ORIGINAL RESEARCH

Do nurses wish to continue working for the UK National Health Service? A comparative study of three generations of nurses Andrew Robson & Fiona Robson Accepted for publication 24 May 2014

Correspondence to F. Robson: e-mail: [email protected] Andrew Robson MSc (Eng) PhD PGCEd Principal Lecturer Newcastle Business School, Northumbria University, UK Fiona Robson MA PhD Principal Lecturer Newcastle Business School, Northumbria University, UK

R O B S O N A . & R O B S O N F . ( 2 0 1 5 ) Do nurses wish to continue working for the UK National Health Service? A comparative study of three generations of nurses. Journal of Advanced Nursing 71(1), 65–77. doi: 10
1111/jan.12468

Abstract Aim. To identify the combination of variables that explain nurses’ continuation intention in the UK National Health Service. This alternative arena has permitted the replication of a private sector Australian study. Background. This study provides understanding about the issues that affect nurse retention in a sector where employee attrition is a key challenge, further exacerbated by an ageing workforce. Design. A quantitative study based on a self-completion survey questionnaire completed in 2010. Methods. Nurses employed in two UK National Health Service Foundation Trusts were surveyed and assessed using seven work-related constructs and various demographics including age generation. Through correlation, multiple regression and stepwise regression analysis, the potential combined effect of various explanatory variables on continuation intention was assessed, across the entire nursing cohort and in three age-generation groups. Results. Three variables act in combination to explain continuation intention: work–family conflict, work attachment and importance of work to the individual. This combination of significant explanatory variables was consistent across the three generations of nursing employee. Work attachment was identified as the strongest marginal predictor of continuation intention. Conclusion. Work orientation has a greater impact on continuation intention compared with employer-directed interventions such as leader–member exchange, teamwork and autonomy. UK nurses are homogeneous across the three agegenerations regarding explanation of continuation intention, with the significant explanatory measures being recognizably narrower in their focus and more greatly concentrated on the individual. This suggests that differentiated approaches to retention should perhaps not be pursued in this sectoral context. Keywords: age, nurses, nursing, retention, UK, workforce

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Why is the research or review needed? • Retaining nurses is problematic worldwide, with nurse attrition resulting in negative implications for both service provider and patient experience. • Existing research suggests differences in intention to remain in nursing between age-generations. To date, this has not been investigated in the UK context. This is addressed here with a study involving nurse participation across two National Health Service Foundation Trusts.

What are the key findings? • Significant associations were found between continuation intention and each of leader–member exchange, work/family conflict, attachment and importance of work. • There were no significant differences in intention to turnover between the three age-generation groups. • The consistency of explanation for continuation intention in each generation band was unexpected and contrasted with patterns exhibited in the original Australian study.

How should the findings be used to influence policy/ practice/research/education? • The impact of individual characteristics on nurses’ continuation intention suggests that Human Resource professionals should design selection strategies prioritizing identification of nursing candidates who exhibit higher attachment to work and have greater orientation towards the importance of working. • Hospital managers should maintain understanding of the generational differences in values and behaviours, despite the commonality of continuation intention in terms of intensity and explanatory measures reported here. • Hospital managers should reflect in general terms on how nurses’ work and how the related environment can be packaged to focus more clearly on patient care, given propensity for greater loyalty to the patient compared with that afforded to the organization.

Introduction Global nursing shortages prevail (Cowden & Cummings 2012); therefore, a key challenge for leading economies is to retain their staff and minimize their intentions to leave (Loan-Clarke et al. 2010), including Canada (Zeytinoglu et al. 2011), USA (Palumbo et al. 2009) and Australia (Hendricks & Cope 2012). In the UK, the National Health Service (NHS) is particularly large and complex, its professional employees being subject to increased accountability (Veronesi & Keasey 2010) and ongoing changes to organizational structure 66

