Abstract

Introduction

Health care professionals (HPs) face specific challenges in their work, such as high workloads and limited resources, which can have a negative impact on their mental and physical health (Bodenheimer & Sinsky, 2014; Lucian Leape Institute, 2013). These challenges are likely to cause high turnover rates in HPs, creating a precarious situation that may lead to a dissatisfied and unprepared workforce (Halter et al., 2017; Shen et al., 2020). This is a major risk for health systems worldwide (Halter et al., 2017; Lucian Leape Institute, 2013; Wakerman et al., 2019). At the same time, health care needs are changing and increasing due to population aging and the rise in non-communicable diseases (Dall et al., 2013; World Health Organization, 2018). With both supply and demand difficulties, there is a growing concern about shortages of HPs (Castro Lopes et al., 2017). Incidentally, the issue is cyclical and systemic as shortages reinforce existing hardships for the health workforce. The COVID-19 pandemic has amplified this phenomenon and showed how little resilient health systems were to crises (American Hospital Association, 2022; Raso et al., 2021). Research can help by investigating factors that compromise the exercise and practice of HPs, as well as the conditions needed for them to thrive (Buchan & Campbell, 2013). In particular, there is a pressing requirement for studies on voluntary departures and the factors that motivate them (Aspden et al., 2021).

Nurses and physicians’ shortages have been clearly recognized and their causes and consequences extensively studied (Halter et al., 2017; OECD, 2008). However, retention issues have also been identified for other health care professions such as physiotherapists, pharmacists, mental health professionals and dietitians (Hawthorne & Anderson, 2009; Hooker et al., 2012; Kakuma et al., 2011; Pretorius et al., 2016). These professions fall into the “allied health workforce” umbrella category, understood here as “trained health professionals, other than nurses and medical practitioners, who are involved in direct patient care or services to the community, or both” (Schoo et al., 2005). Allied health services play a sometimes less visible but none the less vital role for the health system. They have for instance be shown to be more effective and less costly than medical services or drugs in certain cases of chronic disease management (Segal & Robertson, 2004).

A recent survey by AMN Healthcare (2022) of 1,005 health care facilities in the United States indicated that 85% of them were experiencing a shortage of allied health professionals (AHPs). Elsewhere, a report by the Australian National Disability Services (2022) has revealed that difficulties in recruiting and retaining AHPs were driving lengthy wait times for therapy services from 6 months to up to 2 years. The literature suggests that health workforce stability can contribute to reduced costs, improved productivity, and better care outcomes, although most of the research concentrated on nurses (Buchan, 2010). Nevertheless, studies have also pointed out that improving paramedic retention was critical in reducing patient suffering and decreasing mortality (Eubanks, 2022), that high turnover among therapists had both a negative impact on the implementation of evidence-based practices (Woltmann et al., 2008) and could threaten the quality and consistency of mental health services (Babbar et al., 2018), and that continuity of care was desirable for the delivery of effective dietetic services (Hewko et al., 2021).

To the best of our knowledge, very few literature reviews focusing on the retention of HPs have considered multiple allied health professions together. Moreover, all the recent ones concerned the rural and remote setting (Campbell et al., 2012; O’Sullivan & Worley, 2020). Consequently, the evidence for other settings is largely fragmented. Grouping and comparing findings across allied health professions serves a dual purpose: first, consolidating the evidence for each individual profession by recognizing what is common, and second, highlighting meaningful differences by discussing what is not. The primary aim of this review was to examine the factors that contribute to AHPs leaving their profession.

It is often challenging to gather data on individuals who already left their profession. Consequently, we relied on the foundational turnover model by Mobley (1977) to achieve our aim. This work introduced a framework for the employee withdrawal decision process. Crucially, it stated that quit intentions are the most proximal and predictive turnover antecedent. Thus, it opened the door to the study of the intent as a proxy for the decision to leave. This conceptual model was upheld over the years, as demonstrated in a meta-analysis by Griffeth et al. (2000). Grounding our research in this lineage of the turnover theory, we considered interchangeably the last two steps of the withdrawal decision process, that is, quit intentions and the actual decision to quit.

Method

We conducted a rapid review of the literature to answer the research question:

• Research Question 1 (RQ1): What are the factors associated with intent to leave the profession for the allied health workforce?

Rapid reviews are an efficient tool to support health policymaking and health systems strengthening by synthesizing and presenting evidence in a resource-effective manner (Moher et al., 2015; Tricco et al., 2017). Due to limited resources, the trade-off between exhaustiveness and efficiency was deemed more appropriate for a rapid review than for a systematic review in this case. Rapid reviews usually involve the following steps: (a) setting a research question, (b) establishing eligibility criteria, (c) developing a search strategy, (d) study selection, (e) data extraction, (f) quality assessment, (g) synthesis of findings (Garritty et al., 2021). We used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement—a seminal 27-item checklist designed to help authors improve the reporting of systematic reviews and meta-analyses—for the reporting of methods and results where appropriate (Moher et al., 2009).

