.83 0.97

NS

Work load

leading to

exhaustion

3.21 1.01 3.06 0.82 1.56

NS

Need for

Automation

and technology

improvement

2.71 1.43 2.46 1.16 1.84

NS

Break

Monotony of

Work

2.94 1.10 2.63 0.88 3.07 **

NS : Not Significant * Significant at 0.05 level ** Significant at

0.01 level

Comparison of the six factors of attrition (Table V) between

male and female respondents yielded significant contribution

to the two forces of attrition namely work- life balance and

break monotony of work.

TABLE VI

COMPARISON OF FACTORS OF ATTRITION BETWEEN

MARRIED AND UNMARRIED RESPONDENTS

Factors of

Attrition

Married (

N= 500)

Unmarried (

N= 307)

t - value

Mean SD Mean SD

Compensation

and Perks

3.37 1.05 3.16 1.18 1.72 NS

Work life

balance

3.33 1.08 3.03 1.07 2.71 NS

Sense of

accomplishment

3.05 0.92 2.90 0.82 1.75 NS

Work load

leading to

exhaustion

3.24 0.98 2.99 0.83 2.69 **

Need for

Automation and

technology

improvement

2.66 1.41 2.51 1.17 1.17 NS

Break Monotony

of Work

2.87 1.09 2.69 0.91 1.74 NS

NS : Not Significant * Significant at 0.05 level ** Significant at 0.01

level

The marital status of the respondents affected the workload

leading to exhaustion (Table VI). Married but divorced

respondents were not considered as a separate entity. They

were considered as a part of unmarried status.

TABLE VII

COMPARISON OF FACTORS OF ATTRITION BASED ON TENURE

OF THE RESPONDENTS IN THE ORGANIZATION

Factors of

Attrition

Upto 1 year

( N= 609 )

>1 year

( N=198 )

t

value Mean SD Mean SD

Compensation

and Perks

3.35 1.12 3.11 1.05 1.88

NS

Work life

balance

3.28 1.09 3.01 1.07 2.09*

Sense of

accomplishment

3.01 0.88 2.93 0.91 0.75

NS

Work load

leading to

exhaustion

3.13 0.96 3.19 0.86 -0.61

NS

Need for

Automation and

technology

improvement

3.12 0.98 2.77 0.77 3.62**

Break Monotony

of Work

2.87 1.07 2.61 0.86 2.33*

NS: Not Significant * Significant at 0.05 level ** Significant at 0.01

level

When the duration of time spent by the respondents in the

organization were considered (Table VII), it was found that

need for technology implementation was significant at 0.01

level while work life balance and break monotony of work

were significant at 0.05 level.

Age of the respondent and education background did not seem

to matter much when the factors of attrition were considered

except for work load (Not shown here).

Nature of the work group of the respondents (Table VIII)

considered seems to throw significant contributions to

attrition. Nearly 4 out of the 6 factors were affected. All the

four factors namely, Compensation and Perks, Work -Life

balance, Sense of accomplishment and Need for Automation

and Technology all were significant at 0.01 level.

Table VIII

COMPARISON OF FACTORS – STUDIES AMONG RESPONDENTS OF NATURE OF WORK GROUPS

( W1 = MEDICAL PROFESSIONALS , W2 = NURSING AND PARAMEDICS , W 3 = ADMINISTRATION) - DUNCAN’S MEAN TEST

Factors of

Attrition

W1

( N = 312 )

W2

( N=297)

W3

( N=198 )

F- Value

Mean SD Mean SD Mean SD

Compensation and

Perks

2.88 .84 3.03 .71 2.53 .80 11.52**

Work life balance 2.65 .78 2.80 .55 2.44 .70 7.77**

Sense of

accomplishment

2.67 .49 2.77 .49 2.6 .55 3.39**

Work load leading

to exhaustion

2.88 .81 2.94 .74 2.9 .84 .24 NS

Need for

Automation and

technology

improvement

2.17 .73 2.40 .72 2.17 .69 4.24**

Break Monotony

of Work

2.94 .83 2.92 .51 2.92 .62 .03 NS

NS : Not Significant * Significant at 0.05 level ** Significant at 0.01 level

Irrespective of the salary package (Table IX) five out of the six factors of attrition identified were significantly found to

contribute to attrition.

