General Problem Statement
The general problem to be addressed is the burnout of Advanced Practice Providers (APP) or Mid-Level Providers as members of the United States health care system.
Student Name
University
April 2023
Topic: Identifying Burnout Among Advanced Practice Providers And Its Stressors
General Problem Statement
The general problem to be addressed is the burnout of Advanced Practice Providers
(APP) or Mid-Level Providers as members of the United States health care system.
Literature Support
Advanced Practice Providers (APP) or Mid-Level Providers have become integral
members of the United States healthcare system. By 2034, the Association of American Medical
Colleges (AAMC) projected a total physician shortage of approximately 124,000 (IHS Markit
Ltd., 2021). To mitigate current and future physician deficits, the usage of APPs has become
more prevalent (Sarzynski & Barry, 2019; Hu & Dill, 2022). However, the increasing demands
of their roles can lead to burnout and high turnover rates (Jyothindran et al., 2021; Orozco et al.,
2019). Although not medical doctors, advanced practice providers are still expected to perform
almost the same duties as their collaborating physicians (Sarzynski & Barry, 2019). Therefore,
assessing the prevalence of APP burnout and the associated stressors could serve as a baseline to
address systemic issues and assist the organization with developing treatment and prevention
strategies specific to the needs of the APPs. Like physician burnout, APP burnout can affect how
well healthcare organizations deliver services (Jyothindran et al., 2021). Retaining APPs can be
complex and costly for healthcare organizations (Williams, 2019). Understanding the factors
contributing to APP burnout could also alleviate their “intent to leave” and the expenses
associated with new provider onboarding, ultimately reducing costs.
Specific Problem Statement
The specific problem to be addressed is the burnout of APPs at “Hospital Name” and the
consequent level of job retention and satisfaction of those employees.
Purpose Statement
The purpose of this qualitative study is to bridge the gap and extend the existing body of
knowledge on physician burnout by integrating advanced practice providers into the equation at
“Hospital Name.” This study will leverage the results of similar studies conducted by the
“Hospital Name Region.” It was determined that while the “Region hospitals” within the same
organization had conducted studies on the prevalence of “Provider” (Attending Physicians,
Fellows, Nurse Practitioners, & Physician Assistants) burnout, none focused on addressing the
specific concerns of APP burnout and its indications. The data obtained from this project will
allow leadership to potentially address systemic issues, prevent APP turnover and job
dissatisfaction, manage risk, and ultimately reduce investment costs. By providing a baseline
prevalence of APP burnout, “Hospital Name” can address systemic issues and better serve the
needs of the APPs.
Research Questions and Methodology Overview
The following research questions will guide this qualitative case study and facilitate an
exhaustive exploration of the causes and effects of APP burnout in the “Hospital Name”
organization.
RQ1: How would you describe your level of burnout and stress while working as an APP?
RQ2: What factors have contributed to the level of burnout and stress among APPs?
RQ3: How does employee burnout and stress impact patient care?
Due to the complexity of human behavior and subjectivity associated with experiences, a
qualitative research approach will be adopted. Data collection is a central research activity and
establishes the foundation upon which researchers generate conclusions around research
problems. Data will be collected by conducting qualitative surveys with research participants.
The results of the analysis of the data collection will be structured around key themes or topics
that emerged.
Radiography 27 (2021) 795e802
Contents lists available at ScienceDirect
Radiography
journal homepage: www.elsevier.com/locate/radi
Retention of radiographers: A qualitative exploration of factors
influencing decisions to leave or remain within the NHS
J. Nightingale a, *, M. Burton a, R. Appleyard a, T. Sevens a, S. Campbell b
a
b
Dept of Allied Health Professions, Sheffield Hallam University, UK
Breast Imaging Department, Yeovil District Hospital NHS Foundation Trust, UK
a r t i c l e i n f o
a b s t r a c t
Article history:
Received 30 October 2020
Received in revised form
2 December 2020
Accepted 23 December 2020
Available online 8 January 2021
Introduction: In many countries a widening imbalance exists between radiographer workforce supply
and demand. Improving retention is a rapid method of workforce expansion which is gaining importance
with policy makers and providers. To better understand the current leaver profile, this study aimed to
identify why radiographers leave the NHS early, and what incentives are important in their decision to
stay.