(Veld et al. 2010). Both factors have a potential impact on nurse retention, which has a detrimental impact on the sector’s modernization agenda (Storey et al. 2009). Intention to leave the sector and profession is further reinforced by an ageing workforce (Carter & Tourangeau 2012), a critical issue compounded by an increasingly older age profile for new recruits (Buchan & Seccombe 2010). The cost implications for the NHS have been significant, as replacing an individual nurse is estimated to cost £5000 per vacancy and the unit cost of training to Registered Nurse level is £50,000 (Shields & Ward 2001). Indirect costs, including reduction in productivity and organizational knowledge losses, also exist and are more challenging to assess (Jones & Gates 2007). High turnover has a negative impact on patient care (O’Brien-Pallas et al. 2006) and patient mortality (Apker et al. 2009) providing further rationale to retain existing staff. Significant attrition of skilled staff increases deployment of temporary replacements, thus increasing costs and diminishing supervision quality and care provision (O’Brien-Pallas et al. 2010). Reduction of leave intention and actual turnover can provide benefits including higher returns on training investment and improved hospital and sector reputation (Bland Jones & Gates 2007), enhancing support and development for future professional recruits (Armstrong-Strassen & Schlosser 2010), improving patient satisfaction and safety (Page 2004) and ensuring general maintenance of sectoral quality standards. The extant literature highlights the potential impact of various determinants on leave and continuation intention, including leader–member exchange (LMX), work–family conflict, teamwork, autonomy, work attachment, work importance and flexible arrangements to work. Related research exists in Australia (Hendricks & Cope 2012, Shacklock & Brunetto 2012), although its UK equivalent has yet to materialize. This gap is highlighted in the metaanalysis of Hayes et al. (2012), where only one study from their sample of 64 was UK based. This research seeks to provide understanding of continuation intention from the UK perspective by replicating the survey of Shacklock and Brunetto (2012) and by doing so, outlining potential consequences for NHS policy.

Background Generational diversity Kupperschmidt (2000, p. 66) defines a ‘generation of employees’ as an ‘identifiable group that shares birth, years, age, location and significant life events at critical

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Do nurses wish to continue working for the UK National Health Service

developmental stages’. This resonates with later work (Cennamo & Gardner 2008, Angeline 2011) by suggesting that employees from different generations may differ in work and social values. Assessment by generation band and associated affiliation rather than specific age is merited from a nursing perspective by Tourangeau et al. (2010). Three commonly used generation groupings used in cross-study comparisons are Baby boomers, Generation X and Generation Y, a summary of corresponding characteristics presented in Table 1. Failure of organizations and managers to recognize different generational values may lead to negative organizational outcomes (Kupperschmidt 2000, Smola & Sutton 2002); examples include communication, reduced organizational commitment and higher leave intention (Wong et al. 2008). In health care, Carter and Tourangeau (2012) identified limited evidence that older nurses exhibited lower turnover intentions, whilst the survey of 900 Australian nurses by Shacklock and Brunetto (2012) recognized differences in response across three generations with regard to various work-centred measures. Hendricks and Cope (2012) signpost the importance of recognizing and responding appropriately to generational differences and indicate work-related implications for nurses, managers and policy makers. LeVasseur et al. (2009) propose that enhanced organizational recruitment and retention plans account for differing generational needs, with successful response to generational diversity representing recruitment advantage, especially in attracting younger nurses into the profession (Hendricks & Cope 2012). Policy development (either externally by NHS decision-makers or internally via HR Departments) in isolation is arguably insufficient, with Disch (2009) emphasizing the

need for nurse managers to understand and respond practically for inter-generational differences. There is limited evidence that understanding generational diversity has been examined by either academic or healthcare audiences, despite the fact it may provide useful information to help shape associated organizational practices. This study responds to the assertion of Shacklock and Brunetto (2012) that generational diversity represents a valuable research opportunity. Work-related variables In terms of nurse retention and leave intention, there are numerous work constructs exhibiting influence (Coomber & Barriball 2007). This study focuses on seven such variables and their potential impact on nurses’ intentions to continue working, as well as considering how intention to leave itself is conceptualized, consistent with the original Australian study (Shacklock & Brunetto 2012). Intention to leave Intention to leave or turnover intention is regularly applied in nursing-related studies, alongside wider management research, given the effectiveness of these measures as predictors of actual turnover (Cox & Todd 2000). This is reflected more recently in the meta-analysis by Hayes et al. (2012), comprising identification and assessment of 68 related studies. Given the nursing context presented in this study, leave intention resonates sufficiently well with actual leaving behaviours as indicated, although alternative measures are identified in the literature (Flinkman et al. 2010), alongside their respective strengths and shortcomings. Central to this study is the use of validated scales employed by Shacklock and Brunetto (2012), hence it is appropriate to

Table 1 Overview of generational groupings. Born between

Work characteristics (adapted from Cennamo & Gardner 2008)

Baby boomers

1945–1964

Generation X

1965–1981

Generation Y

1982–2000

Strong focus on hard work and achievement. Value status and extrinsic recognition for loyalty and commitment. Good workplace relationships are important. May prefer organizations who provide opportunities to learn new skills, personal improvement and creativity at work are important. Demonstrate independence and autonomy in the workplace. Have lower expectations of job security. Commitment may be more focused towards own career (rather than their organization). May prefer organizations that value skills development, productivity and work–life balance. Most adaptable generation in terms of technological skills. Values intrinsic elements of work to remain marketable. Demonstrates freedom work values.