Synthesis of Findings

Selected articles were heterogeneous in terms of methodologies, study designs, analytical approaches, as well as in the ways the outcome and the determinants were measured. Thus, it was not appropriate to perform a meta-analysis, and we undertook a narrative synthesis of the findings—drawing from all the steps described above. Studies designated similar concepts with different wordings, so we operated a correspondence between all factors. This allowed us to highlight main themes that are common across studies. As an additional synthesis step, we categorized these typical factors into four distinct groups.

We designed two synthesis tools to help with the interpretation of the results and visually summarize the extent of research found on the typical factors. First, we noted whether each factor was studied at least once for the principal professions represented in our review (Table 2). Second, we counted the overall number of times each factor was mentioned in the selected literature and displayed those numbers graphically (Figure 2). The corresponding associations had to feature in at least two different articles to be included in these synthesis tools.

Table 2.

Correspondence Between Typical Factors of the Intent to Leave and Allied Health Professions.

Factor group	Factor	Pharmacist	Psychologist	Dietitian	Physical therapist	EMS professional	Occupational therapist
Job characteristics	Remuneration	X	X		X	X	X
	Work location		X	X			X
	Years in the job						X
Organizational factors	Career opportunities	X		X		X	X
	Workload	X	X	X		X	X
	Professional development		X	X		X	X
	Work environment	X	X		X	X
	Autonomy			X	X
	Schedule flexibility		X	X
	Task diversity			X
Psychological factors	Burnout		X	X		X	X
	Job satisfaction	X	X				X
	Professional identity	X			X	X	X
	Disengagement						X
Team and management	Leadership	X		X		X	X
	Relationship with manager and peers	X	X	X		X
	Recognition	X					X

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Note. A cross indicates that the factor appeared at least once for the corresponding profession in the selected literature. Only professions studied by multiple articles in the rapid review are shown. Typical factors have been classified into four thematic groups. EMS = emergency medical services.

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Figure 2.

N = 29. The Frequency Represents How Often (in Percentage) Each Typical Factor Was Highlighted in the Selected Literature.

Results

After removal of duplicates, 1,305 articles were available for screening by the reviewers. 1,199 articles were excluded based on the title and abstract. Then, a further 77 articles were excluded based on the full text. Out of the 29 articles kept for data extraction, 21 were of quantitative nature, 6 were qualitative, and 2 had a mixed design. All the selected articles analyzed different sets of data and all were in English. Figure 1 provides the flow diagram for the study selection.

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Figure 1.

Flow Diagram for the Rapid Review.

Discussion

This rapid review consolidates the evidence from the literature on factors that affect (positively or negatively) AHPs’ work life. By collecting fragmented results and summarizing them into general themes, it provides actionable insights on how to improve the working conditions of AHPs in most common situations. Thus, more than any other factor, adequate remuneration was highlighted as essential to keep AHPs in the workforce. Financial rewards are not however the only significant reason for staying in one’s job and may be complemented with organizational improvements. Our results suggest that organizations wishing to retain their AHPs should give them opportunities for career progression and professional development, or else they may leave to find these opportunities elsewhere. It is also important for AHPs that their working hours are not excessive and that their workload is in line with their working time. Furthermore, promoting professional environments that are ethical and supportive will help prevent AHPs from leaving their job. Where relevant, managerial support is also key. To inspire AHPs, leadership should put effective communication at its center. Finally, our findings acknowledge the fundamental link between psychological factors and retention, thus reiterating the importance of recognizing and preventing burnout early, by for instance providing individual and group supports for AHPs to enhance their mental health and well-being and develop their resilience to work stressors. Differences were also observed across allied health professions, which inform on the positive and negative elements of specific settings. Hence, task diversity and autonomy should be preserved to prevent dieticians from leaving their professions. Besides, a particular focus should be put on improving the recognition toward pharmacists’ activities. Several factors leading to excessive turnover (high workload and burnout for instance) have been amplified during the COVID-19 pandemic. However, this crisis has also shed light on the working conditions of HPs and created an opportunity for change. It is vital for a better post-pandemic recovery to put in place policies and processes that tackle the main underlying determinants of turnover exposed in this paper.

