Review Article
Incentives for improving human resource outcomes in health care: overview of reviews
Journal of Health Services Research & Policy 2014, Vol 19(1) 52–61 ! The Author(s) 2013 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1355819613505746 jhsrp.rsmjournals.com
Renee Misfeldt1, Jordana Linder2, Jana Lait2, Shelanne Hepp2, Gail Armitage2, Karen Jackson1 and Esther Suter3
Abstract Objectives: To review the effectiveness of financial and nonfinancial incentives for improving the benefits (recruitment, retention, job satisfaction, absenteeism, turnover, intent to leave) of human resource strategies in health care. Methods: Overview of 33 reviews published from 2000 to 2012 summarized the effectiveness of incentives for improving human resource outcomes in health care (such as job satisfaction, turnover rates, recruitment, and retention) that met the inclusion criteria and were assessed by at least two research members using the Assessment of Multiple Systematic Reviews quality assessment tool. Of those, 13 reviews met the quality criteria and were included in the overview. Information was extracted on a description of the review, the incentives considered, and their impact on human resource outcomes. The information on the relationship between incentives and outcomes was assessed and synthesized. Results: While financial compensation is the best-recognized approach within an incentives package, there is evidence that health care practitioners respond positively to incentives linked to the quality of the working environments including opportunities for professional development, improved work life balance, interprofessional collaboration, and professional autonomy. There is less evidence that workload factors such as job demand, restructured staffing models, re-engineered work designs, ward practices, employment status, or staff skill mix have an impact on human resource outcomes. Conclusions: Overall, evidence of effective strategies for improving outcomes is mixed. While financial incentives play a key role in enhancing outcomes, they need to be considered as only one strategy within an incentives package. There is stronger evidence that improving the work place environment and instituting mechanisms for work-life balance need to be part of an overall strategy to improve outcomes for health care practitioners.
Keywords workload, human resources, outcomes
Introduction Discussions about human resources in health care have intensified around the globe due to shortages of some types of health care workers plus distributional imbalances by geography, sex, occupation, and institution.1,2 These emerging trends require new strategies to attract and retain a productive and motivated health workforce to where they are most needed.3 While financial incentives such as higher wages, loans, and bonuses have been, and will continue to be, an integral component of employment contracts, nonfinancial incentives including work autonomy, clarity of roles, workload management, flexibility, work-life balance, child care, and support for career and professional development
are important for improving the management of human resources.2 Incentives are tools that employers can utilize to design an organizational incentives 1 Senior Research and Evaluation Consultant, Workforce Research and Evaluation, Alberta Health Services, Alberta, Canada 2 Research and Evaluation Consultant, Workforce Research and Evaluation, Alberta Health Services, Alberta, Canada 3 Director, Workforce Research and Evaluation, Alberta Health Services, Alberta, Canada
Corresponding author: Renee Misfeldt, Workforce Research and Evaluation, Alberta Health Services, Suite 200, Collins Barrow Centre, PO Bag 5030, 3942 – 50A Avenue, Red Deer, Alberta, T4N 6H2 Canada. Email: [email protected]
Misfeldt et al. package and for planners to develop strategic plans for human resources. There has been much discussion and research into the links between both financial and nonfinancial incentives and human resource outcomes: recruitment, retention, job satisfaction, absenteeism, turnover rates, and the intent to leave or continue practice. There has, however, been no review of this literature. Identifying and understanding the most effective strategies for improving outcomes is complex. Incentives suitable for urban communities, for instance, may not be appropriate for rural and remote communities.4 Incentives may need to be tailored to different generations,5,6 work contexts and settings, and types of health care workers. Moreover, the mix and effectiveness of incentives is influenced by labor market conditions and the organization of professional groups (such as union coverage) amongst other factors. Employers and planners may also face challenges related to the availability of both human and financial resources when developing incentives.2 This overview of reviews was conducted to identify and highlight financial and nonfinancial strategies for improving health workforce outcomes to support evidence-based recruitment and retention strategies.
Methods Search strategy An overview of reviews (Cochrane reviews, systematic reviews, narrative reviews) of financial and nonfinancial incentives and their effectiveness to improve human resource outcomes was conducted.7 We developed the search terms and search parameters in consultation with a human resources manager responsible for recruitment and retention for a large health care organization and a research librarian proficient with health care databases, who executed the search strategy. The following incentives were used as search terms : salary; wage; bursaries/scholarships; pensions; pensions; subsidies/allowance; child care; travel; loan repayment; educational loans; insurance (e.g. life and health); benefits, holiday/vacation; study leave; professional development; job security; flexible work environments; flexible scheduling arrangements, earned days off, career advancements; laddering; practice relief; recreational facilities; coaching/mentoring; leaves of absence including parental compassionate, terminal care, pressing necessity, and other leaves; paid overtime; leadership development opportunities; recognition of work; staffing models; professional autonomy; manageable workload; onsite childcare and professional supports. The outcome measures included in the search were: recruitment; retention; motivation;
53 turnover; intent to leave; engagement; productivity; absenteeism; and satisfaction. The search was conducted to capture different contexts (demographics and workforce dynamics). Databases searched covered 2000–2012 and included MEDLINE (Ovid); Embase; CINAHL; Cochrane Database of Reviews; PsycINFO; Evidence-Based Medicine Reviews; ABI Inform Trade & Industry; and Business Source Complete. A hand search of the health systems evidence repository of the McMaster Health Forum was also conducted. The full search strategy is available online.8
Assessment for inclusion The assessment process for inclusion was multistaged. In Stage 1, abstracts were downloaded into a reference database and duplicates removed. Each abstract was independently screened by three readers for eligibility according to the following criteria: identification of regulated or unregulated health care providers; English or French language; published between 2000 and 2012; reviews relating to Canada, the United States, or publicly funded health care systems similar to Canada (e.g. New Zealand, Australia, United Kingdom, Sweden, Denmark, France, Germany, Finland, and Norway); inclusion of one or more financial or nonfinancial incentive and inclusion of one or more human resource outcomes; and peer-reviewed. Differences in agreement amongst readers about inclusion were resolved. Reviews that met the inclusion criteria were then retrieved (Stage 2) and read by two researchers to determine eligibility using the same inclusion criteria as used during the abstract screening. Reading of the full reviews led to the exclusion of a number of reviews as they did not meet criteria. Differences in agreement between researchers were resolved and the remaining reviews advanced to Stage 3 where they were rated independently by two researchers for methodological quality using the Assessment of Multiple Systematic Reviews tool.9 This is a validated tool composed of 11 criteria (such as if the scientific quality of the included studies was assessed and documented, was a list of included studies provided, and were potential biases evident/declared). Reviews scoring five or higher were considered of moderate or high quality and included in the overview.