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A. Robson and F. Robson

correspondingly deploy both their definitions and measurement tool here. Leader–member exchange (LMX) The nurse–manager relationship is crucial to organizational outcomes (Van der Heijden et al. 2010) and specifically nurses’ leave intention (Shacklock & Brunetto 2012). LMX was originally introduced by Dansereau et al. (1973), referring to the quality of the exchange relationship between employees and managers. Where positive relationships exist, it is posited that this leads to mutually positive outcomes, realized through enhanced employee commitment and demonstration of additional workplace effort (Joo 2010). These outcomes potentially lead to reduced turnover intention (Maertz & Griffeth 2004). Regarding health care, Chen et al. (2008) reported that higher levels of LMX-enhanced commitment were associated with significantly reduced levels of nurse turnover. From the Australian perspective, Shacklock and Brunetto (2012) found that intention to continue working was significantly and positively related to supervisor– subordinate relationship quality, particularly for Generation X. Work–family conflict Work–family conflict encapsulates employee challenges arising from competing priorities for time and resources. This traditionally involved childcare, but has extended more recently to capture wider caring obligations such as the need to look after elderly parents or relatives. Grzywacz et al. (2006) confirm the significance of this challenge for nurses, a majority of their respondents indicating regular chronic work-driven interference with family responsibilities. In their Finnish study, Flinkman et al. (2008) reported association between poor perceptions of work–family conflict and leave intention, whilst Shacklock and Brunetto (2012) identified a negative relationship with continuation intention. The latter was particularly significant for the Baby boomers. Teamwork The benefits of teamwork in nursing and medical professions have been recognized by Thomas et al. (2003), pointing to positive outcomes for patients and associated care quality. Teamwork’s omission as a key theme in two recent meta-analyses (Flinkman et al. 2010, Hayes et al. 2012) contradicts previous research (Estryn-Be0 har et al. 2007, p. 939) that provided the powerful conclusion ‘A serious lack of teamwork seems to be associated with a fivefold risk of intention to leave in seven countries’. 68

Tourangeau et al. (2010) report that their focus-group participants identified working effectively as a team reduced their quit intentions, whilst the Baby boomers exhibited significant associations between both teamwork and work relationships with turnover intention (Shacklock & Brunetto 2012). Autonomy Role autonomy relates to the extent to which employees can control role-related tasks and work. For nurses, autonomy has been considered in isolation and as part of a broader remit (O’Brien-Pallas et al. 2006), the latter involving incorporation into wider ‘professional practice’. Autonomy has been identified as exhibiting a negative relationship with leave intention (Davidson et al. 1997). From the Australian perspective, Baby boomers exhibited significant association between high autonomy levels and continuation intention (Shacklock & Brunetto 2012). Attachment to work In health care, work attachment is particularly important, given the plethora of stakeholders with whom nurses may form attachment, particularly care recipients (Buchan 2002). Moore (2001) and Angerami et al. (2000) provided evidence that nurses’ attachment and professionalism mediated their leave intentions, compensating for dissatisfaction with other work areas or the organization. Work attachment’s impact on continuation is endorsed for all three nursing generations, particularly its relative marginal effect for Generation Y (Shacklock & Brunetto 2012). Importance of work Individuals working in organizations have various commitments and obligations. Importance of work refers to the positioning of ‘work’ in these individual preferences and has been assessed by researchers including the Meaning of Working International Research Team (1987). Shacklock et al. (2009) demonstrated that older employees regarding work as an important part of their lives have a higher continuation propensity. More recently, Shacklock and Brunetto (2012) revealed that importance of work was significantly related to continuation intention sector-wide, with a particularly strong role for Baby boomers. Flexible work arrangements Flexible work arrangements are highly valued by nurses (Loan-Clarke et al. 2010), evidence suggesting that availability of flexible working options associates with declining © 2014 John Wiley & Sons Ltd

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leave intention. Flexible working advantages have been widely reported from a nursing perspective. Brookes and Swailes (2002) further highlight these organizational benefits, claiming that the NHS is actively seeking to widen its related practices. This priority is ongoing, in part, being a consequence of the Improving Working Lives Initiative, requiring NHS Boards to evidence flexible working commitments (Mercer et al. 2010). Zeytinoglu et al. (2011) determined that part-time Canadian nurses had lower quit intentions than their full-time counterparts, although intention rates did not differ by alternative modes of flexible working. Where such arrangements are available for nurses, they have had a positive impact on work continuation, although this relationship was non-significant in the Shacklock and Brunetto (2012) study, either sample-wide or in any of the generation bands. This represented the only explanatory variable that made no significant contribution to leave intention. In the study presented below, the combined impact of the seven work-related variables considered above on nurses’ workcontinuation intention will be assessed group-wide and by age-generation.