Methods: A qualitative framework methodology used semi-structured telephone interviews to explore
the perspectives of radiography managers, radiographers who have left the NHS, and those considering
leaving. Purposive sampling ensured representation across radiography professional groups, geographical and organisational diversity, and stages of career.
Results: Three over-arching themes were identified across all radiographer professional groups (n ¼ 44):
1) Challenging working patterns and the impact on employee health and wellbeing; 2) Lack of flexibility
in working terms and conditions; 3) Lack of timely career progression and access to CPD, and the need to
feel valued. Radiographers were keen to express how they ‘loved being a radiographer’; small concessions and changes to workplace culture might be the incentive to remain in radiography that some were
clearly searching for. Manager participants recognised the need to offer greater flexibility in working
patterns but this was challenging within financial and service delivery constraints.
Conclusions: While some influencing factors varied between radiographer professional groups, the three
themes were consistent across participants. Failure to address these concerns will exacerbate the loss of
experienced and highly trained staff from the NHS at a time when demand for services continues to rise.
Impact on practice: Recommendations are presented related to three primary themes which will be a
catalyst for sharing of best practice between radiology and radiotherapy centres.
© 2021 The College of Radiographers. Published by Elsevier Ltd. All rights reserved.
Keywords:
Workforce
Retention
Flexible working
Career progression
Continuing professional development
Shift working
Introduction
In the United Kingdom (UK), as in many other countries, there is
a growing imbalance between radiographer workforce supply and
demand.1,2 To meet an ambitious 45% growth target by 2029,2,3 a
further 4000 radiographers are required in addition to the planned
growth targets.4,5 This aspirational growth is compounded by high
UK radiographer vacancy rates,6,7 alongside significant workforce
challenges in some disciplines including breast imaging and
sonography.8e10 Ambitious workforce transformation strategies
have been implemented, though some are contentious and none
deliver a ‘quick fix’ to address current workforce deficits.10e14
* Corresponding author.
E-mail address: J.Nightingale@shu.ac.uk (J. Nightingale).
These workforce deficits cannot be addressed by recruitment
initiatives alone; retention of the current workforce is vital.
Alarmingly, 28% of the National Health Service (NHS) workforce are
predicted to leave for non-retirement reasons,2 with attrition from
the registered therapeutic radiographer workforce higher than
many other professions (28% over five years).3 Retention strategies
must be based upon a sound understanding of factors influencing
the decision to leave or remain. Previous UK research in therapeutic
radiography suggests a worrying correlation between radiographer
burnout, emotional exhaustion, job dissatisfaction and intention to
leave,15e18 with international therapeutic19,20 and diagnostic21e27
radiography studies citing pressure at work, large workloads and
long shifts impacting on radiographers’ intentions to stay. Probst
and Griffiths9 highlighted two primary moderators for radiographer retention: the importance of mental challenge and access to
personal development; and the essential role of managers in
https://doi.org/10.1016/j.radi.2020.12.008
1078-8174/© 2021 The College of Radiographers. Published by Elsevier Ltd. All rights reserved.
J. Nightingale, M. Burton, R. Appleyard et al.
Radiography 27 (2021) 795e802
researcher with oncology experience. Approximately 40e50 interviews were anticipated, with data collection continuing until
data saturation was reached.
A framework process was used to analyse the data.28 Initial
transcripts were read by each researcher and codes agreed. An
analytical framework was then developed which was applied to the
remaining interviews. A peer-debriefing approach to data analysis
was used to enhance rigour, credibility and trustworthiness. Several
participants were subsequently invited to comment on the
emerging findings to further enhance credibility.
moderating burnout and improving retention. However most previous research is focused on single departments and individual
radiography professions, with several published nearly a decade
ago. The pressures on the radiography workforce will have changed
over time and therefore the motivations for remaining within the
NHS will also change. This research explores why diagnostic and
therapeutic radiographers may consider leaving NHS employment
and how they might be incentivised to stay.
Methods
A qualitative research design employed semi-structured interviews (Fig. 1) within a pragmatic framework methodology.28
Framework analysis is well suited to applied research with specific questions, multiple researchers, a pre-designed sample and a
priori issues.