Data extraction Two reviewers sequentially extracted data from the included reviews using an extraction sheet that captured details of each review’s aim, details of the search, number, and designs of studies included in the review, countries represented, providers, settings (e.g. acute care, primary care), and conclusions.
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The second extractor reviewed the first extractor’s data and validated and complemented the information as needed.
and work design (e.g. staffing models, employment status, and collaboration). While a range of human resource outcomes was included in the search strategy, the following are those that were discussed within the included reviews.
Results Incentives identified in the reviews
Effectiveness of financial incentives
Figure 1 displays the number of abstracts or reviews at each stage and reasons for exclusion. A meta-analysis was not performed as not all reviews reported on quantitative findings. Table 1 displays the characteristics of the reviews relevant to workforce incentives. Often incentives were part of a larger discussion of variables that have an impact on human resource outcomes (e.g. job stress) or discussed within the wider context of workforce incentives and an array of outcomes (e.g. patient outcomes or clinical practice).10–12 The incentives were separated into financial and nonfinancial. Nonfinancial incentives were categorized as: positive work environments; supports for career and professional development (e.g. promotional opportunities, clinical supervision, and education programs);
There were mixed results from the use of financial incentives. Financial incentives may have a positive influence on job satisfaction and recruitment of health care providers but may not be as relevant for retention.11–13 Higher wages appear to have a positive influence on job satisfaction and potentially aid in the recruitment and the initial stages of retention.12,14 However, there is evidence that the effectiveness of financial incentives on employee retention declines after five years.15 Moreover, financial compensation is not necessarily the most effective strategy for retaining nurses compared to other factors such as a positive work environment.16 One important relationship is the linkage between financial compensation, scholarship schemes, benefits
Abstracts screened (Stage 1) n = 416
Abstracts excluded based on inclusion criteria (Stage 1) n = 352
Reviews eligibility screened (Stage 2) n = 64
Reviews excluded based on inclusion criteria (Stage 2) n = 31
Reviews quality screened (Stage 3) n = 33
Reviews excluded based on inclusion criteria (Stage 3) n = 14
Reviews excluded based on quality rating (Stage 3) n=6
Reviews included in overview n = 13
Figure 1. Process of reviewing abstracts and reviews.
Impact of hospital nursing staff models on patient and staff outcomes
Retention strategies for health workers in rural/remote areas in Australia
Evidence-based factors supporting recruitment and retention of nurses in aged and dementia care
Buykx, 2010
Chenoweth, 2010
Focus of review
Butler, 2011
First author, year
Table 1. Characteristics of reviews.
Individual studies include: evaluations (n ¼ 6), review articles (n ¼ 8)
Total studies: 25 Individual studies include: not reported
Seven databases
1990-2008 12 databases
individual studies include: Australia, Netherlands, USA, Canada, England
Individual studies include: RCT (n ¼ 8); controlled clinical trials (n ¼ 2); controlled before/ after (n ¼ 5)
Individual studies include: Australia, UK, USA, Sweden, Canada, Finland (other countries not specified)
Corresponding author: Australia
Individual studies include: USA, Australia, Canada, Japan, New Zealand, Africa (other countries not specified)
Corresponding author: Australia
Corresponding author: Ireland
Total studies: 15
Total studies: 14
Countries represented
Description of studies
2000–2009
1977–2009 databases not reported
Details of search
Dementia and aged care nurses (registered, enrolled, licensed, practical, director of nursing, advanced practice)
Doctors, nurses, multidisciplinary, hospital administrators, allied health
Hospital nursing staff (RNs or equivalent, licensed practical, or equivalent, unlicensed assistive personnel or equivalent)
Description of providers in studies
Aged care settings (acute, residential, community)
Rural/remote areas (not specified)
Hospitals (acute, nonacute, all sizes, teaching, and nonteaching, and public and private
Type of settings in studies
(continued)
Developing a family-friendly, learning environment that values its staff is important for recruiting and retaining nursing staff. Some successful nurse recruitment and retention strategies include: careful selection of student nurse clinical placements and ongoing supervision and education; training for new and existing nurses; increased autonomy; pay parity across health settings; and family friendly policies. There was less evidence that skill mix or work load impact health human resources outcomes such as absenteeism and nurse retention. It is more effective to combine different strategies rather than relying on a single incentive.
There is inconclusive evidence that financial incentives are the most important factor in the decision to remain in rural/remote areas. The authors found evidence that nonfinancial incentives such as adequate relief, autonomy, and child care/ family supports influence retention. There is supporting evidence for the use of strategies that ‘‘bundle’’ retention incentives rather than relying on one strategy alone.
Interventions relating to hospital nurse staffing models may improve some staff-related outcomes. In particular, primary nursing and self scheduling may reduce staff turnover.
Main Results
Misfeldt et al. 55
Predictors of shortterm absences of staff nurses working in hospital settings
Effectiveness of intervention strategies to attract and retain health workers in remote and rural areas
Evaluation of nursing models in residential aged care designed to reduce negative and improve positive outcomes for residents
The influence of continuing professional development on enhancing the recruitment and retention of occupational therapists
Dolea, 2010
Hodgkinson, 2011
Hunter, 2002
Focus of review
Davey, 2009
First author, year
Table 1. Continued.
Total studies: 13 Individual studies include: not reported
3 databases, 1 bulletin
Individual Studies Include: Interrupted time series (n ¼ 1), Controlled beforeand-after (n ¼ 1)
Six databases
1990–1999
Total studies: 2
1989–2007
Individual studies include: longitudinal cohort (n ¼ 5); retrospective (n ¼ 3); pre and post (n ¼ 5); control (n ¼ 1); cross-sectional observation (n ¼ 12)
3 databases, websites
Individual studies include: prospective studies (n ¼ 7); others not reported (n ¼ 7)
10 databases
Total studies: 27
Total studies: 14
1986–2006
1995–2009
Description of studies
Details of search
Individual Studies Include: USA, UK
Corresponding author: not reported
Individual studies include: Canada, Netherlands
Corresponding author: Australia
Individual studies include: Australia, Canada, Japan, New Zealand, USA, Africa, Latin America, southeastern Asia
Corresponding author: Switzerland
Individual studies include: USA, Canada, Netherlands, Israel (other countries not specified)
Corresponding author: Canada
Countries represented
Occupational therapists, clinical specialists
Nurses (registered and enrolled), personal care attendants
Hospitals, not reported
Aged care settings (residential, subacute, and extended)
Rural/remote settings (not specified)
Acute care hospitals
Nurses (registered, licensed practical, ICU, general, new)
Health providers
Type of settings in studies
Description of providers in studies
(continued)
Recruitment and retention of occupational therapists is influenced by a combination of personal and professional factors (e.g. autonomy, opportunities to develop skills, and salary). There is insufficient evidence to conclude that continuing professional development alone increases recruitment and retention.