The study Aim The aim of this study was to assess NHS nurses’ work-continuation intention, considering: Hypothesis 1: Differences exist in ‘intention to continue working’ between three age-generations. Hypothesis 2: ‘Intention to continue working’ is explained by a combination of LMX, work–family conflict, teamwork, auton-

Do nurses wish to continue working for the UK National Health Service

‘intention to continue working’. The regression analysis is conducted both sample-wide and by individual age band.

Sample/participants and data collection The population represents qualified NHS nurses, numbers exceeding 500,000 across numerous employment centres (Nursing & Midwifery Council 2009). This makes (quasi) random sampling for this study difficult, costly and timeconsuming. As such, attention was focussed only on NHS Foundation Trusts located in the same region as the researchers. Following protocol agreements with the regional NHS Research Ethics Committee (REC), the choice of NHS Trusts was determined by geography, targeting those with relatively close proximity to the researchers as indicated. In the corresponding NHS region, all foundation Trusts were invited to participate in the study, with two Trusts volunteering to take part. The number of nurses employed in the volunteering selected trusts, combined with anticipated participation of 20–30%, permitted the generation of a potential sample of around 400 participants that was sufficient to meet the research objectives. All nurses were eligible to participate, irrespective of mode of employment, each individual engaging in the study in his/her respective work schedule. Every potential participant received an introductory letter, study protocol and a copy of the questionnaire. Two reminders were sent as appropriate via the organizational ‘gatekeepers’. Completed questionnaires were anonymous, being securely returned directly to the researchers. Across the two trusts, 2000 questionnaires were distributed, resulting in 435 completed returns, a response rate of 21
75%. The time invested by each respondent in completing the questionnaire was about 30 minutes.

omy, attachment to work, importance of working and flexible working arrangements, for nursing professionals in their entirety and within each age-generation: Generation X, Generation Y and Baby boomers.

Design This study provides confirmatory analysis, based on hypotheses 1 and 2. It replicates the work of Shacklock and Brunetto (2012) by considering nursing professionals in the UK NHS. A sample of participants located in two NHS Trusts responded to a self-completion survey in Spring 2010, comprising pre-defined questions using validated scales. Data analysis comprises reliability analysis followed by correlation and multiple regression analysis to explain nurses’ © 2014 John Wiley & Sons Ltd

Survey instrument The questionnaire comprised four closed demographic questions, including age-generation, alongside 30 items covering seven scales and a dependent variable. The scales comprise LMX (Graen & Uhl-Bien 1995), work–family conflict (Netemeyer et al. 1996), teamwork (Rubin et al. 1994), autonomy (Spreitzer 1995), attachment to work (Spreitzer 1995), importance of working to the individual (Meaning of Working International Research Team 1987) and flexible working arrangements (Shacklock et al. 2009). The dependent measure ‘I want to continue working as a nurse for as long as I am able’ represented ‘intention to continue working’, based on developments by Shacklock et al. (2009), see Shacklock and Brunetto (2012) for details and examples of 69

A. Robson and F. Robson

particular items in each of the scale sets. A six-point Likert scale was used for each item, ranging from ‘strongly disagree’ to ‘strongly agree’. Minor modifications were made to item wording reflecting national differences in terminology.

Ethical considerations Initial approval was obtained from the University Ethics Committee with further endorsement provided by the local NHS REC, with organizational consent being granted after successful submissions to both Foundation Trusts. Anonymity in subsequent research outputs was guaranteed. The participants were not required to provide identifiable data and were afforded voluntary participation assurances.

