Determining the relative salience of recognised push variables on health professional decisions to leave the UK National Health Service (NHS) using the method of paired comparisons.

OBJECTIVE: The primary and secondary impacts from the COVID-19 pandemic are claimed to have had a detrimental impact on health professional retention within the UK National Health Service (NHS). This study set out to identify priorities for intervention by scaling the relative importance of widely cited push (leave) influences. DESIGN: During Summer/Autumn 2021, a UK-wide opportunity sample (n=1958) of NHS health professionals completed an online paired-comparisons exercise to determine the relative salience of work-related stress, workload intensity, time pressure, staffing levels, working hours, work-homelife balance, recognition of effort and pay as reasons why health professionals leave NHS employment. SETTING: The study is believed to be the first large-scale systematic assessment of factors driving staff exits from the NHS since the COVID-19 pandemic. RESULTS: All professions gave primacy to work-related stress, workload intensity and staffing levels. Pay was typically located around the midpoint of the respective scales; recognition of effort and working hours were ranked lowest. However, differences were apparent in the rank order and relative weighting of push variables between health professions and care delivery functions. Ambulance paramedics present as an outlier, notably with respect to staffing level (F-stat 4.47, p=0.004) and the primacy of work-homelife balance. Relative to staffing level, other push variables exert a stronger influence on paramedics than nurses or doctors (f 4.29, p=0.006). CONCLUSION: Findings are relevant to future NHS health professional retention intervention strategy. Excepting paramedics/ambulance services, rankings of leave variables across the different health professional families and organisation types exhibit strong alignment at the ordinal level. However, demographic differences in the weightings and rankings, ascribed to push factors by professional family and organisation type, suggests that, in addition to signposting universal (all-staff) priorities for intervention, bespoke solutions for different professions and functions may be needed.

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

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

Self-preservation comes at a cost: Why British National Health Service paramedics might be choosing a healthier, but poorer, retirement.

OBJECTIVES: To explore and portray the perspectives of National Health Service Ambulance personnel related to the latest rise in the National Health Service occupational pension age. METHODS: Data gathering took the form of 35 in-depth interviews. A thematic analysis was used to characterise and articulate key concepts and meanings. The analysis applied interpretive techniques, as views expressed were from personal experiences, and allowed for an in-depth analysis of shared meanings. RESULTS: The themes reported captured the desire of many Ambulance personnel to exit their employment well in advance of their retirement age, despite satisfaction gained from patient care. This early exit is being driven by increased worry that the work demands of the job are unsustainable, especially for older workers, as clinical responsibilities increase and their social support diminishes. Also, Ambulance personnel feel betrayed by their employers, because their retirement is being delayed further by another change in their pensionable age. CONCLUSION: There is an increased orientation for 'living for today' and indications of a willingness to sacrifice salary and pension income in order to protect their health in older age, which has implications for long-term financial and general well-being in retirement.

Multiple triangulation and collaborative research using qualitative methods to explore decision making in pre-hospital emergency care.

BACKGROUND: Paramedics make important and increasingly complex decisions at scene about patient care. Patient safety implications of influences on decision making in the pre-hospital setting were previously under-researched. Cutting edge perspectives advocate exploring the whole system rather than individual influences on patient safety. Ethnography (the study of people and cultures) has been acknowledged as a suitable method for identifying health care issues as they occur within the natural context. In this paper we compare multiple methods used in a multi-site, qualitative study that aimed to identify system influences on decision making. METHODS: The study was conducted in three NHS Ambulance Trusts in England and involved researchers from each Trust working alongside academic researchers. Exploratory interviews with key informants e.g. managers (n = 16) and document review provided contextual information. Between October 2012 and July 2013 researchers observed 34 paramedic shifts and ten paramedics provided additional accounts via audio-recorded 'digital diaries' (155 events). Three staff focus groups (total n = 21) and three service user focus groups (total n = 23) explored a range of experiences and perceptions. Data collection and analysis was carried out by academic and ambulance service researchers as well as service users. Workshops were held at each site to elicit feedback on the findings and facilitate prioritisation of issues identified. RESULTS: The use of a multi-method qualitative approach allowed cross-validation of important issues for ambulance service staff and service users. A key factor in successful implementation of the study was establishing good working relationships with academic and ambulance service teams. Enrolling at least one research lead at each site facilitated the recruitment process as well as study progress. Active involvement with the study allowed ambulance service researchers and service users to gain a better understanding of the research process. Feedback workshops allowed stakeholders to discuss and prioritise findings as well as identify new research areas. CONCLUSION: Combining multiple qualitative methods with a collaborative research approach can facilitate exploration of system influences on patient safety in under-researched settings. The paper highlights empirical issues, strengths and limitations for this approach. Feedback workshops were effective for verifying findings and prioritising areas for future intervention and research.