Ethical approval of the study was acquired via the Research
Ethics Committee at Sheffield Hallam University, ID: ER15453637.
Participant Information Sheets were provided and signed consent
acquired prior to each interview. As some of the conversations were
potentially sensitive in nature, all participants were assured of
anonymity. Recruitment was via advertisements in a professional
journal and professional social media. Purposive, maximum variation sampling was adopted to ensure adequate representation
across disciplines, career stages, geography and organisational
types (Fig. 1).
Semi-structured interviews followed a literature-informed topic
guide based around six exploratory questions (Fig. 2). Telephone
interviews of 30e40 min duration were audio recorded to facilitate
professional transcription. Following two pilot interviews to test
understanding and question flow, the topic guide remained unchanged. The research team included four radiographers with
different professional backgrounds (diagnostic radiography, therapeutic radiography, sonography and breast imaging) and one health
Results
The research team interviewed 44 participants prior to reaching
data saturation (Table 1).
The over-arching positive message which emerged from all
participants was that they enjoy being a radiographer, particularly
the patient interactions. This is a significant finding for both
recruitment of students into the diagnostic and therapeutic radiography professions, and for the potential success of any strategies
to retain radiographers within the NHS.
… I couldn’t bring myself to do it for many months. Because I just
didn’t want to stop being a radiographer
[Mammo, left]
The radiographers expressed sadness in leaving the NHS, but for
many the negative impacts had eventually out-weighed their love for
the profession. These negative impacts are expressed to some degree
across all disciplines, and are summarised in Fig. 3. Each of these
primary themes will be discussed using participant quotations for
illustration using the following abbreviations: diagnostic radiography
(DR); therapeutic radiography (TR); sonography (sonog), breast
Figure 1. Qualitative study design. DR ¼ diagnostic radiography; TR ¼ therapeutic radiography.
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J. Nightingale, M. Burton, R. Appleyard et al.
Radiography 27 (2021) 795e802
Figure 2. Exploratory questions within the interview topic guides which assisted in framing the analysis.
Table 1
Numbers of participants in each category following purposive sampling.
Participant groups following purposive sampling
Interview categories (n ¼ 44)
Radiography discipline (n ¼ 44)
Radiographer career stages (n ¼ 32)
a
b
Radiography managers
12
Diagnostic radiographya
19
Early career (first 5 years)
7
Radiographers considering leaving
9
Therapeutic radiographyb
10
Mid-career
15
Radiographers who have left in last 2 years
23
Sonography
7
Late career (last 10 years)
10
N/A
Mammography
8
N/A
Includes general radiography, CT, MRI, interventional/fluoroscopy, radiographer reporting.
Includes radiotherapy planning/pre-treatment, radiotherapy treatment roles, radiotherapy review.
Figure 3. Three primary themes and eight sub-themes developed from the interviews.
imaging (mammo); magnetic resonance imaging (MRI); computed
tomography (CT). Where relevant, any differences between the
radiography professions and disciplines (modality) will be illustrated.
working days and weekend working now being the norm in many
centres.
Theme 1. Working patterns and the impact on employee health
and wellbeing
Increasing workload pressures were noted by all participants.
MRI services, for example, have transformed to a ‘front line’ modality, accommodating sicker patients and more complex timeconsuming procedures. This expansion resulted in extended
CT and MRI, it’s so much in demand. Every year was like 10% increase … But we had no more staff. [MRI/CT, late career, left]
… and the other thing is the increase in the workload because I do
Sonographer participants also reported increasing workloads
coupled with persistent workforce deficits:
797
J. Nightingale, M. Burton, R. Appleyard et al.
Radiography 27 (2021) 795e802
… ultrasound departments are literally run on bare minimum. So if
somebody goes off, it is a big problem because there is no fill-in. So
there’s people doing two people’s jobs at a time.
Unrealistic appointment times with insufficient time to provide
a good patient experience increasingly resulted in strain on radiographers’ physical and mental health:
[Sonog leaving]
… they think a renal scan doesn’t take 20 minutes anymore so now
A lot of the ones we’ve trained have then decided to leave because
of working conditions.
it’s booked in to 15
[Sonog, leaving]
[Sonog leaving]
I’m certainly starting to see staff leaving because of the pressure of
work as opposed to I’ve got a better opportunity if I go somewhere else
General and rotational radiographers often bear the brunt of
staff vacancies; this ‘transient’ workforce provides the supply chain
to other modalities.
