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• To be aware of research that explored whether a psychological theory linking beliefs to behaviour can predict intention to leave and actual turnover of staff working in learning disability social care services
• To identify areas that can be addressed to reduce the turnover of staff working in learning disability social care services
• To consider ways that learning disability nurses can reduce turnover by developing and delivering staff training and mentoring, supervising and supporting colleagues
Background Staff working in learning disability social care services have high turnover rates resulting in disruption to care and financial costs to employers in relation to recruiting new staff.
Aims To explore whether the theory of planned behaviour can be used as a framework to predict intention to leave their job and actual staff turnover, and to identify whether including measures of organisational ‘fulfilment’, work-related stress, perceived job equity and receiving positive behaviour support (PBS) training improved prediction of staff turnover.
Method A quantitative design was used. Respondents were 285 social care staff working in learning disability services. Path analysis was used to explore the relationships between staff turnover and the theory of planned behaviour components, perceived equity score (the extent to which respondents believed they benefited from work compared with what they put into it), organisational fulfilment score (the extent to which respondents believed their organisation offered the elements they valued), stress score and group status (that is, whether respondents had undergone the PBS programme).
Results Staff turnover was significantly predicted by perceived equity score at one and nine months after baseline, by stress score at six months and by whether respondents had undergone the PBS programme at six and nine months.
Conclusion Reducing staff stress, increasing their perceived equity and offering PBS training may be ways of increasing staff retention.
Learning Disability Practice. doi: 10.7748/ldp.2022.e2189
Peer reviewThis article has been subject to external double-blind peer review and checked for plagiarism using automated software
Correspondence Conflict of interestNone declared
McKenzie K, Murray G, Metcalfe D et al (2022) Predicting staff turnover in learning disability social care services. Learning Disability Practice. doi: 10.7748/ldp.2022.e2189
AcknowledgementsThe authors would like to thank all the respondents and members of the positive behaviour support group past and present. Funding was from Middlesbrough Council on behalf of Tees local authorities, NHS England Cumbria and North East and NHS South Tyneside Clinical Commissioning Group (CCG) on behalf of regional CCGs
Published online: 14 July 2022
Nurses work closely with their colleagues in social care services. Many nurses also carry out essential roles in the social care workforce, with an estimated 34,000 working in all areas of adult social care in 2020-21 (Skills for Care 2021). The social care workforce in the UK is, however, experiencing staffing challenges. Many social care organisations experience significant challenges with recruiting and retaining staff, with figures indicating total vacancy rates of approximately 112,000 in 2019-20 and a turnover of 430,000 staff per year (Skills for Care 2019). This is in the context of increasing demand for social care (Public Health England (PHE) 2017). Research suggests that nurses working in social care organisations also have high turnover rates, with 11,000 nurses leaving in 2020-21, a turnover rate of 38% (Skills for Care 2021). They have similar reasons for leaving to other staff working in the social care sector (McKenzie et al 2021a).
Some authors have noted the potential benefits of nursing staff turnover, such as new staff bringing fresh skills and innovation to organisations (Jones and Gates 2007). There is, however, recognition that inadequate staff retention has many negative consequences. These include disruption to care for those being supported and the financial costs to employers of recruiting new staff (Stevens et al 2019).
Inadequate staff retention can also present significant challenges to the implementation of policy recommendations. As an example, the successful implementation of the Transforming Care policy (NHS England 2014), which aimed to provide community-based care for people with a learning disability, relied on there being enough skilled and competent staff in the workforce. In this context, it was suggested that approximately 7,500 additional staff would be needed to support people with a learning disability (PHE 2017).
• Learning disability nurses can support social care organisations to improve staff retention by:
• Advising managers on important areas that can predict staff turnover
• Identifying ways to assess the perceived equity of staff and the areas which they value in their work
• Contributing to the development and delivery of evidence-based stress management strategies
• Ensuring that they provide positive and effective training, mentoring, supervision and support to colleagues
• Influencing the ways in which educational input for staff is commissioned, developed, delivered and evaluated
• Developing evidence-based interventions and evaluating their effect on staff retention
The theory of planned behaviour is a model that has been used to attempt to predict a range of behaviours, including staff turnover (Ajzen 1991). In general, the model has been found to be useful in predicting turnover in different staff groups, including nurses, physiotherapists and radiographers (Arnold et al 2006). To the authors’ knowledge, there has been no research exploring the use of the theory of planned behaviour in predicting the turnover of staff working in social care services for people with a learning disability.