A qualitative study of systemic influences on paramedic decision making: care transitions and patient safety.

OBJECTIVES: Paramedics routinely make critical decisions about the most appropriate care to deliver in a complex system characterized by significant variation in patient case-mix, care pathways and linked service providers. There has been little research carried out in the ambulance service to identify areas of risk associated with decisions about patient care. The aim of this study was to explore systemic influences on decision making by paramedics relating to care transitions to identify potential risk factors. METHODS: An exploratory multi-method qualitative study was conducted in three English National Health Service (NHS) Ambulance Service Trusts, focusing on decision making by paramedic and specialist paramedic staff. Researchers observed 57 staff across 34 shifts. Ten staff completed digital diaries and three focus groups were conducted with 21 staff. RESULTS: Nine types of decision were identified, ranging from emergency department conveyance and specialist emergency pathways to non-conveyance. Seven overarching systemic influences and risk factors potentially influencing decision making were identified: demand; performance priorities; access to care options; risk tolerance; training and development; communication and feedback and resources. CONCLUSIONS: Use of multiple methods provided a consistent picture of key systemic influences and potential risk factors. The study highlighted the increased complexity of paramedic decisions and multi-level system influences that may exacerbate risk. The findings have implications at the level of individual NHS Ambulance Service Trusts (e.g. ensuring an appropriately skilled workforce to manage diverse patient needs and reduce emergency department conveyance) and at the wider prehospital emergency care system level (e.g. ensuring access to appropriate patient care options as alternatives to the emergency department).

Risk, trust, and safety culture in U.K. train operating companies.

Organizational safety culture reflects the attitudes and behaviors that individuals share in considering and reacting to hazards and risks. We first argue that trust is an underdeveloped and important concept in relation to theories of safety culture and high-reliability organizations. The article then reports findings from a two-year qualitative study of train operating companies (TOCs) in the United Kingdom, which sought to explore in detail the linkages between safety culture and the postprivatized railway industry. In-depth interviews and focus groups were carried out with a sample of over 500 employees, from four organizations, and representing all key functional levels. Our analysis suggests that the 1993 privatization, and subsequent organizational restructuring of the U.K. railway industry, has had important repercussions for both safety culture and trust relationships. We explore our findings in relation to three key constructs within "safe organizations" theories (namely, flexibility, commitment, and learning), and discuss how the safe organization model might be usefully supplemented by a consideration of trust issues.

Investigation into issues of passenger egress in Ladbroke Grove rail disaster.

This paper provides an overview of findings from the Health and Safety Laboratory investigation into human factors issues surrounding passenger escape and evacuation in the Ladbroke Grove train crash (1999). Drawing upon a range of contextual information the investigation focused upon identifying barriers and delays to evacuation following the incident. Findings highlight a number of important design shortcomings, as well as scope for the enhancement of both passive and active communication systems. The need to take account of passengers' mental models, intuitions and situation awareness when designing communication systems and emergency egress equipment for the railway carriage environment is highlighted.

Investigating the influence of organizational role on perceptions of risk in deep coal mines.

The authors replicated O. Ostberg's (1980) study of forestry workers using a range of personnel groups in coal mines. Findings demonstrate a high level of consensus between a range of personnel groups for a set of pictorially depicted behavioral risks, at the level of rank order, but significant differences in terms of relative magnitudes. Magnitudes of perceived risk were found to be greater for those closest to the point of hazard than for members of more geographically and experientially distal groups. Findings are interpreted with reference to experiential influences associated with organizational role. Revealed differences between personnel groups are explained in terms of cognitive availability, specifically effects associated with habituation and familiarity with risk, these sources of perceptual bias appearing to interact with organizational role.