Other recently published literature reviews investigated factors contributing to the recruitment and retention of diverse AHPs, either as the main research question or as secondary outcome, but always restricted to a rural and remote setting (Campbell et al., 2012; Obamiro et al., 2020; O’Sullivan & Worley, 2020; Roots & Li, 2013; Terry et al., 2021). Professional development and career opportunities were identified as key determinants of rural and remote retention issues—for the allied health workforce generally (Campbell et al., 2012; O’Sullivan & Worley, 2020) and for occupational therapists, physiotherapists, and pharmacists specifically (Obamiro et al., 2020; Roots & Li, 2013; Terry et al., 2021). The importance of sufficient workplace supervision was also underlined in the context of reduced density of health care providers, which characterizes this setting (Campbell et al., 2012; O’Sullivan & Worley, 2020; Roots & Li, 2013). Likewise, AHPs in remote areas reported suffering from professional isolation (Campbell et al., 2012), and feeling valued by communities they serve emerged again as a central determinant for the rural pharmacist workforce (Obamiro et al., 2020; Terry et al., 2021). Finally, a factor essential for the rural and remote workforce that appeared only marginally in our rapid review is the training pathway, or how much previous experiences have prepared for the realities of one’s professional activity (Obamiro et al., 2020; O’Sullivan & Worley, 2020; Roots & Li, 2013; Terry et al., 2021).

Findings from literature reviews on the reasons for nurses and physicians to leave their profession share many similarities with what we found for the allied health workforce. For instance, stress and burnout, as well as managerial style, were highlighted as essential determinants of nursing staff turnover in two overviews of reviews (Courvoisier et al., 2023; Halter et al., 2017). When reviewing interventions to improve nurses’ job satisfaction, and thus retention, Niskala et al. (2020) found that strengthening their professional identity was particularly effective. Although professional growth in all its forms is generally recognized as an important determinant of nurses’ turnover intentions (Halter et al., 2017), this is especially true in rural settings (Smith et al., 2019). For physicians, excessive working hours appeared strongly associated with intent to leave (Degen et al., 2015). Thus, the core determinants of a sustainable workforce are common across health professions. A further example of this is a supportive working environment, which is emphasized in a review considering multiple health professions together (Wakerman et al., 2019). Interestingly, Roncalli and Byrne (2016) reported the same risk of burnout in psychologists than in health workers requiring comparatively lower psychological mindedness in the exercise of their professional activity.

Our literature review’s outcome of interest varied from article to article. A few studies reached out to AHPs who already left the profession (Aspden et al., 2021; Cash et al., 2018; Mak et al., 2013; Rivard, Cash, Woodyard, et al., 2020), but the majority evaluated the intentions of AHPs who were still practicing at the time. We based ourselves on the foundational turnover model by Mobley (1977) to use the intent as a surrogate for the decision and thus, to increase the pool of research on which our findings were based. This modus operandi has been largely adopted in the turnover literature (Hom et al., 2017). Our results were consistent with Mobley’s theory, since for instance when interviewing pharmacists who left their profession, the most common themes identified by Mak et al. (2013) corresponded exactly to the most common job characteristics and organizational factors highlighted elsewhere in relation to turnover intention (i.e., remuneration, career opportunities, workload, and work environment; see Figure 2). Moreover, Aspden et al. (2021) found when comparing pharmacists who left their profession with pharmacists who were seriously considering leaving that the rationale was very close across the two groups. Notwithstanding, some authors have criticized this framework as insufficient (Halter et al., 2017).

Furthermore, a couple of studies investigated the reasons for staying in the profession instead (Collins, 2012; Stokes et al., 2010). Although there exists a significant overlap between intent to leave and intent to stay, they do not measure entirely the same construct (Nancarrow et al., 2014). Finally, some studies assessed intent to leave the current job, some studies assessed intent to leave the profession, and some studies assessed both. Where both were considered, it was always in relation with the same factors (Boccio et al., 2016; Cash et al., 2019; Crowe et al., 2018; Williams et al., 2021). The reported associations were of similar magnitude, indicating a stronger effect on the intent to leave the current job than the profession in all but Crowe et al. (2018). Articles focusing on keeping professionals in specific positions or organizations (Cantu et al., 2022; Collins, 2012; Druwé et al., 2021; Yanchus et al., 2017) may seem less relevant to the general AHPs retention issues but we believe that all findings related to alleviating shortages where they occur can inform strategic interventions elsewhere. The same reasoning applies to the heterogeneity manifest in the outcome’s timescale (from intent to leave in the next 6 months to the next 5 years).

Conclusion

To optimize its performance, a health system needs to enhance patient experience, improve population health, reduce costs, and improve the work life of HPs. In this article, we highlighted retention themes common to several allied health professions. Depending on the resources available, many of these factors constitute levers that can be acted upon. We hope that our findings will inspire initiatives aimed at resolving shortfalls across the allied health workforce, and by doing so, strengthen evidence-based decisions in health human resource planning.

Supplemental Material

Footnotes

References