There is some evidence to suggest that a primary-care model is preferred by staff over team nursing; however, there were no significant improvements in staff outcomes (i.e. job satisfaction, absenteeism, and turnover).
Rurally oriented medical education programmes, professional support and financial incentives (e.g. allowance, scholarships/loan repayment programs) positively influence the decision of graduates to practise in rural areas.
There is inconclusive and mixed evidence on the association between absenteeism and several workforce incentives including pay, staffing levels, work responsibilities, and role ambiguity. One exception is the significant negative influence of a part-time staffing ration and absenteeism. More research is needed on these linkages.
Main Results
56 Journal of Health Services Research & Policy 19(1)
The determinants of front line nurse managers’ job satisfaction
The relationship between human resource management (HRM) and individual and organizational outcomes
Organization retention strategies for new graduate nurses
Patterson, 2010
Salt 2008
Focus of review
Lee, 2008
First author, year
Table 1. Continued.
Total studies: 10 Individual studies Include: experimental (n ¼ 2); prospective (n ¼ 8)
Total studies: 16 Individual studies include: one-time experimental case study design (n ¼ 9); one-group pretestposttest design (n ¼ 3); nonrandomized control group pretest-posttest design (n ¼ 3); static group comparison design (n ¼ 1)
20 databases
1979–2006 11 databases, 8 research web sites, reference lists of key selected articles
Individual studies include: quantitative (n ¼ 12); mixed methods (n ¼ 1); qualitative (n ¼ 1)
10 databases, 4 journals, 7 websites
1996–2006
Total studies: 14
Description of studies
1990–2006
Details of search
Individual studies include: USA
Corresponding Author: Canada
Individual studies include: UK, USA, Denmark, Sweden, the Netherlands
Corresponding author: United Kingdom
Individual studies include: USA, Canada, Hong Kong , UK
Corresponding author: Canada
Countries represented
NGNs, registered nurse residents, registered nurse interns, registered nurse externship, preceptors, managers, patient care directors, experienced nurses
Health professionals
Frontline nurse managers (nurses in leadership roles responsible for managing a nursing unit or team, and having direct supervision of staff nurses in a healthcare organization)
Description of providers in studies
Hospitals
Not reported
Healthcare organizations
Type of settings in studies
(continued)
Four types of retention strategies were implemented to increase retention rates for NGN. Implementing a retention strategy is effective for increasing retention rates of NGNs. The most successful retention rates were linked to a preceptor program model with an NGN focus and a program length of 3 to 6 months, while strategies implemented for less than 3 months were least successful.
Human resource management methods can be used to support organizational change. Work design practices that enhance employee autonomy and control positively influenced job satisfaction, absence, and health. Involving employees in the design/implementation of changes that affect their work is an effective strategy for enhancing HHR outcomes including job satisfaction. Incorporating training to support implementing change was emphasized.
Strategies that address autonomy, workload, increasing organizational support for managers, and empowering managers to participate in decision-making improve job satisfaction for nurse managers.
Main Results
Misfeldt et al. 57
The effects of preventative staff-support interventions for health workers
The relationship between autonomy, job stress, and nurse-physician collaboration on jobsatisfaction among registered nurses
van Wyk 2010
Zangaro, 2007
HGNs: new graduate nurses.
The factors that influence job satisfaction of general practitioners
Focus of review
Van Ham 2006
First author, year
Table 1. Continued.
Total studies: 31 Individual studies include: not reported
Seven databases
Individual studies include: RCTs
Seven databases
1991–2003
Total studies: 10
Individual studies include: not reported
Four databases, reference lists
1983–2008
Total studies: 24
Description of studies
1990–2006
Details of search
Individual studies include: England, USA, Canada, Australia, Taiwan, Sweden, Israel, Hong Kong, Scotland, United Kingdom
Corresponding author: USA
Individual studies include: USA, Canada, Taiwan, Japan (other countries not specified)
Corresponding author: South Africa
Individual studies include: not specified
Corresponding author: not reported
Countries represented
Staff nurses
Nurses of various ranks (from nurse managers to nursing aides) , mixture of health professionals, healthcare team as a unit
General practitioners
Description of providers in studies
Hospitals, specialty facility, multiple sites
Tertiary, secondary, various settings including tertiary, secondary, residential, community, referral
Not reported
Type of settings in studies
There is supportive evidence that good collaboration between nurses and physicians and fostering autonomy in improves job satisfaction for nurses.
There is strong evidence to support the effectiveness of an intensive, longterm stress management training intervention on reducing job stress and risk of burnout among a wide range of health workers in various settings. However, insufficient evidence was found to conclude that stress management training interventions positively affected job satisfaction and absenteeism over the short and medium term.
Job satisfaction for general practitioners is increased by work diversity, relations and contact with colleagues, and being involved in teaching medical students. The main factors that decrease job satisfaction include low income, too many working hours, high workloads, and lack of recognition.