Data analysis No consideration was given to data outliers, given the use of six-point Likert scales and closed demographics questions, beyond verification of correct coding. Assessment of non-response for each question was undertaken. The data were stored and analysed using IBM SPSS Statistics 20 (IBM, New York, NY, USA). Scale reliability has been assessed using Cronbach’s alpha coefficients, whilst standard summary statistics have been presented for the indices representing each scale (calculated using item mean scores, incorporating necessary reverse scoring). The substantive analysis centres on intention to continue working and its relationship with various explanatory variables. This involves tests of significance in absolute terms (one-sample t-test) to assess sectoral intention, as well as between age bands (one-way ANOVA), thus addressing hypothesis 1. Statistical significance, where evident, has been reported at standard levels (‘P < 0
05’, ‘P < 0
01’). No adjustments to Type I error rates have been used, as multiple hypothesis testing has not taken place. Correlation analysis involving intention to continue working and the explanatory variables was conducted,

followed by multiple regression analysis, the latter samplewide and for each generation band. The multiple regression analysis adopted the ‘Enter’ method of variable selection to assess all potential explanatory variables in combination, consistent with the Australian study. Stepwise regression was employed, thus ensuring collinearity of variables was tested prior to entry into the model (adopting ‘Stepwise’ in SPSS), results from both multiple regression approaches being reported.

Validity and reliability As indicated by Shacklock and Brunetto (2012), established and valid scale sets were employed, permitting validity to be assumed in this subsequent replication. High inter-item reliability levels are reconfirmed here. This is demonstrated by the alpha coefficients, displayed in Table 2, ranging from 0
656–0
923, all apart from two exceeding 0
8 (Bryman & Cramer 1994:72).

Results Sample overview Nurses (n = 435) responded to the survey, which they received. Initial data screening indicated almost full response across the questionnaire items, which combined into scales, resulted in only one explanatory measure having an individual missing score. The demographic measures yielded almost full response, generation band apart, where 15% of the 435 nurses chose not to respond. It is not possible to confirm why this group of participants did not want to provide demographic information; however, it is common for participants not to share information, which they think could be used to identify them, even when assurance of anonymity is provided by the researchers. Given the criticality of age to this study, any non-response to age resulted in case exclusion, thereby yielding a sample of 370 participants (18
5% of the target group).

Table 2 Assessment of scales by summary statistics and inter-item reliability (Cronbach’s alpha coefficients), n = 370. Construct

Mean

SD

Alpha-coefficient

No. of variables

Origin of scale

Leader–member exchange (LMX) Work–family conflict (WFC) Teamwork (TEAM) Autonomy (AUT) Attachment to work (ATT) Importance of working (IOW)

4
294 2
999 4
563 4
245 5
222 2
214

1
013 1
005 0
725 1
067 0
734 0
971

0
922 0
872 0
809 0
891 0
923 0
656

7 5 5 3 3 3

Flexible working arrangements (FWA)

3
650

1
182

0
725

3

Graen and Uhl-Bien (1995) Netemeyer et al. (1996) Rubin et al. (1994) Spreitzer (1995) Spreitzer (1995) Meaning of Working International Research Team (1987) Shacklock et al. (2009)

70

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For the amended sample, 95% were female, 62% Registered Nurses, 15% nurse managers and 9
5% clinical nurses, the remainder categorized as ‘others’. Respondents were asked about role tenure, results indicating varying experience, with 14% having served 0
05, d.f. = 3, 366).

Association between intention to continue working and potential explanatory variables The correlation analysis in Table 3 indicates statistically significant associations between continuation intention and LMX, work–family conflict, attachment to work and importance of working. The three remaining measures, more than in the original study, display non-significant association, team working (r = 0
068, P = 0
189 > 0
05), autonomy (r = 0
082, P = 0
116 > 0
05) and flexible working arrangements (r = 0
066, P = 0
208 > 0
05). The © 2014 John Wiley & Sons Ltd

Do nurses wish to continue working for the UK National Health Service

strongest association, albeit moderate in magnitude, relates to attachment to work (r = 0
401, P < 0
01), again resonating with Shacklock and Brunetto (2012). The correlations indicate inter-association between the explanatory variables. This, in addition to the non-significant associations above, suggests potential for various explanatory variables having no significant impact on continuation intention.