TABLE IX

COMPARISON OF FACTORS – STUDIES AMONG RESPONDENTS OF INCOME GROUPS

(I1 = UPTO RS.10,000/- , I2 = RS.11 – 20,000/- , I 3 = RS21 – 30,000/-, I 4 = RS.31 – 40,000/-, I 5 = MORE THAN RS.40,000/- ) - DUNCAN’S MEAN TEST

Factors of Attrition

I1 ( N = 165 )

I2 ( N=152) I3 ( N= 213) I4 ( N=132) I5 ( N= 144) F -

Value

Mean SD Mean SD Mean SD Mean SD Mean SD

Compensation and

Perks

3.00 .69 2.87 .88 2.61 .85 2.99 .77 2.9 .73 3.45**

Work life balance 2.73 .47 2.66 .68 2.57 .80 2.79 .75 2.57 .67 1.49 NS

Sense of

accomplishment

2.81 .51 2.68 .50 2.65 .56 2.83 .49 2.50 .38 4.93**

Work load leading to

exhaustion

3.01 .69 2.95 .77 2.74 .72 2.95 .82 2.95 .97 1.57**

Need for Automation

and technology

improvement

2.47 .78 2.39 .63 2.18 .75 2.24 .69 1.98 .65 5.29**

Break Monotony of

Work

3.02 .43 3.02 .63 2.97 .75 2.73 .73 2.85 .76 2.33**

NS : Not Significant * Significant at 0.05 level ** Significant at 0.01 level

Similarly when the six factors were analysed with respect to the location of the organization being rural or urban it was found

that five factors namely compensation and perks, work – life balance, sense of accomplishment, work load leading to

exhaustion, need for automation and technology improvement were affected in different extent. Similarly, two factors, namely

work load leading to exhaustion, need for automation and technology improvement were affected whether the organization is a

private or public. TABLE X

COMPARISON OF FACTORS – STUDIES AMONG RESPONDENTS BASED ON TYPE AND LOCATION OF ORGANIZATION

Factors of Attrition Urban (N=

586)

Rural

(N=221)

t - value Public (N=

318)

Private

(N=489)

t - value

Mean Mean Mean Mean

Compensation and Perks 2.98 3.60 3.82* 0.72 0.85 0.91 NS

Work life balance 2.95 3.90 2.82** 0.66 0.71 0.7 NS

Sense of accomplishment 2.85 3.38 3.06* 0.5 0.52 0.3 NS

Work load leading to

exhaustion

3.11 3.22 1.16** 0.86 0.74 2.98**

Need for Automation and

technology improvement

2.44 3.03 3.62** 1.10 0.88 3.07 **

Break Monotony of Work 2.67 3.16 0.97 NS 0.67 0.69 0.07 NS

NS : Not Significant * Significant at 0.05 level ** Significant at 0.01 level

Further the knowledge existing awareness in IT related to

healthcare, attitude of the healthcare professionals towards

utilizing it, current usage and their perception towards using

IT in future were also analysed. The following figures and

tables illustrate the results. Among the 807 respondents,

81.7% doctors, 76.8% nurses and 71.2% administrative staff

had awareness of computers out of which 68% of doctors,

51% of nurses and 60 % of administrators used computers for

their work. The percentage of healthcare professionals using

the computers was more among the males (80%), compared to

their female (73%) counter parts. Among the professionals

who were using IT for their work there was no difference

based on their education, experience or marital status.

Percentage of IT usage was higher amongst age bracket of 26

– 35 years than other age groups.

Fig 2 Percentage of Respondents using IT (Age wise distribution)

When the details regarding usage of computers was analyzed

it was seen that while greatest use of IT was adopted for

official administrative purposes, communication between

professionals and for knowledge gathering (guideline)

compared to use of hospital and health management

systems.More than 40% usage was identified for providing

prescriptions to the patients (Fig 3).

The respondents were queried regarding the importance of

implementing HIT for betterment of their work and also

probed to summarise their interest in undergoing training

regarding the same. While 60% of the respondents felt the

need of implementing technology 83% were keen on

undergoing training for the same (Fig. 4).

V. DISCUSSION AND CONCLUSION

The findings of this study have limited generalizability as it

covers only the northern part of India and the sample response

is only 40% of respondents approached. However, confirming

to the views of earlier articles that it is difficult to obtain

desired response rates from medical professionals, and it is

common to achieve lower rates in such studies, the current

findings are directly compared with some of the earlier

reports. Results from this survey demonstrated that 24% of the

respondents were dissatisfied with their job. This was less

than what has been reported in literature by many authors.