Main Results
58 Journal of Health Services Research & Policy 19(1)
Misfeldt et al. and loan repayments, and recruitment among health care providers in rural and remote areas.13,15 In particular, these factors are important elements within an incentives package for recruiting medical students and physicians to rural or remote communities.15 However, there is less evidence that financial incentives are an important factor in their retention.13
Effectiveness of nonfinancial incentives Work environment. The work environment includes components such as workload, level of professional autonomy, the availability of clinical and social supports, and work-life balance. The most promising strategies for improving job satisfaction and retention are related to professional autonomy and work-life balance. The latter improves retention and decreases turnover rates.14,17 Self-scheduling reduces turnover rates17 while flexibility in work schedules, family friendly policies, child care facilities, social hours, and work-life balance improve retention rates.14,16 Workplace supports, including adequate time away from the community, are particularly effective for minimizing burnout and job dissatisfaction among rural and remote health care providers.13 Several reviews found that promoting professional autonomy was also an important strategy for improving retention and job satisfaction.11,14,16,18 However, one review found that autonomy did not have a significant relationship with absenteeism for staff nurses.11 There is mixed evidence for the effects of clinical and social support on outcomes.12,19 One review found little evidence that connects stress management courses with improved outcomes, such as a risk of burnout.20 Likewise, there is only modest evidence of a significant relationship between workload and related factors such as job demand, role overload, task complexity, work variety, and work responsibilities with job satisfaction, retention, and absenteeism.11,12,21 There is, however, some evidence that increased workload and work hours decreased job satisfaction for general practitioners while variation in tasks increased their job satisfaction.21 Supports for career and professional development. Overall, the reviews confirm a positive relationship between various supports for career and professional development, educational programs, clinical supervision, and outcomes;11,16,19,20 having avenues available for opportunities of promotion reduces absenteeism;11 good clinical supervision positively influences rates of recruitment and retention for nurses and occupational therapists, particularly when a good supervisor–mentee relationship is fostered;14,16 opportunities for professional education and training, such as leadership
59 training, have a positive influence on recruitment and retention of health care providers;14,16,19 access to mentoring programs, clinical placements, preceptor-guided clinical experiences during orientation, needs-based orientation, externship programmes, and specialty training are important for recruiting and retaining new graduate nurse;22 and rural curriculum, rural clinical rotations, a rurally located medical school, and multifaceted education are effective for attracting new medical graduates to rural and remote programs.15 Work design. Evidence is mixed on the effectiveness that restructuring staffing models and re-engineering work and ward practices on improving turnover rates and absenteeism.13,20 There is no conclusive evidence that changes to staffing models improve human resource outcomes. For instance, one review found that changes to staffing models and re-engineered work are positively related with job satisfaction,16 while in another review, staffing models did not have any influence on job satisfaction or absenteeism.10 There is also no conclusive evidence of a relationship between staff mix and outcomes. For instance, in one review, there was no evidence that having the right staff mix is effective in retaining health care providers,16 whereas in another review, there is evidence that collaboration between nurses and doctors significantly improves job satisfaction for the nurses.18 Multiprofessional team work also improves job satisfaction for occupational therapists.14
Discussion Main findings Financial incentives, including direct compensation through salaries or indirect payment through benefits packages, are often the first incentives considered. The findings suggest that higher salaries and indirect financial compensation through bonuses and scholarships continue to be popular though there is conflicting evidence of their effectiveness on several key outcomes. Nevertheless, there is evidence that financial incentives may be effective for recruiting, but not necessarily retaining, health care providers in rural and remote communities. Financial compensation as a term was seldom defined in the reviews, and therefore, it is difficult to discern whether the authors were referring to direct or indirect compensation. Also, the studies did not disclose the magnitude of the incentives, a factor likely to influence their effectiveness. Overall, a strategy that combines financial compensation with nonfinancial incentives, such as high-quality working environments and opportunities for professional growth, may be
60 more effective for improving human resource outcomes than financial incentives alone. While the evidence overall on the effectiveness of nonfinancial incentives is mixed, strategies such as providing opportunities for collaboration and incentives that emphasize work-life balance (e.g. child care) improve job satisfaction and staff retention.20,22,23 However, although child care supports, social hours, and family supports seem to be effective incentives, they are not always well defined in the reviews. Similarly, although making adjustments to workload is one of the commonest incentives used, their impact on job satisfaction, staff retention, and absenteeism is unclear.
Limitations First, the quality of the evidence in the reviews varied. Some of the reviews only included randomized controlled trials, while others included qualitative studies and reports that had not been peer-reviewed. Few reviews report the statistical significance of the effect of the incentive on the outcome. Therefore, statements made about relationships between incentives and outcomes are tentative, and the results of this overview should be considered with caution. Second, the search strategy and inclusion criteria may have resulted in relevant reviews being missed. The reviews yielded by the literature search discussed fewer than half the incentives included in the search parameters. Third, several of the reviews report on studies conducted in the 1980s and 1990s, which may not be relevant to today’s context. Fourth, while overviews of reviews are valuable for summarizing evidence, recent studies could be missed. The reviews did not provide data on effect size, nor did the majority of reviews provide a clear description of the incentives or outcomes reported. It was impossible to discern the magnitude of the incentives (e.g. the amount of the financial package and number of education days), which limits our ability to link specific incentives with outcomes.
Implications for policy and research While the evidence on effective financial and nonfinancial incentives is mixed, some strategies show more promise than others. Financial incentives are likely to assist with recruiting health care providers to rural and remote areas. The effectiveness of some nonfinancial incentives, such as opportunities for professional development and for collaboration, is emerged as effective mechanisms for improving human resource outcomes and requires further examination.
Journal of Health Services Research & Policy 19(1) Other areas for further exploration include the relationship between incentives and outcomes as there is a lack of well-designed studies (e.g. controlled trials) on effective and largely untested interventions for underserved and rural areas.4,23 Moreover, there was little discussion within the reviews of the costs associated with various incentives and the feasibility of targeted incentives packages that recognize the specific needs and expectations of different professional groups, staff demographics, and health care and employment contexts. In addition, despite including all health care professions in the search terms, many of the reviews focused on nurses, with few reporting on other health care practitioners. Finally, the settings captured in the reviews relate to either acute care or continuing care, while none explored incentives for primary care or community care. Funding This study was funded by the Institute of Health Economics at the University of Alberta, Canada.
References 1. Bourgeault I, Kuhlmann E, Neiterman E, et al. How can optimal skill mix be effectively implemented and why? Geneva: World Health Organization, 2008. 2. International Council of Nurses. Guidelines: incentives for health professionals. International Council of Nurses, 2008. 3. Custers T, Hurley J, Klazinga N, et al. Selecting effective incentive structures in health care: a decision framework to support health care purchasers in finding the right incentives to drive performance. BMC Health Serv Res 2008; 8. 4. Grobler L, Marais BJ, Mabunda SA, et al. Interventions for increasing the proportion of health professionals practicing in rural and other underserved areas. Cochr Database Rev 2009; 1: 1–25. 5. Wortsman A and Janowitz S. Taking steps forward: retaining and valuing experienced nurses. Ottawa: Canadian Federation of Nurses Unions, 2006. 6. Laschinger H, Finegan J and Wilk P. New graduate burnout: the impact of professional practice environment, workplace civility, and empowerment. Nurs Econ 2009; 27: 377–383. 7. Thomson D, Russell K, Becker L, et al. The evolution of a new publication type: steps and challenges of producing overviews of reviews. Res Synth Method 2010; 1: 198–211. 8. Workforce Research and Evaluation Unit, Alberta Health Services. Incentives for health care providers: an overview of reviews. Calgary: Workforce Research and Evaluation Unit, Alberta Health Services, 2012, http://www.alberta healthservices.ca/wre.asp (2012, accessed 24 June 2013). 9. Shea B, Grimshaw J, Wells G, et al. Development of AMSTAR: a measurement tool to assess the methodological quality of systematic reviews. BMC Med Res Methodol 2007; 7.
