Nurses who left the British NHS for private complementary medical practice: why did they leave? Would they return?

Relationship between labour force satisfaction, wages and retention within the UK National Health Service: a systematic review of the literature

OBJECTIVES

A systematic review was undertaken to understand the nature of the relationship between the UK National Health Service (NHS) labour force and satisfaction, retention and wages.

DESIGN

Narrative systematic review.

DATA SOURCES

The literature was searched using seven databases in January 2020: MEDLINE (1996-present), the Cumulative Index to Nursing and Allied Health Literature (CINAHL via EBSCO) (1984-present), Embase (1996-present), PsycINFO (1987-present), ProQuest (1996-present), Scopus (all years) and Cochrane library (all years). We used medical subject headings and key words relating to 'retention', 'satisfaction' and 'wages'.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Primary research studies or reviews that focused on the following relationships within the NHS workforce: wages and job satisfaction, job satisfaction and retention or wages and retention.

DATA EXTRACTION AND SYNTHESIS

Two independent reviewers screened all titles, abstracts and full texts, with arbitration by a third reviewer.

RESULTS

27 803 articles were identified and after removing duplicates (n=17 156), articles were removed at the title (n=10 421), abstract (n=150) and full-text (n=45) stages. A total of 31 full-text articles were included. They identified three broad themes, low job satisfaction impacting negatively on job retention, poor pay impacting negatively on staff satisfaction and the limitations of increasing pay as a means of improving staff retention. Several factors affected these relationships, including the environment, discrimination, flexibility, autonomy, training and staffing levels.

CONCLUSIONS

This review highlighted how multiple factors influence NHS labour force retention. Pay was found to influence satisfaction, which in turn affected retention. An increase in wages alone is unlikely to be sufficient to ameliorate the concerns of NHS workers. More research is needed to identify the role of autonomy on retention. A system leadership approach underpinned by data is required to implement bespoke job satisfaction improvement strategies to improve retention and achieve the goals of the NHS Long Term Plan.

The North American yoga therapy workforce survey

OBJECTIVE

To describe the personal, professional, practice, service and consumer characteristics of the North American yoga therapy workforce.

DESIGN

Cross-sectional, descriptive survey developed and informed by the contemporary workforce literature. A link to the e-survey was distributed to members of the International Association of Yoga Therapists.

RESULTS

367 members responded (∼20% of eligible participants). Most were aged 40-69 years (88%) and female (91%). Almost half (42%) identified as a "seasoned yoga therapist" and few (9%) graduated from an accredited 800-h yoga therapy program. An average of 8h/week was spent in clinical practice with many (41%) earning an annual income of <US$10,000 from yoga therapy. Practice was informed by twenty different styles of yoga. Urban (39%) and suburban (38.1%) regions were the most common locations of practice. Most therapists conducted therapeutic yoga classes (91%) and 1:1 sessions (94%), with more than half delivering 1-10 therapeutic classes/month (53%) and 1-10 1:1 sessions/month (52%). Conditions seen most frequently were anxiety (77%), back/neck pain (77%) and joint pain/stiffness (67%).

CONCLUSION

While yoga therapists shared demographic characteristics with other complementary and integrative health (CIH) providers, they tended to work less and earn less than their CIH counterparts. Yoga therapists were less likely to work in rural settings, possibly contributing to the underutilization of yoga in underserved populations. Improving access to yoga therapy services, identifying common core components across the various styles of yoga, and building a stronger evidence-base for key health indications may increase acceptance of, and demand for, yoga therapy.

A preliminary study of complementary and alternative medicine (CAM) practitioners in Singapore

OBJECTIVES

To investigate the profile and health attitudes of complementary and alternative medicine (CAM) practitioners in Singapore.

DESIGN AND SETTING

A descriptive survey with convenience and snowball sampling were used. An anonymous self-administered survey was sent to 130 practitioners found in publicly accessible online practitioner registers, groups, and directories practicing CAM modalities from April 2010 to October 2010.

MAIN OUTCOME MEASURES

Participants' demographics, business structure, and attitudes towards health, CAM and orthodox medicine (OM).