Based on the focus group discussions and on the responses to

the open ended questions provided in the questionnaire it was

understood that many healthcare professionals though not

happy with their job were not clear in their level of

dissatisfaction. When their responses to shifting jobs in near

future if opportunity arises is combined with their satisfaction

level, then the calculated proportion of respondents

dissatisfied with their job increased to that of 49%. The

doctors were more dissatisfied than nurses and administrators.

Manjunath et al [45] had conducted a study earlier among

doctors, nurses and administrators where they determined the

attrition rates to be less among doctors compared to nurses.

The difference in the current study compared to that might be

due to the difference in the type of the sample considered for

study. It has been identified in the current study that doctors

were satisfied with certain aspects of their work and

dissatisfied with other aspects. Overall, however, doctors in

the private sector were more dissatisfied (37%) than public

(nearly 20%). Since there are evidences that doctor

satisfaction may be positively correlated with their

performance [46, 47] and is an important determinant of

where they intended to work [48], these findings have

important implications for the provision, costs and quality of

health services of health care organizations. Considering the

job satisfaction among nurses and administrators, the current

findings indicate a dis-satisfaction among both nurses and

administrators. Nurse and other health care employees‟

satisfaction have been found to have several impacts on the

quality of care delivered which ultimately influences the level

of patient satisfaction [49].

Overall participants reported low satisfaction with salaries, not

being involved in decision making, doing a lot of non-clinical

tasks and not having sufficient work-life balance. Morrison, et

al. [50] outlined several ways in which the lack of engagement

and high turnover rates impact health care organizations.

Some of these factors include turnover costs, which according

to Waldman & Kelly [51] range between 3.4% and 5.8% of

their operating budget. When employees feel unsatisfied and

unappreciated they leave the organization and this puts higher

workloads and stress levels on those who remain and

ultimately further drives down satisfaction for both employees

and patients [52]. Employees‟ needs and motivators vary so it

is important to understand what motivates them to perform.

Hence it is imperative to analyse the factors that influence job

satisfaction which in turn affects attrition. Based on the factor

analysis of the responses recorded by the respondents, initially

10 factors were identified. They were further reduced into 6

major factors on the basis of the inter-correlation between the

items.

Factor 1 (Compensation and perks) refers to the providing

incentives and extra income to the doctors in terms of

benefits. There are reports that provide such examples where

the use of provider incentives and enablers has known to

increase the performance under certain conditions [53]. Such

financial incentives usually take the form of bonuses paid over

and above the physician‟s base income from fee-for-service

payments, capitation, or salary. There are difficulties

involved, since paying incentives to reduce attrition might

increase indicators of activity to be measured, crafting proper

incentives and monitoring issues. Effect of pay structure on

job satisfaction is a complicated aspect to be dealt with. In the

current study in comparable with others [54] both „salary‟ or

„salary and fringe benefits‟, are considered as one which

enhances comparability of findings. This factor was affected

by difference in the work group (Table VIII) and based on

the location of organization (Table X). This reflects the pay

disparities available among the doctors, nurses and

administrators. Even though the salary bands are higher in

urban areas compared to rural locations, the cost of living in

cities is greater and this leads to greater salary expectation in

the urban areas. In terms of practical contribution, the findings

of this study may be used as guidelines by healthcare

organizations to improve the design of pay structure. Many

factors need to be taken into consideration while doing this.

The level of pay needs to be increased equal with employees‟

contributions to their organizations, national cost of living and

in-line with industry standard.. This will help high performers

and/or employees who have family responsibilities to fulfil

necessity needs, improve standard of living and upgrade status

in society. When employees feel that their structures of pay

are adequately allocated, it may lead to higher job satisfaction,

organizational commitment and thus reduce attrition.

Factor 2 (Work life balance) is about helping employees

better manage their work and personal (non-work) time. This

refers to family friendly work arrangements and alternative

work arrangement [55]. This depends on the nature of the

work, type of the workplace and issues in the workplace.

Without proper balance between work and family life, work-

family conflict can create series of unfavorable issues,

including decreased employee performance, reduced job

satisfaction, high absenteeism, and high attrition [56]. Hectic

nature of the healthcare industry can create work-family

conflict for the healthcare workers. As a result, high turnover

rate is one of the most common problems for healthcare

facility.Introducing strategies like flexible work options,

specialized leave policies, paid maternal leave, paternal leave;

home tele-commuting subsidized exercise for fitness centre

etc. can increase the satisfaction level of the healthcare

professionals.. In a research conducted in Thailand [57]

among healthcare staff, factors like workloads, work

flexibility, and family role conflict were found to affect work

–family conflict. It was observed that personal factors like

gender, age, work position, marital status and personal income

did not affect work –family conflict. In the current study work

life balance has been identified as one of the major factors

leading to attrition. This factor does not differentiate the male

and female respondents but seem to play an important role

especially when the type of work of the respondents is

considered. Doctors and administrators who spend greater

time of the day in the hospital are affected by work life

balance issues. Any strategy to be designed should take into

consideration the different working environment of the

healthcare professionals.