Misfeldt et al. 10. Hodgkinson B, Haesler E, Nay R, et al. Effectiveness of staffing models in residential, subacute, extended aged care settings on patient and staff outcomes. Cochr Collab 2011; 6. 11. Davey M, Cummings G, Newburn-Cook C, et al. Predictors of nurse absenteeism in hospitals: a review. J Nurs Manage 2009; 17: 312–330. 12. Patterson M, Rick J, Wood S, et al. Systematic review of the links between human resource management practices and performance. Health Technol Assess 2010; 14. 13. Buykx P, Humphreys J, Wakerman J, et al. Review of effective retention incentives for health workers in rural and remote areas: towards evidence-based policy. Aust J Rural Health 2010; 18: 102–109. 14. Hunter E and Nicol M. Systematic review: evidence of the value of continuing professional development to enhance recruitment and retention of occupational therapists in mental health. Br J Occup Ther 2002; 65: 207–215. 15. Dolea C, Stormont L and Braichet JM. Evaluated strategies to increase attraction and retention of health workers in remote and rural areas. Bull World Health Org 2010; 88: 379–385. 16. Chenoweth L, Jeon YH, Merlyn T, et al. A systematic review of what factors attract and retain
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Incentives for improving human resource outcomes in health care: overview of reviews
Journal of Health Services Research & Policy 2014, Vol 19(1) 52–61 ! The Author(s) 2013 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1355819613505746 jhsrp.rsmjournals.com
Renee Misfeldt1, Jordana Linder2, Jana Lait2, Shelanne Hepp2, Gail Armitage2, Karen Jackson1 and Esther Suter3
Abstract Objectives: To review the effectiveness of financial and nonfinancial incentives for improving the benefits (recruitment, retention, job satisfaction, absenteeism, turnover, intent to leave) of human resource strategies in health care. Methods: Overview of 33 reviews published from 2000 to 2012 summarized the effectiveness of incentives for improving human resource outcomes in health care (such as job satisfaction, turnover rates, recruitment, and retention) that met the inclusion criteria and were assessed by at least two research members using the Assessment of Multiple Systematic Reviews quality assessment tool. Of those, 13 reviews met the quality criteria and were included in the overview. Information was extracted on a description of the review, the incentives considered, and their impact on human resource outcomes. The information on the relationship between incentives and outcomes was assessed and synthesized. Results: While financial compensation is the best-recognized approach within an incentives package, there is evidence that health care practitioners respond positively to incentives linked to the quality of the working environments including opportunities for professional development, improved work life balance, interprofessional collaboration, and professional autonomy. There is less evidence that workload factors such as job demand, restructured staffing models, re-engineered work designs, ward practices, employment status, or staff skill mix have an impact on human resource outcomes. Conclusions: Overall, evidence of effective strategies for improving outcomes is mixed. While financial incentives play a key role in enhancing outcomes, they need to be considered as only one strategy within an incentives package. There is stronger evidence that improving the work place environment and instituting mechanisms for work-life balance need to be part of an overall strategy to improve outcomes for health care practitioners.
Keywords workload, human resources, outcomes
Introduction Discussions about human resources in health care have intensified around the globe due to shortages of some types of health care workers plus distributional imbalances by geography, sex, occupation, and institution.1,2 These emerging trends require new strategies to attract and retain a productive and motivated health workforce to where they are most needed.3 While financial incentives such as higher wages, loans, and bonuses have been, and will continue to be, an integral component of employment contracts, nonfinancial incentives including work autonomy, clarity of roles, workload management, flexibility, work-life balance, child care, and support for career and professional development
are important for improving the management of human resources.2 Incentives are tools that employers can utilize to design an organizational incentives 1 Senior Research and Evaluation Consultant, Workforce Research and Evaluation, Alberta Health Services, Alberta, Canada 2 Research and Evaluation Consultant, Workforce Research and Evaluation, Alberta Health Services, Alberta, Canada 3 Director, Workforce Research and Evaluation, Alberta Health Services, Alberta, Canada
Corresponding author: Renee Misfeldt, Workforce Research and Evaluation, Alberta Health Services, Suite 200, Collins Barrow Centre, PO Bag 5030, 3942 – 50A Avenue, Red Deer, Alberta, T4N 6H2 Canada. Email: [email protected]
Misfeldt et al. package and for planners to develop strategic plans for human resources. There has been much discussion and research into the links between both financial and nonfinancial incentives and human resource outcomes: recruitment, retention, job satisfaction, absenteeism, turnover rates, and the intent to leave or continue practice. There has, however, been no review of this literature. Identifying and understanding the most effective strategies for improving outcomes is complex. Incentives suitable for urban communities, for instance, may not be appropriate for rural and remote communities.4 Incentives may need to be tailored to different generations,5,6 work contexts and settings, and types of health care workers. Moreover, the mix and effectiveness of incentives is influenced by labor market conditions and the organization of professional groups (such as union coverage) amongst other factors. Employers and planners may also face challenges related to the availability of both human and financial resources when developing incentives.2 This overview of reviews was conducted to identify and highlight financial and nonfinancial strategies for improving health workforce outcomes to support evidence-based recruitment and retention strategies.