RESULTS

Response rate was 32%. The data suggest that the typical CAM practitioner in Singapore is a middle-aged female who specialises in more than one CAM modality. Almost half (45%) of the participants possessed a degree and massage is the most commonly practiced modality. Participants practiced an average of 2-3 therapies and group-practice size ranged from 2 to 15 practitioners. Most participants (69%) experienced a radical change in job type to become a CAM practitioner and their previous employment suggests a slightly middle-class profile. The cost and duration of initial consultation and treatment ranged from SG$20 to SG$345 and 30-120min, respectively. The most common source of CAM information was seminars/lectures/workshops (76%). Communication and referral between CAM and orthodox medicine practitioners are high (>70%). Participants perceived CAM to be more suitable for disease prevention than treatment of serious medical conditions.

CONCLUSIONS

This study provides important base-line data that will help future researchers explore further Singaporean CAM practitioners' business aspirations, and attitudes towards regulation and integration with OM.

Malnutrition in elder care: qualitative analysis of ethical perceptions of politicians and civil servants

BACKGROUND

Few studies have paid attention to ethical responsibility related to malnutrition in elder care. The aim was to illuminate whether politicians and civil servants reason about malnutrition in elder care in relation to ethical responsibility, and further about possible causes and how to address them.

METHOD

Eighteen elected politicians and appointed civil servants at the municipality and county council level from two counties in Sweden were interviewed. They worked at a planning, control and executive level, with responsibility for both the elder care budget and quality of care. Qualitative method was used for the data analysis.

RESULTS

Two themes emerged from their reasoning about malnutrition related to ethical responsibility. The theme assumed role involves the subthemes quality of care and costs, competent staff and govern at a distance. Old and ill patients were mentioned as being at risk for malnutrition. Caregivers were expected to be knowledgeable and stated primary responsible for providing adequate nutritional care. Extended physician responsibility was requested owing to patients' illnesses. Little was reported on the local management's role or on their own follow-up routines. The theme moral perception includes the subthemes discomfort, trust and distrust. Feelings of discomfort concerned caregivers having to work in a hurried, task-oriented manner. Trust meant that they believed for the most part that caregivers had the competence to deal appropriately with nutritional care, but they felt distrust when nutritional problems reappeared on their agenda. No differences could be seen between the politicians and civil servants.

CONCLUSION

New knowledge about malnutrition in elder care related to ethical responsibility was illuminated by persons holding top positions. Malnutrition was stressed as an important dimension of the elder care quality. Governing at a distance meant having trust in the staff, on the one hand, and discomfort and distrust when confronted with reports of malnutrition, on the other. Distrust was directed at caregivers, because despite the fact that education had been provided, problems reappeared. Discomfort was felt when confronted with examples of poor nutritional care and indicates that the participants experienced failure in their ethical responsibility because the quality of nutritional care was at risk.

Clinical supervision and complementary therapists: an exploration of the rewards and challenges of cancer care

AIM

The study explored the experiences of therapists working in cancer care settings and more specifically, the value of clinical supervision.

METHODOLOGY

Invitations for therapists to participate in three focus groups were sent to five cancer care settings. Each group responded to seven trigger questions, formulated from the literature review. Audiotapes were transcribed aided by notes taken during the sessions.

FINDINGS

There were 15 therapists participated in the three groups. Themes and sub - themes were identified; these related to the rewards of being in a privileged and honoured position, the importance of prior experience and motivation, and supervision as a supportive resource. Participants acknowledged and explored shared experiences and identified common coping and 'taking care of self' strategies.

LIMITATIONS

The participants were all from the North West of England cancer care centres with local support and supervision arrangements in place. Limited demographic details were collected. One group fell short of the recommended number of participants.

CONCLUSION

This exploratory study identified that supervision was appreciated, with therapists reporting that the work itself helped sustain them. Individuals also reported that they used complementary therapies to manage work related stress.

Complementary therapists' training and cancer care: a multi-site study

PURPOSE

To explore professional experience and training of complementary therapists working within cancer care.

METHOD

A Questionnaire survey of complementary therapists practising in three cancer care settings in North West England.