[Sonog, manager]
staff don’t particularly want to stay in plain film [general radiography], they want to progress to other modalities.
The Therapeutic Radiographer participants were less likely to
identify physical demands or burnout as prominent reasons for
leaving. Nevertheless one Therapeutic Radiography service manager noted that they had been able to retain members of staff who
were intending to retire early, adjusting roles to less physically
challenging ones that allowed individuals’ to exploit their own
specific skillsets without changing their pay banding.
[DR manager]
Many diagnostic radiographer participants raised unsociable
and physically challenging working patterns as a major influence
on their decision to leave.
Theme 2. Lack of flexibility in working terms and conditions
Many participants described a ‘one size fits all’ approach, including
inflexibility in financial remuneration. Managers recognised that shift
systems had removed any extra earning capability, resulting in some
staff signing on with an agency alongside their core employment.
Ironically, the ‘moonlighting’ radiographers had no spare capacity to
pick up additional shifts at the parent hospital if required.
Morning and the afternoon breaks went a good 15 years ago
[Sonog, leaving]
The shifts can be quite brutal sometimes so ‘institutionalised
overtime’ is probably the best way of describing it.
[DR, Early career, left]
we now have a more structured shift pattern of working. With that
there was a loss of income for many radiographers … we have lost
at least three or four really good radiographers because we’ve not
been able to give them that monetary incentive and they’ve gone to
work for agency companies.
They need to bring the hours of shifts down to a reasonable rate,
because the younger ones are just burning out now.
[Sonog, late career, leaving]
[DR, Manager]
Several managers acknowledged that the traditional ‘on call’
systems had worked well in their departments; those (often
younger) radiographers who wanted to earn ‘overtime’ took the
extra sessions, while those with family commitments were happy
to step back. The rapid move to shift patterns required all radiographers to participate. This can be a struggle physically, particularly
for older radiographers:
[Agency poaching] tends to be one of the things that leads to an
instability in your staffing, if they feel the need to rush off and
moonlight at St Elsewhere … then St Elsewhere will make them an
offer they can’t refuse and then you end up losing your staff that
way.
[MRI, Manager]
I think we’re more prone to injury, we’re more prone to slowing
down, and I don’t think the system allows for that at all. It doesn’t
accept the fact that you are getting older. [Sonog, leaving]
Sonography participants expressed concerns regarding variable
pay rates for similar levels of practice, not only between hospitals,
but also between departments. These inequities were driven by the
perpetually high vacancy rates in some centres:
… I would work 12 days in a row, probably be three or four 12 hour
shifts on that as well … As soon as I’d come home I was fast asleep.. I
was absolutely exhausted. Increasingly affecting my health …
The sonographers that only did obs and gynae were paid by women
and children’s health, and they were a band 8a and we [in radiology] were only a 7. Which we didn’t feel was very fair
[DR, Late career, left]
Physical challenges in sonography and mammography include
musculo-skeletal repetitive strain injuries and pain as an ‘occupational hazard’.
[Sonog left]
Sonographers argued that their pay, given several years of public
sector pay restrictions, was not necessarily commensurate with the
responsibility:
The physical side of it scares me. What will my shoulder be like at
68?
[Sonog, leaving]
I think mammographers’ workload is quite high with repetitive
strain instances … we don’t get breaks morning or afternoon … we
work through them, to get through the workload
it’s quite a responsible job when you don’t get recognition or
payment. I’m getting paid £8 per scan when you’ve taken tax off for
looking in detail at a foetal heart. And that could mean a big difference to a mum and a baby, but I’m paid £8.
[Mammo, left]
[Sonog leaving]
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Radiography 27 (2021) 795e802
The most common reason for participants to leave the NHS was
a lack of flexibility in working terms and conditions. Workload
pressures, health problems or caring responsibilities often precipitated a request for flexible working which were often denied,
leading to loss of an experienced radiographer from the service.