Factor 3(Sense of accomplishment) is about job satisfaction

felt by the healthcare workers. This does not depend upon the

monetary issues and it deals with the sense of achievement

and fulfilment felt by the employees. Employees feel sense of

accomplishment when they feel oneness with the organization.

This happens when the organization delivery systems share

the same mission, vision, goals, objectives and strategies. A

key to build such a culture is by involving the medical staff

members to make collaborative decisions in clinical and

operational issues

[58]. Medical staff thus involved is

philosophically and economically aligned with the

organization, feel a sense of accomplishment and are likely to

make decisions that benefit the organization, thereby

benefiting the patients served by the organization. In accord

with past research [59, 60], perceived clinical freedom was

also found to be strong and positive predictor of this

dimension of job satisfaction. This reiterates the importance of

professional autonomy in practice and suggests that

restrictions to one of the core aspirations of knowledge

workers can result in adverse outcomes in a health context.

Factor 4 (Work load leading to exhaustion) and Factor 6

(Break monotony of Work) refers to the overworked health

care professionals. A negative relationship between stress and

job satisfaction (p< 0.01) was also reported as having an

important influence on turnover in the meta-analysis of

nursing turnover conducted by Yin and Yang [61]. Stress was

indicated as one of 12 variables related to turnover from the

factors included in studies undertaken in Taiwan. Though

there has been inconsistency in ranking stress as an important

factor, it has been identified as one of the factor affecting

employee turnover and hence attrition. The current findings

are somewhat similar to these. In the current findings, though

stress was not identified as a major problem in urban

hospitals, it was more prominent in the rural areas. In the

urban hospitals, though the workload is expected to be heavy

due to a greater number of patients, these hospitals are mostly

equipped with newer medical technologies which greatly

reduce the workflow for the nurses and doctors. Also there is

an availability of greater resource in terms of nurses and

doctors. As hospitals in underserved rural areas often have

higher workloads, cover large geographic areas, have lower

access to specialists, encounter problems in recruiting and

retaining clinical staff, and treat a broad array of complex

patients. The Indian public health system has a shortage of

medical and paramedical personnel. Government estimates

(based on vacancies in sanctioned posts) indicate that 18% of

primary health centres are without a doctor, about 38% are

without a laboratory technician, and 16% are without a

pharmacist. This increases the work load which further causes

exhaustion and stress. This specifies the need to improve

working conditions and the professional interface with other

health professionals and society in the rural areas.

Factor 5 (Need for Automation and Technology

Improvement) implies the requirement of HIT implementation

in the health care industry. The supply of good support,

education and training is a key approach to attracting and

retaining allied health practitioners, especially in rural

locations [62,63]. HIT enables health care professionals to

confidently access, interpret, and apply organisational

knowledge, patient care procedures, professional workforce

competencies, best practice knowledge and other skills

information in a manner that improves patient satisfaction,

achieves positive clinical outcomes, and maximises cost

savings for the organisation [64, 65]. The middle aged

healthcare professionals were more aware of computers than

the senior people. This reflects the changing times where

computer literacy is a part of medical curriculum and also to

the fact that current digital era where computers are prevalent

in every walk of life. The distribution of computer awareness

among the respondents is in line with earlier studies[66]. In

this present study irrespective of gender, age & education the

importance of implementing HIT was stressed by almost all

respondents. The nature of work done by respondents seems

to play a significant role in assigning the need for automation

and technology as a major factor of attrition. This observation

is compounded by the data collected regarding the information

technology usage statistics (Table V). The doctors seemed to

be the preferred users of computers, then healthcare

administrators and then the nurses and paramedics. Also the

difference in the salary does not seem to detract the fact that

implementation of HIT was seen as a basic requirement of

healthcare professionals. More than three-fifths of respondents

said their level of computer literacy level was "just

conversant," with nearly 30 percent "well conversant." The

fact that more than 80 % have some level of computer

knowledge is comparable to the 98 percent of physicians at

the University of Pennsylvania Medical School [67]. While

most respondents had some computer knowledge, more than

80% had no formal computer training. A 2004 study by

Banga and Padda [68] found that more than 95 percent of

health professionals surveyed desired formal training.