Methods Search strategy An overview of reviews (Cochrane reviews, systematic reviews, narrative reviews) of financial and nonfinancial incentives and their effectiveness to improve human resource outcomes was conducted.7 We developed the search terms and search parameters in consultation with a human resources manager responsible for recruitment and retention for a large health care organization and a research librarian proficient with health care databases, who executed the search strategy. The following incentives were used as search terms : salary; wage; bursaries/scholarships; pensions; pensions; subsidies/allowance; child care; travel; loan repayment; educational loans; insurance (e.g. life and health); benefits, holiday/vacation; study leave; professional development; job security; flexible work environments; flexible scheduling arrangements, earned days off, career advancements; laddering; practice relief; recreational facilities; coaching/mentoring; leaves of absence including parental compassionate, terminal care, pressing necessity, and other leaves; paid overtime; leadership development opportunities; recognition of work; staffing models; professional autonomy; manageable workload; onsite childcare and professional supports. The outcome measures included in the search were: recruitment; retention; motivation;
53 turnover; intent to leave; engagement; productivity; absenteeism; and satisfaction. The search was conducted to capture different contexts (demographics and workforce dynamics). Databases searched covered 2000–2012 and included MEDLINE (Ovid); Embase; CINAHL; Cochrane Database of Reviews; PsycINFO; Evidence-Based Medicine Reviews; ABI Inform Trade & Industry; and Business Source Complete. A hand search of the health systems evidence repository of the McMaster Health Forum was also conducted. The full search strategy is available online.8
Assessment for inclusion The assessment process for inclusion was multistaged. In Stage 1, abstracts were downloaded into a reference database and duplicates removed. Each abstract was independently screened by three readers for eligibility according to the following criteria: identification of regulated or unregulated health care providers; English or French language; published between 2000 and 2012; reviews relating to Canada, the United States, or publicly funded health care systems similar to Canada (e.g. New Zealand, Australia, United Kingdom, Sweden, Denmark, France, Germany, Finland, and Norway); inclusion of one or more financial or nonfinancial incentive and inclusion of one or more human resource outcomes; and peer-reviewed. Differences in agreement amongst readers about inclusion were resolved. Reviews that met the inclusion criteria were then retrieved (Stage 2) and read by two researchers to determine eligibility using the same inclusion criteria as used during the abstract screening. Reading of the full reviews led to the exclusion of a number of reviews as they did not meet criteria. Differences in agreement between researchers were resolved and the remaining reviews advanced to Stage 3 where they were rated independently by two researchers for methodological quality using the Assessment of Multiple Systematic Reviews tool.9 This is a validated tool composed of 11 criteria (such as if the scientific quality of the included studies was assessed and documented, was a list of included studies provided, and were potential biases evident/declared). Reviews scoring five or higher were considered of moderate or high quality and included in the overview.
Data extraction Two reviewers sequentially extracted data from the included reviews using an extraction sheet that captured details of each review’s aim, details of the search, number, and designs of studies included in the review, countries represented, providers, settings (e.g. acute care, primary care), and conclusions.
54
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The second extractor reviewed the first extractor’s data and validated and complemented the information as needed.
and work design (e.g. staffing models, employment status, and collaboration). While a range of human resource outcomes was included in the search strategy, the following are those that were discussed within the included reviews.
Results Incentives identified in the reviews
Effectiveness of financial incentives
Figure 1 displays the number of abstracts or reviews at each stage and reasons for exclusion. A meta-analysis was not performed as not all reviews reported on quantitative findings. Table 1 displays the characteristics of the reviews relevant to workforce incentives. Often incentives were part of a larger discussion of variables that have an impact on human resource outcomes (e.g. job stress) or discussed within the wider context of workforce incentives and an array of outcomes (e.g. patient outcomes or clinical practice).10–12 The incentives were separated into financial and nonfinancial. Nonfinancial incentives were categorized as: positive work environments; supports for career and professional development (e.g. promotional opportunities, clinical supervision, and education programs);
There were mixed results from the use of financial incentives. Financial incentives may have a positive influence on job satisfaction and recruitment of health care providers but may not be as relevant for retention.11–13 Higher wages appear to have a positive influence on job satisfaction and potentially aid in the recruitment and the initial stages of retention.12,14 However, there is evidence that the effectiveness of financial incentives on employee retention declines after five years.15 Moreover, financial compensation is not necessarily the most effective strategy for retaining nurses compared to other factors such as a positive work environment.16 One important relationship is the linkage between financial compensation, scholarship schemes, benefits
Abstracts screened (Stage 1) n = 416
Abstracts excluded based on inclusion criteria (Stage 1) n = 352
Reviews eligibility screened (Stage 2) n = 64
Reviews excluded based on inclusion criteria (Stage 2) n = 31
Reviews quality screened (Stage 3) n = 33
Reviews excluded based on inclusion criteria (Stage 3) n = 14
Reviews excluded based on quality rating (Stage 3) n=6
Reviews included in overview n = 13
Figure 1. Process of reviewing abstracts and reviews.
Impact of hospital nursing staff models on patient and staff outcomes
Retention strategies for health workers in rural/remote areas in Australia
Evidence-based factors supporting recruitment and retention of nurses in aged and dementia care
Buykx, 2010
Chenoweth, 2010
Focus of review
Butler, 2011
First author, year
Table 1. Characteristics of reviews.
Individual studies include: evaluations (n ¼ 6), review articles (n ¼ 8)
Total studies: 25 Individual studies include: not reported
Seven databases
1990-2008 12 databases
individual studies include: Australia, Netherlands, USA, Canada, England
Individual studies include: RCT (n ¼ 8); controlled clinical trials (n ¼ 2); controlled before/ after (n ¼ 5)
Individual studies include: Australia, UK, USA, Sweden, Canada, Finland (other countries not specified)
Corresponding author: Australia
Individual studies include: USA, Australia, Canada, Japan, New Zealand, Africa (other countries not specified)
Corresponding author: Australia
Corresponding author: Ireland
Total studies: 15
Total studies: 14
Countries represented
Description of studies
2000–2009
1977–2009 databases not reported
Details of search
Dementia and aged care nurses (registered, enrolled, licensed, practical, director of nursing, advanced practice)
Doctors, nurses, multidisciplinary, hospital administrators, allied health
Hospital nursing staff (RNs or equivalent, licensed practical, or equivalent, unlicensed assistive personnel or equivalent)
Description of providers in studies
Aged care settings (acute, residential, community)
Rural/remote areas (not specified)
Hospitals (acute, nonacute, all sizes, teaching, and nonteaching, and public and private
Type of settings in studies
(continued)
Developing a family-friendly, learning environment that values its staff is important for recruiting and retaining nursing staff. Some successful nurse recruitment and retention strategies include: careful selection of student nurse clinical placements and ongoing supervision and education; training for new and existing nurses; increased autonomy; pay parity across health settings; and family friendly policies. There was less evidence that skill mix or work load impact health human resources outcomes such as absenteeism and nurse retention. It is more effective to combine different strategies rather than relying on a single incentive.
There is inconclusive evidence that financial incentives are the most important factor in the decision to remain in rural/remote areas. The authors found evidence that nonfinancial incentives such as adequate relief, autonomy, and child care/ family supports influence retention. There is supporting evidence for the use of strategies that ‘‘bundle’’ retention incentives rather than relying on one strategy alone.
Interventions relating to hospital nurse staffing models may improve some staff-related outcomes. In particular, primary nursing and self scheduling may reduce staff turnover.