Regression analysis and comparison by age-generation To establish which combination of predictors best explain intention to continue working, multiple regression analysis involving this measure defined as the dependent variable was undertaken including all seven indices as the explanatory variables. This was undertaken sample-wide and separately by generation, as presented in Table 4. For the entire data, there is significance overall (F = 15
803, P < 0
01), with a moderate proportion, 21
9% of the variation in intention to continue working, explained by the linear model. Three predictors are seen to be statistically significant, with each P < 0
01, work–family conflict (b = 0
182), attachment to work (b = 0
631) and importance of working (b = 0
300), the remaining explanatory measures being non-significant. Stepwise analysis further confirms that the three significant measures identified are statistically significant in combination; model statistics (F-test, R2, b coefficients and P values) shown in Table 5. The Baby boomers analysis is similar, the explanation of intention to continue working statistically significant overall (F = 6
907, P < 0
01) and a moderate 20
8% of the variation explained by the linear model. Three predictors are statistically significant, the former at the 5% significance level, the remainder at the 1% level, these being work–family conflict (b = 0
187), attachment to work (b = 0
757) and importance of working (b = 0
377). The greatest marginal impact relates to attachment to work followed by importance of working. Stepwise analysis confirms the statistical significance of the three measures in combination, Tables 4 and 5 summarizing both models. For Generation X nurses, a significant overall explanation of the dependent variable is provided (F = 7
643, P < 0
01), with 23
1% of its variation being explained by the same three variables in combination being statistically significant. The first two variables have P < 0
01, the last measure with P < 0
05, namely work–family conflict (b = 0
243), attachment to work (b = 0
611) and importance of working (b = 0
191) as presented in Table 4. The variable exhibiting the greatest marginal explanatory power is attachment to work, with work–family conflict demonstrating greater 71

A. Robson and F. Robson

Table 3 Correlations between ‘intention to continue working’ and the explanatory variables. Continue intention

Leader–member exchange

Continue intention r 1
000 0
140† Sig (2-tailed) 0
007 Leader–member exchange r 1
000 Sig (2-tailed) Work–family conflict r Sig (2-tailed) Teamwork r Sig (2-tailed) Autonomy r Sig (2-tailed) Attachment to work r Sig (2-tailed) Importance of working r Sig (2-tailed) Flexible working arrangements r Sig (2-tailed)

Work–family conflict

Teamwork

Autonomy

Attachment to work

Importance of working

Flexible working arrangements

0
164† 0
002

0
068 0
189

0
082 0
116

0
401† 0
000

0
266† 0
000

0
066 0
208

0
101 0
051

0
340† 0
000

0
327† 0
000

0
240† 0
000

0
040 0
442

0
039 0
454

1
000

0
103* 0
048

0
158† 0
002

1
000

0
077 0
137

0
009 0
860

0
183† 0
000

0
388† 0
000

0
209† 0
000

0
029 0
579

0
027 0
600

1
000

0
238† 0
000

0
164† 0
002

0
008 0
873

1
000

0
124* 0
017

0
065 0
214

1
000

0
162† 0
002 1
000

*Statistical significance at the 5% level – P < 0
05 (two-sided). Statistical significance at the 1% level – P < 0
01 (two-sided), n = 370, d.f. = 368 (n  2). r, correlation coefficient. †

importance for Generation X. This may be attributable to the fact that Generation X nurses are more likely to have wider caring responsibilities, for example, children and elderly relatives. The first two measures are statistically significant in the stepwise analysis displayed in Table 5. For Generation Y, the model, whilst statistically significant, does not provide as strong an explanation compared with the previous generation bands (F = 2
848, P < 0
05). Only 19
0% of variation in intention to continue working is explained. Two predictors are statistically significant in combination, attachment to work (b = 0
594, P < 0
01) and importance of working (b = 0
307, P < 0
05), detailed in Table 4. This is further confirmed by the stepwise analysis in Table 5.

Discussion Nurses’ intentions to continue working Nurses’ continuation intention, in its entirety and for each age-generation, is relatively positive, which should 72

be encouraging to the UK NHS. From the seven explanatory variables, six were expected to demonstrate association with continuation intention, although this is not the case. Significant associations were found involving LMX, work/family conflict, attachment and importance of work. The LMX findings are consistent with the literature (Maertz & Griffeth 2004, Chen et al. 2008), where highly perceived LMX is associated with lower levels of leave intention. Association between work–family conflict and leave intention is also established and concurs with previous studies (Flinkman et al. 2008, Shacklock & Brunetto 2012). This is perhaps intuitive, where employees without experience of conflicts in balancing personal and professional demands are less likely to exhibit leave intention. There is expectation from extant research (Angerami et al. 2000, Moore 2001) that association would also exist between attachment to work and leave intention, again this is supported. As limited research exists relating to the importance of work as a determinant of leave intention, it is more difficult to consider how the significant association © 2014 John Wiley & Sons Ltd

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Do nurses wish to continue working for the UK National Health Service

Table 4 Multiple regression models assessing ‘intention to con-

Table 5 Stepwise multiple regression models – ‘intention to con-

tinue working’ by each of the explanatory variables.

tinue working’ evaluated by a subset of explanatory variables (coefficients displayed for retained variables only).