Maximum usage was found for teaching or learning purposes

and official work compared to utilization for healthcare

delivery inline with earlier such study. This highlights the fact

that while healthcare organizations are implementing

technology for competitive advantage, increased patient safety

and other related perceived benefits, proper focus is not

provided for training the healthcare professionals to use the

same,

Based on the above discussions we propose a theoretical

strategy where IT implementation and training can be used as

a part of the strategy to reduce attrition. Implementing IT

technology through EHR, HMIS etc and training the

professionals to use them helps to reduce work load of the

medical professionals. It also helps to create standardized

automated processes that help to reduce medical errors. By

learning new skills and gaining knowledge, burnout due to

monotonous work load is reduced. This also provides job

enrichment which further provides sense of accomplishment

to the employees. Through networking using technology and

using it to gain latest knowledge in their area, the employees

are empowered to perform well in the job. Such a learning

environment in the organization increases their commitment

towards their work and the organization leading to a reduced

attrition.

Employee Expectations

Organization Inputs

Start of Job

Compensation and perks

(Industry Standard &

work based)

IT(Proper training and usage, new

technologies)

Job Enrichment(new skill

training, job rotation)

Work Load and Stress

(Proper distribution

of work)

Self Accomplishment

(autonomy,

collaborative decisions)

Work-Life Balance

(Flexi time, leave benefits)

Net Impact of

Factors

R

E

D

U

C

E

D

A

T

T

R

I

T

I

O

N

Fig 5. Theoretical Framework for reducing attrition using HIT

In the current study, variables such as the opportunity to

develop, responsibility, patient care and staff relations were

seen to have a significant influence on job satisfaction. This is

not surprising, in that these findings are in line with the two-

factor theory proposed by Herzberg and Mausner [69], which

lists the following factors as motivators resulting in

satisfaction: responsibility, achievement, recognition and

opportunities to develop. A surprising factor that was

perceived by the respondents to increase their job satisfaction

was the implementation of information technology in their

work in the form of healthcare information technology. This

involves healthcare organizations and professionals using

hospital information systems, lab information systems,

Electronic Health Records etc. Reasons for dissatisfaction in

this study were also found to be in line with the factors

responsible for job dissatisfaction, which include salaries,

quality of supervision and working conditions. The factors

that have been identified through statistical analyses provide a

deeper understanding of the relationships between forces that

influence attrition rate. The results also provide evidence to

demonstrate that economic motivation as a factor for changing

jobs is not an independent, stand-alone factor in itself, but

rather a component of broader factors that takes into

consideration the yearning to improvise both developments in

both professional and personal front. This finding is a

departure from previous studies that indicate the intention of

healthcare professionals to frequently change jobs and

migration to foreign countries is mainly dependent on

remuneration. This may be partly because those studies did

not take into account the deeper analysis of relationships

between factors [70,71]. The supply of good support,

education and training is a key approach to attracting and

retaining allied health practitioners especially in the rural

locations. This enables health care professionals to confidently

access, interpret, and apply organisational knowledge, patient

care procedures, professional workforce competencies, best

practice knowledge and other skills information in a manner

that improves patient satisfaction, achieves positive clinical

outcomes, and maximises cost savings for the organisation

[72]. Most importantly, to address India‟s crisis in human

public health resources, increased emphasis on recruiting

candidates from rural areas, training them and enabling them

to work in these areas would be very beneficial. As it is

difficult and in many instances difficult to train each health

worker individually, the education and training of these

professionals can be done through information technology

using teleconferencing, virtual reality, chat forums and many

other technology advancements. It is high time to bring this as

a part of employee recruitment process to gain a meaningful

use. A potential solution to bridge acute shortage of healthcare

workers and reduce attrition rate is through providing

accessibility to online healthcare, which has emerged as very

important tool for offering healthcare services that can be

accessed by patients across boundaries. Online healthcare

connects patients and doctors via internet services. Online

health portals can reduce workload and streamline processes

for consultations, booking appointments, maintaining patient

health records, getting second opinions, among various other

services offered.

The main limitation of this work is that it has taken into

consideration only those organizations where at least basic

computer facilities are available. The second major limitation

is that the proposed strategy has not been supported by

evaluating information technology implementation with

attrition rate. Further work in this area is under progress.

ACKNOWLEDGEMENT

The authors acknowledge all the respondents and

administrative staff in over 40 hospitals for allowing

conducting the survey.

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