Main Results
Misfeldt et al. 55
Predictors of shortterm absences of staff nurses working in hospital settings
Effectiveness of intervention strategies to attract and retain health workers in remote and rural areas
Evaluation of nursing models in residential aged care designed to reduce negative and improve positive outcomes for residents
The influence of continuing professional development on enhancing the recruitment and retention of occupational therapists
Dolea, 2010
Hodgkinson, 2011
Hunter, 2002
Focus of review
Davey, 2009
First author, year
Table 1. Continued.
Total studies: 13 Individual studies include: not reported
3 databases, 1 bulletin
Individual Studies Include: Interrupted time series (n ¼ 1), Controlled beforeand-after (n ¼ 1)
Six databases
1990–1999
Total studies: 2
1989–2007
Individual studies include: longitudinal cohort (n ¼ 5); retrospective (n ¼ 3); pre and post (n ¼ 5); control (n ¼ 1); cross-sectional observation (n ¼ 12)
3 databases, websites
Individual studies include: prospective studies (n ¼ 7); others not reported (n ¼ 7)
10 databases
Total studies: 27
Total studies: 14
1986–2006
1995–2009
Description of studies
Details of search
Individual Studies Include: USA, UK
Corresponding author: not reported
Individual studies include: Canada, Netherlands
Corresponding author: Australia
Individual studies include: Australia, Canada, Japan, New Zealand, USA, Africa, Latin America, southeastern Asia
Corresponding author: Switzerland
Individual studies include: USA, Canada, Netherlands, Israel (other countries not specified)
Corresponding author: Canada
Countries represented
Occupational therapists, clinical specialists
Nurses (registered and enrolled), personal care attendants
Hospitals, not reported
Aged care settings (residential, subacute, and extended)
Rural/remote settings (not specified)
Acute care hospitals
Nurses (registered, licensed practical, ICU, general, new)
Health providers
Type of settings in studies
Description of providers in studies
(continued)
Recruitment and retention of occupational therapists is influenced by a combination of personal and professional factors (e.g. autonomy, opportunities to develop skills, and salary). There is insufficient evidence to conclude that continuing professional development alone increases recruitment and retention.
There is some evidence to suggest that a primary-care model is preferred by staff over team nursing; however, there were no significant improvements in staff outcomes (i.e. job satisfaction, absenteeism, and turnover).
Rurally oriented medical education programmes, professional support and financial incentives (e.g. allowance, scholarships/loan repayment programs) positively influence the decision of graduates to practise in rural areas.
There is inconclusive and mixed evidence on the association between absenteeism and several workforce incentives including pay, staffing levels, work responsibilities, and role ambiguity. One exception is the significant negative influence of a part-time staffing ration and absenteeism. More research is needed on these linkages.
Main Results
56 Journal of Health Services Research & Policy 19(1)
The determinants of front line nurse managers’ job satisfaction
The relationship between human resource management (HRM) and individual and organizational outcomes
Organization retention strategies for new graduate nurses
Patterson, 2010
Salt 2008
Focus of review
Lee, 2008
First author, year
Table 1. Continued.
Total studies: 10 Individual studies Include: experimental (n ¼ 2); prospective (n ¼ 8)
Total studies: 16 Individual studies include: one-time experimental case study design (n ¼ 9); one-group pretestposttest design (n ¼ 3); nonrandomized control group pretest-posttest design (n ¼ 3); static group comparison design (n ¼ 1)
20 databases
1979–2006 11 databases, 8 research web sites, reference lists of key selected articles
Individual studies include: quantitative (n ¼ 12); mixed methods (n ¼ 1); qualitative (n ¼ 1)
10 databases, 4 journals, 7 websites
1996–2006
Total studies: 14
Description of studies
1990–2006
Details of search
Individual studies include: USA
Corresponding Author: Canada
Individual studies include: UK, USA, Denmark, Sweden, the Netherlands
Corresponding author: United Kingdom
Individual studies include: USA, Canada, Hong Kong , UK
Corresponding author: Canada
Countries represented
NGNs, registered nurse residents, registered nurse interns, registered nurse externship, preceptors, managers, patient care directors, experienced nurses
Health professionals
Frontline nurse managers (nurses in leadership roles responsible for managing a nursing unit or team, and having direct supervision of staff nurses in a healthcare organization)
Description of providers in studies
Hospitals
Not reported
Healthcare organizations
Type of settings in studies
(continued)
Four types of retention strategies were implemented to increase retention rates for NGN. Implementing a retention strategy is effective for increasing retention rates of NGNs. The most successful retention rates were linked to a preceptor program model with an NGN focus and a program length of 3 to 6 months, while strategies implemented for less than 3 months were least successful.
Human resource management methods can be used to support organizational change. Work design practices that enhance employee autonomy and control positively influenced job satisfaction, absence, and health. Involving employees in the design/implementation of changes that affect their work is an effective strategy for enhancing HHR outcomes including job satisfaction. Incorporating training to support implementing change was emphasized.
Strategies that address autonomy, workload, increasing organizational support for managers, and empowering managers to participate in decision-making improve job satisfaction for nurse managers.
Main Results
Misfeldt et al. 57
The effects of preventative staff-support interventions for health workers
The relationship between autonomy, job stress, and nurse-physician collaboration on jobsatisfaction among registered nurses
van Wyk 2010
Zangaro, 2007
HGNs: new graduate nurses.
The factors that influence job satisfaction of general practitioners
Focus of review
Van Ham 2006
First author, year
Table 1. Continued.
Total studies: 31 Individual studies include: not reported
Seven databases
Individual studies include: RCTs
Seven databases
1991–2003
Total studies: 10
Individual studies include: not reported
Four databases, reference lists
1983–2008
Total studies: 24
Description of studies
1990–2006
Details of search
Individual studies include: England, USA, Canada, Australia, Taiwan, Sweden, Israel, Hong Kong, Scotland, United Kingdom
Corresponding author: USA
Individual studies include: USA, Canada, Taiwan, Japan (other countries not specified)
Corresponding author: South Africa
Individual studies include: not specified
Corresponding author: not reported
Countries represented
Staff nurses
Nurses of various ranks (from nurse managers to nursing aides) , mixture of health professionals, healthcare team as a unit
General practitioners
Description of providers in studies
Hospitals, specialty facility, multiple sites
Tertiary, secondary, various settings including tertiary, secondary, residential, community, referral
Not reported
Type of settings in studies
There is supportive evidence that good collaboration between nurses and physicians and fostering autonomy in improves job satisfaction for nurses.
There is strong evidence to support the effectiveness of an intensive, longterm stress management training intervention on reducing job stress and risk of burnout among a wide range of health workers in various settings. However, insufficient evidence was found to conclude that stress management training interventions positively affected job satisfaction and absenteeism over the short and medium term.