Theme 3. Timely career progression, access to CPD and the need
to feel valued
Many therapeutic radiography participants highlighted limited
career progression opportunities and a feeling of waiting to fill
‘dead man’s shoes’:
I loved [working there] … but for my work-life balance and for my
mental health it is better for me to do this at the moment … I don’t
think that within the NHS you are supported very well in terms of
flexibility. It was absolutely the reason I left.
… I was really career driven, and I felt very blocked at band 6 level
… people have to literally leave or come to retirement before you
can get a band 7 … so I had itchy feet …
[TR, left]
[TR left]
when I applied for flexible working at the Trust I had gone to, they
said no. And at that point I just thought I’ll just hand my notice in
then.
Many leavers, particularly mature entrants to the profession,
expressed frustration that role progression was based upon length
of service rather than capability:
[Sonog leaving]
I did have a lot of work experience and I felt this wasn’t acknowledged in the NHS / I’ve had the opposite experience working in a
private centre
I’d applied to drop my days to three but they said, no, band 7 you’ve
got to do four …. And, yeah, that was kind of the last straw really …
[TR mid-career, left]
[TR, left]
I think there was a lack of appreciation by managers with a focus on
the number of years you’ve worked instead
Caring responsibilities were the main reasons for flexible
working requests, though elderly caring responsibilities were not
always recognised in the same way as childcare:
[TR, early career, left]
… they’re not flexible with childcare, because childcare ends at half
… every little avenue that I attempted to go down it was always
knocked back … which was frustrating … but the private sector
took a punt on me and it’s worked out.
[Sonog leaving]
[TR left]
five and they still expect you to work into the evening.
If somebody takes time off for their children … whereas I don’t get
that same consideration with my father or mother … I think that’s
where we do have problems, and they’re not being addressed
either.
Managers recognised the potential of their intermediate level
radiographers (NHS Agenda for Change Band 6), yet their hands
were tied with tight financial restraints limiting their capacity to be
innovative. Senior staff also complained that their skills and
knowledge were not exploited or appreciated; these experienced
radiographers were gradually drawn to using their transferable
skills in roles outside radiography.
Participants from all disciplines cited reducing opportunities for
continuing professional development (CPD); insufficient funding
and time release due to habitually low staffing levels were the main
causes.
[Sonog leaving]
The manager participants recognised the value of flexible
working, but the reality of already stretched and resource-poor
services meant that they were not always able to facilitate flexible working requests:
there are a number of staff who are really being pushed to the edge
…, most of them don’t have the opportunity to do things part-time
or work flexibly because it’s just not, can’t be done in order to keep
the service running.
No one could go on any courses because there was no money …
[Sonog, manager]
I don’t feel there’s the training or support that was available when I
first went into mammography … And now the funding for that sort
of education has disappeared completely.
[DR, Manager]
… the manager says if I give you part-time it’s costly for the
department; whereas if I let you go I can take a locum on to replace
you. And that’s what they did. Rather than pay me from the
departmental budget, the locums are paid for by the trust budget.
[Mammo, leaving]
The commitment to training and development is very poor.
[DR, Late career, Left]
[TR left]
Several therapeutic radiographers stated that flexibility, a good
work-life balance and some degree of ‘freedom’ was considered as
important, if not more so, than pay.
MRI participants highlighted a lack of educational parity between disciplines; for those specialising in MRI, postgraduate
qualifications were desirable rather than essential, limiting opportunities for career development and advanced practice. One
radiographer described how she had worked in MRI/CT for 12 years,
had responsibility for junior staff training, had no access to internal
or external CPD and still remained as a Band 6. While she was
extremely efficient, she was bored and felt undervalued; this led to
her leaving without other employment. Managers also recognised
I’ve got a huge amount of autonomy now … very different to the
radiotherapy environment where there’s zero autonomy and you’re
not really listened to.
[TR mid-career left]
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Radiography 27 (2021) 795e802
work-life balance. Migrating traditional ‘on call’ emergency cover
to 24/7 services has caused fundamental difficulties acknowledged by both radiographers and managers. Shift working was
significantly related to overall job stress in a Finnish radiographer
survey, particularly for mid-career radiographers.25 In our study,
many mid/late career diagnostic radiographers found the 12 h
shifts physically demanding. Regularly working evenings and
nights can increase the risk of developing a collection of symptoms categorised as Shift Work Disorder, correlated with potential for increased errors.29 Visual and mental fatigue among
radiology professionals have been shown to occur towards the
end of long work-days, and to have negative effects on lesion
detection and decision-making.30 This is important information
particularly
for
those
radiographers
with
reporting
responsibilities.