The theory of planned behaviour identifies three main components that are believed to be important in predicting behaviour (Ajzen 1991):
1. The attitude that the person holds towards the behaviour (attitude) – in this case leaving their job.
2. The attitudes of relevant others to the behaviour (subjective norm).
3. The extent to which the person considers they have control over the behaviour (perceived behavioural control).
These components are assumed to lead to an intention to carry out the behaviour or not (intention). As an example, if a staff member believed it would be beneficial to leave their job (attitude), their family believed it would be a positive decision (subjective norm) and the staff member believed there were no constraints on their leaving, such as financial implications (perceived behavioural control), they would be predicted to have a strong intention to leave. As well as influencing intention, perceived behavioural control is believed to influence behaviour directly. In summary, the theory of planned behaviour predicts that the greater the intention the person has in relation to a behaviour, the more likely it is that they will undertake that behaviour, particularly if they have control over it.
Researchers have added other factors that are relevant to particular behaviours to the main components of the theory of planned behaviour to improve the model’s ability to predict that behaviour. Some of the factors that have been found to be associated with social care staff turnover are outlined below.
A review of issues related to improving recruitment and retention in learning disability services suggested that ensuring that pay, other benefits and working conditions were equivalent to, or better than, those of comparable jobs was important for retention (McKenzie et al 2021a). Other important areas were providing high quality training, supervision and support, facilitating values-based work practices and promoting positive relationships with those being supported and their wider networks, for example families.
Disley et al (2009) explored the relevance of equity theory to staff retention in learning disability services in a literature review. Equity theory provides an explanatory model whereby the extent to which the individual believes that what they contribute (to their job in the study presented in this article) is equal to, greater or less than what they get out. Disley et al (2009) found an association between believing that there was a negative imbalance between the effort put into work and what was received in return (that is, feeling ‘under-benefited’) and burnout and intention to leave the job. The researchers suggested that this is an important area to consider in the context of workforce issues.
Murray et al (2022) explored the relative importance of different work-related factors to social care staff working in learning disability services and the extent to which they were met by their employing organisations. The researchers found that the relationships which staff had with the people they supported was identified as the most important factor by the greatest number of participants, followed by pay. The study also found an association between the extent to which the staff member’s organisation addressed the area identified as the most important (fulfilment score) and whether they had looked for a job in the previous three months (Murray et al 2022). This suggests that organisational ‘fulfilment’ may be worth exploring further as a predictor of staff turnover.
Stress has been associated with staff burnout and staff turnover. McKenzie et al (2021a) outlined the most common of the numerous factors that influence staff stress, including the amount and nature of support provided to staff, level of work demands, control and decision-making, and suboptimal work relationships and communication.
Behaviours that challenge, such as aggression, have been found to be associated with staff turnover (McKenzie et al 2021a), which emphasises the need for effective interventions to address their causes. One such intervention is positive behaviour support (PBS), a person-centred intervention that uses behavioural approaches to understand the function of the behaviour for the person. This is then addressed by teaching the person constructive alternatives that serve the same purpose, in the context of high quality support (Gore et al 2022). PBS has been found to be effective at reducing behaviours that challenge (Bowring et al 2020). This suggests that teaching staff PBS approaches may have a positive effect on staff retention. Indeed, an evaluation of a region-wide PBS workforce development approach found that staff who had received PBS training were more likely to be still in their job immediately after the training and at follow-up compared with those in the control group (McKenzie et al 2021b). However, it was unclear if this was due to the PBS training or to other factors. The study presented in this article explored this relationship further.
The aims of the study, in relation to staff working in learning disability social care settings, were to:
• Explore whether the theory of planned behaviour can be used as a framework to predict staff intention to leave work and actual staff turnover.
• Identify whether including measures of organisational ‘fulfilment’, staff work-related stress, perceived job equity and receiving PBS input improved prediction of staff turnover.
In total, 285 respondents took part (see Table 1 for demographic information), of whom 183 (64%) received PBS input (PBS group) and 102 (36%) did not (control group). The inclusion criteria for both groups were adults (aged ≥ 18 years) who worked in a social care setting with people with a learning disability. Those in the PBS group met the criteria of having undertaken a PBS programme.
Respondents were asked to complete measures in addition to providing demographic information. All measures were hosted on an online survey platform.
This questionnaire was developed following the guidance outlined by Ajzen (2019) and measured attitude, subjective norm, perceived behavioural control and intention. The behaviour of interest was staff turnover which had two elements – whether the person had left their job or was actively seeking another job.