RESULTS

Respondents (n=51; n=47 female; mean age 50 years, range 23-78 years) had varied career backgrounds; 24 were healthcare professionals who also practised as complementary therapists (nurse n=19; physiotherapist n=3; doctor n=2) whilst 27 were complementary therapists with no prior healthcare background. Twenty-eight respondents reported working as therapists within a supportive and palliative care setting for over 6 years. Forty-seven respondents had undertaken healthcare-related continuing professional development in complementary therapies, although only just over half of the sample (n=27) had received cancer-specific training. Cancer-related complementary therapy training related to the adaptation of therapies and comprised predominantly short courses. There was a lack of standardisation in the training received, nor was it clear how many courses were accredited.

CONCLUSION

Findings highlight the need for standardisation of training for complementary therapy provision in cancer care and statutory review of continuing professional development within this emerging field.

Complementary therapists' motivation to work in cancer/supportive and palliative care: a multi-centre case study

PURPOSE

To uncover complementary therapists' motivation to work in cancer/supportive and palliative care.

METHOD

The study employed a multiple case-study design, involving three cancer/supportive and palliative care settings in the North West of England. A questionnaire survey (n=51) was undertaken, followed by semi-structured interviews with a subgroup of the sample (n=28).

RESULTS

Participants had a mean age of 50 years, were predominantly female and had varied career backgrounds, including prior professional experience in healthcare, teaching and private complementary therapy practice. Motivation for working in cancer/supportive and palliative care included vocational drive with a desire to provide individualised treatment and adopt a person centred, empowering and caring approach; disillusionment with conventional care; career development and personal experience of cancer or other serious illness.

CONCLUSION

Findings indicated that motivational factors for therapists working in cancer care/supportive and palliative care were varied and highlighted a combination of 'push and pull' factors, particularly for therapists who are also health care practitioners. Further research related to volunteering, sustainable services and support and training for therapists is required.

Despite shattered expectations a willingness to care for elders remains with education and clinical supervision

The aim was to describe nursing home (NH) caregivers' work experiences while receiving education and clinical supervision for 2 years. Working in elder care seems to be losing its attraction especially with organizational changes, cutbacks and changes in work place conditions. Clinical supervision has been reported to increase job satisfaction and creativity. Semi-structured interviews from caregivers working at an NH in Sweden were conducted, at the start and again at 12 and 24 months. At about 12 months the caregivers were informed of planned cutbacks. Content analysis was the method used to analyse the interviews from seven caregivers who participated throughout the entire period. Findings show that the value of a caring milieu was one category generated by the subcategories: experiences related to work activities and changes, and experiences related to relationships. The value of knowledge was the other category that was influenced by the experiences related to the different backgrounds and the experiences related to increased knowledge gained from the support through education and clinical supervision. The categories contained positive as well as negative influences on care. The initial focus on practical duties associated with the opening of the NH shifted towards caregiver activities with the elders they spoke warmly about. After 2 years the caregivers' willingness to care continued despite their disappointment in the worsened working conditions. The main theme that resulted was: Despite shattered expectations a willingness to care for elders remained. Continued education and clinical supervision seems to be one factor behind the retained willingness. These findings demonstrate that support and caregiver involvement in educational programmes are important during times of change and when disappointments arise in the workplace.

Silent voices: Women, complementary medicine, and the co-optation of change

Despite the prominence of complementary and alternative medicine (CAM) in public and policy debates, our knowledge of the relationship between CAM and gender remains undeveloped. By tracing two dominant strands of research involving the women's health movement and the implications of CAM's increasing popularity among women, this article draws attention to the need for research addressing the roles of women as practitioners and students of CAM. It is argued that the medicalization and co-optation of CAM has serious implications for women's health by constraining CAM's potential to challenge, resist, and transform the hegemony and inequalities of biomedicine.