The repetitive nature of sonography/mammography procedures
caused work-related musculoskeletal disorders and pain; up to 80%
of sonographers have been previously estimated to be scanning in
pain.31 Whilst good ergonomic education and practice will reduce
the incidence of such disorders, sensible workload scheduling is
vitally important but is often overlooked.31,32 As in our research, a
study of work-related stressors in radiology also cited staff shortages and heavy workload as the greatest sources of pressure at
work.25
Participants in senior diagnostic roles and in therapeutic
radiography were more likely to highlight emotional exhaustion,
often a precursor to ‘burnout’.16,17 Burnout is a state of mental
weariness which is a sustained response to chronic workplace
stressors, leading to decreased effectiveness, reduced commitment, and negative effects on home life.33 Causes of burnout
include having too many bureaucratic tasks, too many work
hours, and increasing levels of computerisation.30 Fatigue and
burnout have been flagged as a patient safety issue in radiology
departments, with leaders recommended to implement strategies
of restoring a sense of control, reducing out-of-hours obligations
and reducing isolation.30
the challenges of securing funding for CPD for their staff. Increasingly they were having to ‘compete’ centrally within their Trust for
CPD funds; Directors of Nursing often held the CPD budget.
Timely career progression and CPD opportunities assist in
raising morale and helping staff to feel valued. This latter concept
was raised by staff at all career levels, but particularly those in later
career stages who had a wealth of experience to share. Some
general radiographers described how without any CPD they felt
they were on a treadmill and this became boring. Monotony was
raised by other interviewees as a reason to leave to undertake other
roles.
Findings summary
Three primary themes articulate the broad factors influencing
radiographer decisions to leave NHS employment: 1) Working
patterns and the impact on employee health and wellbeing; 2) Lack
of flexibility in working terms and conditions; 3) Timely career
progression, access to CPD and the need to feel valued. These
themes encompass findings which were common to all of the
participant groups, however each radiography profession and
discipline had particular themes which were either unique to their
group or were strongly voiced within their group (Table 2).
Discussion
Demand for radiology and radiotherapy services continues to
outweigh radiographer supply, characterised by high vacancy
rates6e10 and high predicted shortfalls.1,4,5 Strategies to increase
entrants to the profession have been implemented, yet reducing
untimely loss of existing radiographers from the service is rarely
considered. In order to better understand this leaver profile, this
study aimed to identify why radiographers leave the NHS early, and
what incentives are important in their decision to stay.
Working patterns in diagnostic radiography were repeatedly
highlighted as unreasonable and incompatible with a healthy
Table 2
Identification of negative influences on decision to leave across different disciplines [EC ¼ early career; MC ¼ mid-career; LC ¼ late career].
Discipline
Group members include:
Diagnostic Radiography (CT, fluoroscopy and projection
radiography)
supply chain to other modalities therefore always in
3 service leads
deficit
1 radiology lead (NHS private wing)
‘family unfriendly’ shift patterns
4 had left the NHS
lack of additional earning potential
4 considering leaving
lack of less physically demanding roles (LC)
2 consultant radiographers
inflexible working
1 service manager
lack of timely progression and CPD (EC)
1 considering leaving
stagnation/under-valued (MC)
7 had left the NHS
2 had left TR but employed by NHS in a separate restricted hierarchy and management culture
role
5 EC/4 MC
problems retaining specialist sonographers
2 sonography managers
staff burnout
3 considering leaving
repetitive strain
2 had left the NHS
pay inequity
2 MC/5 LC
training challenges
lack of manager support
isolation and emotional aspects
3 Band 6
lack of flexible working
1 senior radiographer
lack of CPD opportunities
2 consultant radiographers
health issues/repetitive strain
1 superintendent/manager
senior staff burnout
3 left, 4 considering
pay inequity and lack of role recognition
5 LC/2 MC
pension trap
4 MRI radiographers
education and training inequity
1 MRI manager
poor CPD opportunities
lack of role recognition and advanced/consultant
practice
recent move towards shifts in many centres
Therapeutic Radiography
Sonography
Mammography
Magnetic Resonance Imaging
800
Negative Influences
J. Nightingale, M. Burton, R. Appleyard et al.
Radiography 27 (2021) 795e802
Table 3
Recommendations relating to the three over-arching themes influencing decision to leave or remain.