This was measured by a single item which asked: ‘How much do you feel you get out of your job compared with what you put in?’ The response options were less=1, the same=2 and more=3.
Respondents chose which area, from 13 options, was most important to them in their work, rated the extent to which they agreed with statements about that area and the extent to which these were met by their organisation. For example, if the chosen option was communication, a statement would be: ‘Managers should have an ‘open door’ policy’. Fulfilment scores were then calculated (Murray et al 2022), with higher scores indicating greater fulfilment.
This was measured by the ten-item version of the Perceived Stress Scale (Cohen et al 1983). Lower scores indicate lower stress. For this study, respondents answered the items in relation to their work. Due to a technical issue, 66 respondents did not complete the stress measure.
Group status was based on whether respondents were undergoing a PBS programme (PBS group) or not (control group). The PBS programme was accredited by a local university, offered online and face-to-face teaching along with work-based supervision and support (see McKenzie et al 2020 for details), and was free to staff from social care organisations in the North East and Cumbria region of England. The programme took place in the context of a region-wide, systemic approach to PBS that was implemented throughout the region. The measures above were completed before the PBS group began the programme, that is at baseline.
These factors were measured by asking respondents to indicate their job status. The options were 1=remained in the same job, 2=actively looking for a new job and 3=left job. This information was gathered one month after the PBS programme began (time point 1), at the end of the PBS programme (approximately six months after the programme began, time point 2) and at follow-up (approximately nine months after the programme began, time point 3).
Respondents were recruited in two ways. The first was via the social care organisations that were participating in the PBS programme. These organisations identified potential respondents for each group (PBS and control groups) who were contacted by the research team, provided with details of the study and invited to take part. For these respondents, the study was one aspect of a wider independent evaluation of the PBS programme conducted by the researchers (McKenzie et al 2021b).
The second – which was to recruit more respondents for the control group – was via relevant learning disability websites and other forms of social media and included details about the study and a link to the online survey. Those who met the inclusion criteria and wanted to take part were asked to follow the link to a website where they could read further information, record their consent and complete the measures. These respondents also provided a contact email which enabled them to be contacted automatically with a reminder at the follow-up time points.
Path analysis was used to explore the relationships between staff turnover and the theory of planned behaviour components, perceived equity score, organisational fulfilment score, stress score and group status – that is, whether respondents had undertaken the PBS programme or not. The analysis related to three time points. At baseline, none of the respondents had started the PBS programme, therefore group status was not included in the analysis at time point 1 (one month after the programme began). Group status and stress scores were included in the analysis at time point 2 (six months after the PBS programme began) and at time point 3 (nine months after the programme began), as those in the PBS group had undertaken the programme at those points.
Table 1 provides demographic information for the two groups and Table 2 illustrates the descriptive statistics for the measures used in the study.
Table 3 illustrates the results of the model for predicting respondents’ behavioural intentions to leave their job. The results show that the theory of planned behaviour components of attitude and subjective norm significantly predicted staff intention to leave their job at all three time points, but perceived behavioural control did not. The symbol B represents the unstandardised coefficients. In Table 3, this means that they represent respondents’ increase in intention to leave work for each unit increase in the predictors of attitude, subjective norm and perceived behavioural control.
Table 4, which shows the model results for predicting staff turnover, illustrates the regression coefficients and odds ratio results for the three time points and shows that only the perceived equity score significantly predicted staff turnover at time point 1. At this time, the more the person felt ‘under-benefited’, the more they were likely to have left their job/be actively seeking another job.
Stress score and group status significantly predicted staff turnover at time point 2. Here, having higher stress levels and being in the control group were associated with a greater likelihood of turnover.
Perceived equity score and group status significantly predicted staff turnover at time point 3. Here, feeling ‘under-benefited’ and being in the control group were associated with higher staff turnover/looking for a new job.
The results for the theory of planned behaviour model in Table 4 showed that intention did not significantly predict staff turnover at any of the three time points. Note that odds ratio values >1 indicate a positive relationship between the predictor and the outcome (job turnover). Values <1 indicate a negative relationship.
In respect of the theory of planned behaviour model, attitude and subjective norm significantly predicted staff intention to leave their job at all three time points, although intention did not significantly predict actual staff turnover. Previous studies have found that intention explains between 20% and 30% of the variance in a range of behaviours including staff turnover (Steil et al 2019). However, it has also been shown that other individual, work-related and wider environmental factors influence retention (Steil et al 2019). The results of the present study suggest that such factors exerted a greater influence on social care staff turnover than intention.