Midwifery managers’ views about the use of complementary therapies in the maternity services

The burgeoning interest in complementary therapies (CTs) in the general population over the last decade has created a demand for CTs to be made available within the NHS. There are some excellent examples of midwives who have introduced CTs into clinical practice and who are providing an enhanced service to women as a result [Budd S. Moxibustion for breech presentation. Complement Therap Nurs Midwifery 2000; 6(4): 176-9; Tiran D. Complementary strategies in antenatal care. Complement Therap Nurs Midwifery 2001; 7: 19-24; Ager C. A complementary therapy clinic, making it work. RCM Midwives J 2002; 5(6): 198-200; Burns E, Blamey C, Ersser S, Lloyd AJ, Barnetsson L. The use of aromatherapy in intrapartum midwifery practice: an observational study. Oxford: OCHRAD; 1999]. Overall, however, service provision remains patchy and ad hoc with little evidence of a robust integration into the maternity services. This article presents the qualitative findings from a national survey of the heads of maternity services in England. They were asked to indicate their views and perceptions about the benefits, promoters and constrainers in relation to CT integration within the maternity services. Our findings show that overall, views are positive, with increasing consumer satisfaction, promotion of normal childbirth and a reduction in medical intervention being seen as the main benefits.

A comparative analysis of contemporary nurses' discontents

AIM

This paper reports a study to evaluate and increase understanding of contemporary Registered Nurses' discontents, and to compare these discontents and their effects with those of nurses 20 years ago.

BACKGROUND

In 1986, Turner argued that nurses' discontents were reflected in a discourse or 'vocabulary of complaint' that provided a sense of solidarity amongst practising nurses, and defused their frustrations rather than channelling them into demands for workplace reform. In this paper, we revisit Turner's notion of a vocabulary of complaint in the context of a study of nurse retention in the contemporary Australian healthcare workplace.

METHODS

This paper draws on the qualitative data from a larger project (completed in 2001) exploring the relationship between job satisfaction and self-concept in both recently graduated and experienced nurses. Here, we elaborate on thematic analyses of the comments of 146 Australian Registered Nurses with more than 5 years' nursing experience.

FINDINGS

There is still a high level of discontent amongst contemporary practising nurses, although the focus of their complaints and their responses to them have changed since Turner's study. Conflicting expectations of nurses and managers and lack of opportunity to provide comprehensive care emerged as the most important issues for experienced nurses today. Rather than contributing to a sense of solidarity as in Turner's study, contemporary nurses' discontents reflect intense personal frustration and underpin individual nurses' decisions to leave, or plan to leave, the workforce.

CONCLUSION

There is an urgent need for increasing health service management and community awareness about the relationship between providing comprehensive nursing care and nurses' job satisfaction. Addressing nurses' discontents, wider nursing involvement in the international policy arena, and the politicization of nurses worldwide may contribute to alleviating the current global nursing shortage.

Actions speak louder than words: mainstream health providers' definitions and behaviour regarding complementary and alternative medicine

The purpose of this paper is to explore how mainstream practitioners define and categorize complementary and alternative medicine (CAM) as one component of assessing their views. The following themes emerged from interviews with Canadian physicians, midwives and nurses: epistemological, evidence-based, medical domain, political-regulatory, funding-based, and role-based definitions of CAM. We also assess any possible links to their behaviour vis-à-vis CAM. We found that classifying something as CAM does not appear to inhibit most providers from recommending, referring for, or supporting their patients' use of these treatments. In conclusion, we highlight that despite their clear definitional boundaries around CAM, providers tend to evaluate each individual therapy on its own merits, taking other situational factors into consideration.

Working in London hospitals: Perceptions of place in nursing students’ employment considerations

During the past decade, a distinct body of research has started to investigate the dynamics between nursing and place. However, despite attention being paid to a wide-range of nursing subjects, few studies have engaged with the important topic of labour force recruitment. In this context, this study uses a combined questionnaire (n=650), interview (n=30) and focus group (n=7) survey of London-based students, and investigates the complex mix of experiences and perceptions that result in hospitals having varying degrees of popularity as potential workplaces. The findings suggest experiences and perceptions of institutions-often gained on clinical placements-to be important, particularly relating to feeling valued, the quality of patient care, clinical and educational opportunities and team cohesion. These are often combined with experiences and perceptions of locality, relating to factors such as cost of living, travel considerations and sense of personnel safety. The study demonstrates that place is relevant to employment decision-making on multiple scales from wards to regions. Furthermore, that perceptions of potential workplaces result from engagements with complex mixes of cultural, economic and physical features, many of which are the consequences of management. It is argued that in order to effectively unpack workplaces, geographical research of nursing labour may benefit from researching simultaneously both 'inside' institutions, focusing on their dominant cultures of production and sub-cultures, and 'outside', focusing on their local urban or rural contexts.