Beta coefficients

All Explanatory variables Leader– 0
075 member exchange Work–family 0
182† conflict Teamwork 0
034 Autonomy 0
093 Attachment 0
631† to work Importance 0
300† of working Flexible 0
025 working arrangements Constant 1
405 F 15
803† Degrees of (7, 362) freedom (d.f.) R2 (adjusted) 0
219

‘Baby boomers’

‘Generation X’

‘Generation Y’

Beta coefficients

All 0
119

0
047

0
187*

0
243†

0
038

0
076 0
019 0
757†

0
025 0
141 0
611†

0
265 0
143 0
594†

0
377†

0
191*

0
307*

0
080

0
101

0
115

0
049

0
565 6
907† (7, 150)

1
656 7
643† (7, 148)

2
433 2
848* (7, 48)

0
208

0
231

0
190

*Statistical significance at the 5% level – P < 0
05 (two-sided). † Statistical significance at the 1% level – P < 0
01 (two-sided).

demonstrated in this study compares, although consistency with the findings of Shacklock and Brunetto (2012) has emerged. There is evidence that self-perception of work-based autonomy associates with leave intention (O’Brien-Pallas et al. 2006), but this was rejected in this study. Similarly, the potential teamwork–leave intention association also proved to be non-significant. For the latter, there is counter evidence from the literature (Estryn-Be0 har et al. 2007), although its recognition via focus-group study perhaps makes its supposition less generalizable. The absence of significance involving flexible working upheld the findings presented in the original nursing study (Shacklock & Brunetto 2012).

Generational differences Generation Y nurses appear long-term committed, matched by their counterparts from Generation X and the Baby boomers. Hypothesis 1 relating to potential differences in continuation intention can be rejected. Although the mean continuation intention score for Generation Y nurses is the highest, perhaps unsurprisingly given age and associated © 2014 John Wiley & Sons Ltd

Explanatory variables Leader– member exchange Work–family 0
166† conflict Teamwork Autonomy Attachment 0
618† to work Importance 0
282† of working Flexible working arrangements Constant 1
326 F 70
655† Degrees of (3, 366) freedom (d.f.) R2 (adjusted) 0
220

‘Baby boomers’

‘Generation X’

0
189*

0
195*

0
794†

0
609†

0
389†

‘Generation Y’

0
609† 0
282*

0
126 15
490† (3, 154)

2
087 22
379† (2, 153)

1
094 9
089† (2, 53)

0
217

0
216

0
227

*Statistical significance at the 5% level – P < 0
05 (two-sided). † Statistical significance at the 1% level – P < 0
01 (two-sided).

remaining length of working life, it is not significantly higher compared with the other age-generations. This finding counters previous studies where Baby boomers appeared most committed (Carter & Tourangeau 2012), with Generation X most likely to leave (Lavoie-Tremblay et al. 2011). Three predictors combine significantly to explain continuation intention: work–family conflict, work attachment and the individuals’ importance given to work. These explanatory variables are consistent across the three generations. The lack of differentiation between generation bands was unexpected in comparison to the Australian results presented by Shacklock and Brunetto (2012). In the latter, clear differences existed, with Generation Y nurses’ work attachment having a critical effect on turnover intention. For Generation X, two main differentiating predictors were identified, LMX and work attachment, contrasting with the UK study, where leave intention predictors for this generation exhibited greater commonality with the other agebands. The findings for the complete nursing cohort uphold hypothesis 2, but only to some extent, given that a majority of explanatory variables are statistically insignificant. This is mirrored in the findings relating to the Baby boomers 73

A. Robson and F. Robson

and Generation X. For Generation Y, hypothesis 2 is supported in a limited way, with fewer explanatory variables combining to describe continuation intention. In the Shacklock and Brunetto (2012) study, Baby boomers exhibited the greatest number of significant associations with turnover, involving five predictor variables, again contrasting with the UK findings with the two different variables being LMX and flexibility. The current literature base does not identify any reasons for this, thereby an interesting area for further research emerges.