Job satisfaction for general practitioners is increased by work diversity, relations and contact with colleagues, and being involved in teaching medical students. The main factors that decrease job satisfaction include low income, too many working hours, high workloads, and lack of recognition.
Main Results
58 Journal of Health Services Research & Policy 19(1)
Misfeldt et al. and loan repayments, and recruitment among health care providers in rural and remote areas.13,15 In particular, these factors are important elements within an incentives package for recruiting medical students and physicians to rural or remote communities.15 However, there is less evidence that financial incentives are an important factor in their retention.13
Effectiveness of nonfinancial incentives Work environment. The work environment includes components such as workload, level of professional autonomy, the availability of clinical and social supports, and work-life balance. The most promising strategies for improving job satisfaction and retention are related to professional autonomy and work-life balance. The latter improves retention and decreases turnover rates.14,17 Self-scheduling reduces turnover rates17 while flexibility in work schedules, family friendly policies, child care facilities, social hours, and work-life balance improve retention rates.14,16 Workplace supports, including adequate time away from the community, are particularly effective for minimizing burnout and job dissatisfaction among rural and remote health care providers.13 Several reviews found that promoting professional autonomy was also an important strategy for improving retention and job satisfaction.11,14,16,18 However, one review found that autonomy did not have a significant relationship with absenteeism for staff nurses.11 There is mixed evidence for the effects of clinical and social support on outcomes.12,19 One review found little evidence that connects stress management courses with improved outcomes, such as a risk of burnout.20 Likewise, there is only modest evidence of a significant relationship between workload and related factors such as job demand, role overload, task complexity, work variety, and work responsibilities with job satisfaction, retention, and absenteeism.11,12,21 There is, however, some evidence that increased workload and work hours decreased job satisfaction for general practitioners while variation in tasks increased their job satisfaction.21 Supports for career and professional development. Overall, the reviews confirm a positive relationship between various supports for career and professional development, educational programs, clinical supervision, and outcomes;11,16,19,20 having avenues available for opportunities of promotion reduces absenteeism;11 good clinical supervision positively influences rates of recruitment and retention for nurses and occupational therapists, particularly when a good supervisor–mentee relationship is fostered;14,16 opportunities for professional education and training, such as leadership
59 training, have a positive influence on recruitment and retention of health care providers;14,16,19 access to mentoring programs, clinical placements, preceptor-guided clinical experiences during orientation, needs-based orientation, externship programmes, and specialty training are important for recruiting and retaining new graduate nurse;22 and rural curriculum, rural clinical rotations, a rurally located medical school, and multifaceted education are effective for attracting new medical graduates to rural and remote programs.15 Work design. Evidence is mixed on the effectiveness that restructuring staffing models and re-engineering work and ward practices on improving turnover rates and absenteeism.13,20 There is no conclusive evidence that changes to staffing models improve human resource outcomes. For instance, one review found that changes to staffing models and re-engineered work are positively related with job satisfaction,16 while in another review, staffing models did not have any influence on job satisfaction or absenteeism.10 There is also no conclusive evidence of a relationship between staff mix and outcomes. For instance, in one review, there was no evidence that having the right staff mix is effective in retaining health care providers,16 whereas in another review, there is evidence that collaboration between nurses and doctors significantly improves job satisfaction for the nurses.18 Multiprofessional team work also improves job satisfaction for occupational therapists.14
Discussion Main findings Financial incentives, including direct compensation through salaries or indirect payment through benefits packages, are often the first incentives considered. The findings suggest that higher salaries and indirect financial compensation through bonuses and scholarships continue to be popular though there is conflicting evidence of their effectiveness on several key outcomes. Nevertheless, there is evidence that financial incentives may be effective for recruiting, but not necessarily retaining, health care providers in rural and remote communities. Financial compensation as a term was seldom defined in the reviews, and therefore, it is difficult to discern whether the authors were referring to direct or indirect compensation. Also, the studies did not disclose the magnitude of the incentives, a factor likely to influence their effectiveness. Overall, a strategy that combines financial compensation with nonfinancial incentives, such as high-quality working environments and opportunities for professional growth, may be
60 more effective for improving human resource outcomes than financial incentives alone. While the evidence overall on the effectiveness of nonfinancial incentives is mixed, strategies such as providing opportunities for collaboration and incentives that emphasize work-life balance (e.g. child care) improve job satisfaction and staff retention.20,22,23 However, although child care supports, social hours, and family supports seem to be effective incentives, they are not always well defined in the reviews. Similarly, although making adjustments to workload is one of the commonest incentives used, their impact on job satisfaction, staff retention, and absenteeism is unclear.
Limitations First, the quality of the evidence in the reviews varied. Some of the reviews only included randomized controlled trials, while others included qualitative studies and reports that had not been peer-reviewed. Few reviews report the statistical significance of the effect of the incentive on the outcome. Therefore, statements made about relationships between incentives and outcomes are tentative, and the results of this overview should be considered with caution. Second, the search strategy and inclusion criteria may have resulted in relevant reviews being missed. The reviews yielded by the literature search discussed fewer than half the incentives included in the search parameters. Third, several of the reviews report on studies conducted in the 1980s and 1990s, which may not be relevant to today’s context. Fourth, while overviews of reviews are valuable for summarizing evidence, recent studies could be missed. The reviews did not provide data on effect size, nor did the majority of reviews provide a clear description of the incentives or outcomes reported. It was impossible to discern the magnitude of the incentives (e.g. the amount of the financial package and number of education days), which limits our ability to link specific incentives with outcomes.
Implications for policy and research While the evidence on effective financial and nonfinancial incentives is mixed, some strategies show more promise than others. Financial incentives are likely to assist with recruiting health care providers to rural and remote areas. The effectiveness of some nonfinancial incentives, such as opportunities for professional development and for collaboration, is emerged as effective mechanisms for improving human resource outcomes and requires further examination.
Journal of Health Services Research & Policy 19(1) Other areas for further exploration include the relationship between incentives and outcomes as there is a lack of well-designed studies (e.g. controlled trials) on effective and largely untested interventions for underserved and rural areas.4,23 Moreover, there was little discussion within the reviews of the costs associated with various incentives and the feasibility of targeted incentives packages that recognize the specific needs and expectations of different professional groups, staff demographics, and health care and employment contexts. In addition, despite including all health care professions in the search terms, many of the reviews focused on nurses, with few reporting on other health care practitioners. Finally, the settings captured in the reviews relate to either acute care or continuing care, while none explored incentives for primary care or community care. Funding This study was funded by the Institute of Health Economics at the University of Alberta, Canada.
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