Place(ment) matters: students' clinical experiences and their preferences for first employers

BACKGROUND

Although a significant volume of nursing research has focused on students' experiences of clinical placements, to date, none has considered these experiences in the context of workforce recruitment and specifically how they may impact upon preferences for working for health care providers.

METHODS

In this context, the research used a place-sensitive geographical perspective and a combined questionnaire (n = 650), interview (n = 30) and focus group (n = 7) method to collect data on the complex range of clinical experiences which together impact upon the perceived attractiveness of different health care settings.

FINDINGS

The data identified a range of experiential factors associated with mentorship, ward management, learning opportunities and racism. An important finding was that although students' experiences are obtained at the micro ward level, even if they may not necessarily reflect what happens throughout the hospital, they potentially impact, both positively and negatively, upon their broader perceptions of the hospital and the likelihood of seeking work there.

IMPLICATIONS

The study highlighted a variety of issues that should be addressed by both higher education institutions and hospitals so that they may be able to provide a more consistent and positive experience for students. In the longer term, this may pay dividends through increased recruitment of new graduates.

Petit bourgeois health care? The big small-business of private complementary medical practice

Although small business private complementary medicine (CAM) has grown to be a significant provider of health care in many Western societies, there has been relatively little research on the sector in business terms and on its wider socio-economic position and role. Using a combined questionnaire and interview survey, and the concept of small business petit bourgeoisie as a framework, this paper considers the character of therapists and their businesses in England and Wales. The findings suggest that typical of the core characteristics of both the petit bourgeoisie and therapists are the selling of goods with a considerable market viability, at the same time financial insecurity; the modest size of businesses; small amounts of direct employment generation and business owners undertaking everyday 'hands-on' work themselves. Certain of the therapists' and business characteristics depart from the stereotypical image of a small businesses class, such as the high incidence of part-time self-employment and incomes being supplemented often by unrelated waged employment. However, given the acknowledged diversity of the petit bourgeoisie between societies and over time, the framework is arguably appropriate in this context, and private CAM a latest guise. Indeed, just as the petit bourgeoisie have traditionally found market niches either neglected or rejected by bigger business, small business CAM has provided the forms of health care neglected and sometimes rejected by orthodox medicine.

Towards a typology of nursing turnover: the role of shocks in nurses' decisions to leave

AIMS

The paper reports a study to explore the decision process nurses go through before leaving, focusing on leaving decisions that are precipitated by a single, jarring event or shock.

BACKGROUND

Nursing turnover is a significant problem. Although a range of initiatives has been adopted to improve retention, recent insights from the academic literature on labour turnover have additional implications for how this problem might be managed.

METHOD

A structured questionnaire, with some open-ended items, was used to collect data. For respondents who reported a shock (n = 153), responses were cluster analysed (hierarchical, agglomerative clustering generated a solution and k-means clustering enhanced the solution). Clusters were validated using responses to open items.

RESULTS

There were three broad clusters of nursing turnover: cluster 1 described nurses whose decision to leave was precipitated by a shock that was work-related, negative and unexpected; cluster 2 described those whose decision was precipitated by a shock that was personal, positive and expected; cluster 3 describes those whose decision unfolded more gradually. Cluster 3 described the conventional picture of how turnover occurs (i.e where there is no shock), whereas clusters 1 and 2 were evidence of different types, where a shock prompts the quitting.

CONCLUSION

In many cases of nurse turnover, a single, jarring event, or shock, initiates thoughts of quitting. Understanding the role of shocks has implications for a range of management activities. Allocation of education, promotion and distribution of other benefits should be managed in such a way as to minimize the likelihood of shocks. Profiling of nurse leavers should be undertaken so that managers have an accurate and detailed picture of turnover.