Perceived equity score was the only significant predictor of staff turnover at time point 1 and both perceived equity and group status (whether the person was in the PBS or control group) predicted staff turnover at time point 3. Equity theory posits that when an individual believes they put more in than they get out – in this case to their job – this leads to tension which the individual acts to resolve. Leaving the situation – in this study staff turnover – is one option for resolving this tension (Disley et al 2009).
The input and the reward in equity theory can comprise different factors; in the present study the perceived equity score may have represented an overall summary of the extent to which respondents felt ‘under-benefited’. This may explain why the fulfilment score was not a predictor of staff turnover, despite previous research finding that fulfilment score had a negative relationship with the extent to which staff had been seeking new employment over the previous three months (Murray et al 2022).
Learning disability nurses, whether working directly or indirectly with social care colleagues, can use the results of this study to develop strategies to improve retention. The simple rating score used to provide perceived equity scores may be useful to organisations in assessing the overall likelihood that a staff member may leave their job. The information captured by the fulfilment score may support organisations to identify specific areas that individual staff members rate as important but believe are not satisfactorily addressed by their employers. This may inform the development of individually tailored or multifactor interventions to address these areas.
One such intervention may be PBS training. This study found that group status significantly predicted staff turnover, with those who had taken part in a PBS programme less likely to leave their job/be actively seeking another job. This may be because the programme was delivered as part of a regional workforce development model and in the context of systemic changes which reflected recommendations relevant to improving retention (McKenzie et al 2021a). This included the ways in which staff were supervised and supported, the promotion of shared organisational values and how optimal practice was modelled and reinforced. Nursing staff can support the development of similar systemic approaches in their local areas and use the results of the study to inform the ways in which educational provision is commissioned, designed, delivered and evaluated.
The study confirmed the influence of staff stress levels on retention, finding that increased staff stress at time point 2 significantly predicted staff turnover. This identifies the need for nurses to assist organisations to implement evidence-based stress management strategies to support staff. These might include providing staff with high quality training, supervision and support, as well as role clarity and control in relation to their work (McKenzie et al 2021a).
Although there are recommendations on ways to reduce turnover in staff who work in learning disability services, there is limited research of the effectiveness of interventions based on those recommendations (McKenzie et al 2021a). Learning disability nurses have a role in developing such interventions and evaluating their effect on staff retention.
There were some unavoidable limitations because of the timing of the study. At time point 3, coronavirus disease 2019 (COVID-19) restrictions were in place which may have affected the ability and/or motivation of staff to leave their job because of high levels of unemployment and closure of many businesses. The restrictions may also have affected respondents’ stress because it became challenging for staff to maintain the activities and quality of life for the people they supported. Research suggests, however, that the PBS programme supported staff to cope with the stress of the COVID-19 pandemic and associated restrictions (McKenzie et al 2021c), which may have reduced the influence of staff stress on turnover for the PBS group at time point 3.
While taking part in the PBS training had a positive effect on staff turnover, this might not be unique to PBS; providing staff with other forms of training may be equally beneficial for reducing staff turnover. Further research that evaluates the effect on retention of providing staff with other forms of quality educational input relevant to their job will clarify this.
There were limitations in respect of some of the measures used. Perceived equity was measured by only one global item. It may be that a more comprehensive assessment of perceived equity may have provided a more nuanced picture of the most influential inputs and rewards for staff. Disley et al (2009) noted the need for measures of perceived equity that are relevant to staff working in learning disability services. Research has provided an indication of some of the individual differences in the factors that social care staff working in learning disability services view as important in their work (Murray et al 2022). It may be that the assessment of fulfilment used in the present study could be adapted to provide a more detailed measure of perceived equity or combined with a global measure to identify those staff at risk of leaving the organisation and individual areas for intervention to reduce this risk.
Finally, the study took place in the north-east of England which raises questions about the extent to which the results can be generalised to other geographical areas.
The study found that two of the theory of planned behaviour components predicted staff intention to leave their job, however their intention did not predict actual turnover. In terms of the additional predictors, perceived equity, group status and stress significantly predicted staff turnover at different time points. The results identify areas that can be addressed to reduce the turnover of staff working in learning disability social care services. Learning disability nurses can contribute to many of these areas by offering their expertise in developing and delivering relevant staff training and in mentoring, supervising and supporting colleagues in effective and positive ways.
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