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 [913]. 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 ones job may result in higher employee turnover, absenteeism, and grievances. Improved job satisfaction, on the other hand, results in increased productivity [18]. From the employees 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 highperformance 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 Bartletts 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 NonResident 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 dont 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.

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 Female Marital Status Married Unmarried Practice < 1 year > 1 year Age 17-25 26-35 36+ Education undergraduate graduate postgraduate Nature of Work Doctors Nurses & paramedics Administrators Income upto 10,000 20.5% 18.9% 26.6% 16.6% 17.9% ( ( ( ( ( 164 151 213 133 143 ) ) ) ) ) 10,000-20,000 20,000-30,000 30,000-40,000 >40,000 38.9% 37.1% 24.7% ( ( ( 311 297 198 ) ) ) 11.6% 54.7% 34.5% ( ( ( 93 438 276 ) ) ) 18.7% 52.1% 30% ( ( ( 150 417 240 ) ) ) 76.1% 24.7% ( ( 609 198 ) ) 62.4% 38.4% ( ( 499 307 ) ) 57.6% 43.2% ( ( 461 346 ) )

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

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.

designed to indicate a job characteristic that has been known to contribute to job satisfaction.
TABLE III Factor Job Item Salary and financial benefits Non Financial Incentives Policies related to Employees Facilities for Employee comfort Work Facilitation Sense of Accomplishment Self Esteem Freedom on Job Work Overload Exhaustion from Work Work Stress Innovation through Automation Information Technology Requirement Technical Support of IT Interesting and Motivating Challenge Skill Variety Factor Loading 0.6814 0.6482 0.6699 0.6796 0.6586 0.7341 0.7186 0.6187 0.8540 0.6086 0.6145 0.8383 Work Life Balance Factor Name Compensation and Perks

Sense of Accomplishme nt Work Load Leading to Exhaustion

0.6815 0.7904 0.9062 0.6788 0.7142

Automation and Technology Improvement

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

Break Monotony of the Work

% Dissatisfied Doctors Nurses & Paramedics Administrators < 1 year Experience > 1 year Experience Public Private Urban Rural 62 19 18 78 22 43 57 65 35

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

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

Component 1 2 3

Total 2.59 0.93 0.83

% of Variance 59.50 21.44 19.06

Cumulative % 59.50 80.94 100

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 Duncans 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

Need for Automation and technology improvement Break Monotony of Work

2.66

1.41

2.51

1.17

1.17 NS

2.87

1.09

2.69

0.91

1.74 NS

NS : Not Significant * Significant at 0.05 level level

** Significant at 0.01

Factors of Attrition Compensation and Perks Work life balance Sense of accomplishmen t Work load leading to exhaustion Need for Automation and technology improvement Break Monotony of Work

Male ( N= 462) Mean SD 3.31 3.32 3.03 1.16 1.15 0.92

Female ( N= 345) Mean SD 3.27 3.08 2.94 1.03 0.98 0.83

tvalue

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

0.35 NS 2.24 ** 0.97 NS 1.56 NS 1.84 NS

Factors of Attrition Compensation and Perks Work life balance Sense of accomplishment Work load leading to exhaustion Need for Automation and technology improvement Break Monotony of Work

Upto 1 year ( N= 609 ) Mean SD 3.35 1.12 3.28 3.01 3.13 1.09 0.88 0.96

>1 year ( N=198 ) Mean SD 3.11 1.05 3.01 2.93 3.19 1.07 0.91 0.86

3.21

1.01

3.06

0.82

t value 1.88 NS 2.09* 0.75 NS -0.61 NS 3.62**

2.71

1.43

2.46

1.16

2.94

1.10

2.63

0.88

3.07 **

3.12

0.98

2.77

0.77

NS : Not Significant * Significant at 0.05 level 0.01 level

** Significant at

2.87

1.07

2.61

0.86

2.33*

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

NS: Not Significant * Significant at 0.05 level level

** Significant at 0.01

Factors of Attrition Compensation and Perks Work life balance Sense of accomplishment Work load leading to exhaustion

Married ( N= 500) Mean SD 3.37 3.33 3.05 3.24 1.05 1.08 0.92 0.98

Unmarried ( N= 307) Mean SD 3.16 3.03 2.90 2.99 1.18 1.07 0.82 0.83

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.

t - value

1.72 NS 2.71 NS 1.75 NS 2.69 **

Table VIII COMPARISON OF FACTORS STUDIES AMONG RESPONDENTS OF NATURE OF WORK GROUPS ( W1 = MEDICAL PROFESSIONALS , W2 = NURSING AND PARAMEDICS , W 3 = ADMINISTRATION) - DUNCANS MEAN TEST

Factors of Attrition Compensation and Perks Work life balance Sense of accomplishment Work load leading to exhaustion Need for Automation and technology improvement Break Monotony of Work

W1 ( N = 312 ) Mean SD 2.88 .84 2.65 2.67 2.88 2.17 .78 .49 .81 .73

W2 ( N=297) Mean SD 3.03 .71 2.80 2.77 2.94 2.40 .55 .49 .74 .72

W3 ( N=198 ) Mean SD 2.53 .80 2.44 2.6 2.9 2.17 .70 .55 .84 .69

F- Value

11.52** 7.77** 3.39** .24 NS 4.24**

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/- ) - DUNCANS MEAN TEST

Factors of Attrition

I1 ( N = 165 ) Mean 3.00 2.73 2.81 3.01 2.47 SD .69 .47 .51 .69 .78

I2 ( N=152) Mean 2.87 2.66 2.68 2.95 2.39 SD .88 .68 .50 .77 .63

I3 ( N= 213) Mean 2.61 2.57 2.65 2.74 2.18 SD .85 .80 .56 .72 .75

I4 ( N=132) Mean 2.99 2.79 2.83 2.95 2.24 SD .77 .75 .49 .82 .69

I5 ( N= 144) Mean 2.9 2.57 2.50 2.95 1.98 SD .73 .67 .38 .97 .65

FValue 3.45** 1.49 NS 4.93** 1.57** 5.29**

Compensation and Perks Work life balance Sense of accomplishment Work load leading to exhaustion Need for Automation and technology improvement 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

Compensation and Perks

Urban (N= 586) Mean 2.98

Rural (N=221) Mean 3.60

t - value

3.82*

Public (N= 318) Mean 0.72

Private (N=489) Mean 0.85

t - value

0.91 NS

Work life balance Sense of accomplishment Work load leading to exhaustion Need for Automation and technology improvement Break Monotony of Work

2.95 2.85 3.11 2.44 2.67

3.90 3.38 3.22 3.03 3.16

2.82** 3.06* 1.16** 3.62** 0.97 NS

0.66 0.5 0.86 1.10 0.67

0.71 0.52 0.74 0.88 0.69

0.7 NS 0.3 NS 2.98** 3.07 ** 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.

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).

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 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 physicians 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, workfamily 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.

Compensation and perks

(Industry Standard & work based)

Employee Expectations

Work-Life Balance
(Flexi time, leave benefits)

Self Accomplishment
(autonomy, collaborative decisions)
Net Impact of Factors

Start of Job

Work Load and Stress

(Proper distribution of work)

R E D U C E D A T T R I T I O N

IT
(Proper training and usage, new technologies)

Organization Inputs

Job Enrichment (new skill training, job rotation)

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 twofactor 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 Indias 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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