Perceptions of nursing: confirmation, change and the student experience

Research has identified a number of negative societal perceptions of nursing related to gendered stereotyping, subordination to doctors, low academic standards, limited career opportunities and poor pay and conditions, and importantly how these perceptions may affect levels of recruitment into nursing. Focusing specifically on nurses, research has also considered the extent to which these societal perceptions are realities in their workplaces, and the direct experiences that contribute to attrition from both nursing courses and jobs. However, to date, few research has actually bridged the above approaches and considered the perceptions that nursing students hold as they first enter their education and how these change, or are confirmed, as a result of their experiences. In this context, the current study uses a combined questionnaire (n = 650), interview (n = 30) and focus group (n = 7) methodology to investigate the experiences of students based at two British Universities. The findings suggest that many students were surprised, yet not overwhelmed, by the high academic standards required of them and came to recognize and value the tremendous knowledge, skills set and responsibilities of nurses as they acquired them. However, their experiences reinforced both society's and their own image of an underpaid, overworked profession that lacks respect and has low morale. The findings support media initiatives that emphasize nurses' skills in order to influence public opinion. They also support a range of subtle changes in nurse education at the institutional level to make student life easier. Nevertheless, it is acknowledged that these may have a limited impact unless pay and conditions are adequately addressed at the national level.

Sharing the spirit of the policy agenda? Private complementary therapists’ attitudes towards practising in the British NHS

During recent years, complementary medicine (CM) has grown as a significant provider of health care in the UK, the majority of this provision being allocated through the small private business sector to privately paying clients. Given the substantial demand for CM, the government acknowledges its structural integration with orthodox medicine (OM) to be a logical progression. However, although the time frame, evidence bases and regulatory structures are as yet undetermined, key to the current emphasis on integration is an underlying assumption that private sector providers would be willing participants, potentially alongside nurses. In this context, using a combined questionnaire (n=426) and interview (n=49) survey, this paper makes an initial exploration and considers the current connections that private therapists have with OM and their attitudes towards collaborating with and working within the NHS. The majority of therapists claimed not to have existing business connections with NHS providers, though many stated that they had established some form of informal arrangements. In general, therapists were happy that they had experienced increasingly positive reactions from orthodox clinicians towards their therapies. The overwhelming majority of therapists were positive about the proposition of working within OM but did have certain reservations. Given the range and intensity of opinion found in this initial investigation, the paper concludes by signposting some substantive avenues of focused research inquiry on the structural integration of CM and OM.

The geography of complementary medicine: perspectives and prospects

While complementary and alternative medicine (CAM) research has benefited from a range of social scientific perspectives, geographical contributions have been only slowly forthcoming. In this context, this paper illuminates the possibilities for CAM researchers to develop dedicated geographical perspectives. Some fundamental changes in the empirical and theoretical foci of medical/health geography are outlined, from a concern with mapping services and diseases in macro-space to investigating the dynamic between health and place. Highlighted are some important relational dynamics among CAM providers, patients/consumers and places of treatment and some general issues that could benefit from a geographical analysis. The concurrent research agenda is located across the sub-disciplinary strata of human geography.

Public, nurse and medical practitioner attitude and practice of natural medicine

In the past 20 years, the popularity of natural medicine has increased, with nurses and medical practitioners being amongst several groups of clinicians expressing a widespread interest in natural therapies. It is argued that the degree of natural therapy use and the attitudes of these practitioners toward natural medicine may not only influence patient exposure to these therapies, but also have some bearing on the future use of natural medicine. Hence, in a critical review of recent studies, the utilisation of natural therapies and the attitudes of nurses, medical practitioners and the public toward natural medicine are explored.

Placing the consumption of private complementary medicine: everyday geographies of older peoples’ use

Using a combined questionnaire and interview survey of older users of complementary medicine, an interpretative framework is developed to examine their consumer behaviour. Collectively, three inter-related levels of interpretation provide a detailed description of complementary medicine as a consumer experience very much associated with particular places and settings. First, structural features of two local private sectors are investigated, including the different organisational modes and local cultures of provision. Second, experiential features are investigated, including how treatment impacts on older users' use of space and on their personal mobility. Third, conceptual features are investigated, including how older users articulate the belief systems associated with complementary medicine. Overlying these levels are a wide-variety of therapeutic settings that make up the total therapeutic experience. These range in scale from the micro-level of clinics and users' homes to the macro-level of towns. The paper unravels the complex, individualized, dispersed and everyday consumer geographies associated with these emerging forms of health care, highlights the intimate dynamics that exist between places and care and showcases how these may be effectively mapped by using qualitative methods and a critical theoretical framework.