Comparison of findings from UK and Australian studies Various similarities and differences emerge between the UK NHS study and its original Australian counterpart. A positive message to be studied materializes about nurses’ continuation intention, which is heartening given sectoral challenges around supply, recruitment and retention, cost and development. Profession-wide and for each age-generation, work attachment was the strongest predictor of continuation intention, consistent with the Australian private sector, although much stronger a marginal predictor in the NHS. Explanation levels provided by the respective multiple models were similar between the UK and Australian studies, overall (22% compared to 21%), Generation X (23% vs. 22%) and Baby boomers (21% vs. 18%), the exception being the greater variation explained in the original study for Generation Y (19% compared to 41%). Predictors of continuation intention in this UK public context display much greater concentration on the individual. This is at the expense of organizational practices, their management or relationships involving fellow employees, represented in this study through measurements involving LMX (Graen & Uhl-Bien 1995), teamwork (Rubin et al. 1994) and autonomy (Spreitzer 1995). In the original study, LMX, autonomy and interpersonal relationships displayed significance, sector-wide and in certain generation bands. Consequently, Shacklock and Brunetto (2012) pointed to the importance of developing initiatives to enhance continuation intention around customized strategies specific to generations. This represented a significant contribution to practice, given the relatively underdeveloped understanding of employee continuation. The UK publicly located nurses, in contrast, exhibit more consistent profiles by generation band; consequently, less bespoke, more generic approaches to addressing retention are better suited here. This represents a chal74

lenge in itself, as it is perhaps more straightforward to implement practices relating to enhancing leadership, recognizing, facilitating and supporting teamwork and encouraging autonomy. These explanatory measures do not, however, play a significant role in explaining role continuation. The implicit employment and managerial practices that build up work attachment and enhance individuals’ personal importance given to work must be encouraged to flourish in the NHS. Equally, value should be afforded to the more tangible working practices that support the balancing of competing and conflicting demands of work and family, particularly for Baby boomers and Generation X.

Limitations Trust participation represents a study limitation and generalization of the study findings to the wider NHS here is difficult. Similarly, the original study findings may not necessarily, in an equivalent way, have been truly representative of the Australian private sector (Shacklock & Brunetto 2012), given the small number of participating organizations. The NHS setting potentially offers useful sectoral and international comparison, addressing desirable and recommended postrunners to the original research. The findings may be less relevant, however, to policy makers in the UK’s private health care. Similar to previous research, the study did not question specifically about intention to de-register or relinquish rights to practise (Flinkman et al. 2010). The study, generation bands aside, does not extend consideration of working intention to demographic characteristics, a shortcoming previously identified by Shacklock and Brunetto (2012).

Conclusion The study aim was to identify the extent to which nurses in two NHS Foundation Trusts intended to continue working and recognize potential differences in response by generation band, thus replicating the work of Shacklock and Brunetto (2012) in an alternative arena and contributing to knowledge by exploring continuation intention by generation. The data analysed in this study show that of the seven variables that were tested, significant associations were found between continuation intention and four of them. Those showing this association were leader–member exchange, work/family conflict, attachment and importance to work. Interestingly, the results of this study show no sig© 2014 John Wiley & Sons Ltd

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nificant differences in intention to turnover between the three age generation bands, which contrasted with the patterns in the original Australian study where differences were observed in the survey findings. The significant finding from this UK study is the impact of individual characteristics on nurses’ leave intention, suggesting that any selection strategy should involve identification, where possible, of nursing candidates who exhibit higher attachment to work and have greater orientation towards the importance of working. Hospital managers should perhaps be mindful of the generational differences in values and behaviours (Cennamo & Gardner 2008), despite the commonality of continuation intention in terms of intensity and explanatory measures reported here. Such differences should be reflected in policies and work organization, alongside the above recommended generic approaches to enhancing continuation intention. Particular attention should be paid to supporting nurses striving for manageable levels of work–family conflict, despite access to flexible working patterns not providing significant explanation of leave intention. Work attachment should be a significant driver of continuation intention and as expected, was confirmed. It may be prudent for hospital managers to consider how nurses’ work and related environment can be packaged to focus more on patient care. Older nurse commitment and continuation intention affords the NHS time in determining necessary support and resources to further underpin this. The equivalent intentions exhibited by the younger nurses point to potential employment attractiveness and, as such, can support related initiatives designed to attract, develop and retain new nursing professionals.

Acknowledgement The authors would like to thank and acknowledge the support from Dr. Yvonne Brunetto and Dr. Kate Shacklock in allowing their research tool to be utilized.

Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Conflict of interest

Do nurses wish to continue working for the UK National Health Service

Author contributions All authors have agreed on the final version and meet at least one of the following criteria [recommended by the ICMJE (http://www.icmje.org/ethical_1author.html)]:

• •

substantial contributions to conception and design, acquisition of data, or analysis and interpretation of data; drafting the article or revising it critically for important intellectual content.

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