No. Recommendation
Details
1
Flexible working initiatives
2
Band 6 engagement strategies to
increase motivation
3
4
Competency based linked grading
system
Pay innovations
5
Review of MRI workforce
e.g. less than full time working (reduced days or hours), term time or school hours working, phased retirement options, bank
contracts.
The physical demands of the job for late career staff should be reviewed, with alternative roles identified to facilitate later
retirement.
Post retirement contracts which have reduced requirements for registration (e.g. assistant practitioner level posts;
volunteering; ‘as and when’ bank contracts) may provide valuable access to highly experienced staff to support new entrants
to the workforce.
e.g. developing leadership and quality enhancement skills and recognition for increased responsibility.
Creating novel rotational posts (e.g. through DEXA or endoscopy) and investigating opportunities for collaboration/
secondments with academia or research may be beneficial. This could include engagement with the NIHR Integrated Clinical
Academic training pathway.
For grades 5e6 and 6e7. To enable radiographers and supervisors to be able to better plan career development and
performance management.
Explore opportunities for system or even regional banks of staff or other innovations for radiographers to increase earning
potential above basic pay rather than work for agencies or other employers.
In sonography, investigate the pay and workload inequity according to roles and consider alignment to the sonography career
framework.
Building on the sonography career framework and in the context of the SCoR Education and Career Framework, including
recommendations for initial entry pathways, CPD and advanced clinical practice.
highlighted the collegial as well as the physical environment as
being of paramount importance in their transition to the workplace.27 They expressed a need to feel welcomed, and ‘get along’
with their peers,27 and this may be more easily achieved in a
smaller department. In contrast, sonographers within this study
who worked in small departments highlighted their relative
isolation in comparison to rotational radiographers.
Radiographers of all professional groups noted poor progression/CPD opportunities, describing how they were ‘stuck in a rut’.
This particularly affected those in intermediate levels of practice; a
study of Agenda for Change Band 5/6 therapeutic radiographers in
the NHS demonstrated that the provision, relevance and quality of
CPD was closely linked to perceptions of job satisfaction.20 MRI
radiographers were particularly dissatisfied as they perceived their
modality was treated differently to others who required underpinning post-graduate education. Therapeutic radiographers were
also disappointed by a lack of early career progression, criticising a
restrictive and hierarchical NHS management culture. Some therapeutic radiographer and MRI participants cited this lack of CPD
and career progression opportunities as a reason to move to independent sector employment.
The purposive sampling strategy ensured a good representation
across diagnostic and therapeutic radiography and most diagnostic
modalities, although a potential limitation relates to the
geographical spread of participants. Whilst the aim was to recruit
radiographers from across the UK, those responding to the adverts
were predominantly from England. However the participants represented a range of different types of healthcare organisation,
based in urban, semi-rural and more remote locations, providing a
wide range of working environments and contexts. A second potential limitation is the recruitment method via professional social
media; inevitably the project attracted radiographers with strong
feelings about retention, many of whom had experienced difficult
and unresolved situations, raising the potential for recruitment
bias.
Opportunities for earning potential beyond basic pay were
scarce, attracting diagnostic radiographers and sonographers to
secure additional agency or bank work, which ultimately may lead
to their leaving their NHS role. Managers noted the paradox of
employing agency staff when their own employees would be
willing to undertake paid overtime. Requests for flexible working
were traditionally from mid-career female radiographers to
manage childcare, but increasingly requests were from late career
radiographers of both genders who had elder caring responsibilities. The 12 h alternating shifts were not family-friendly,
and made arranging care challenging; requests for flexible working were invariably denied and the radiographer left the NHS
altogether. This loss of experienced staff to the service is not only a
radiography phenomenon. The 2019 0 Closing the Gap’ report by the
King’s Fund calls on the NHS to review their workforce practices to
improve retention of staff, particularly for older staff.34 Flexibility in
working patterns is also central to the NHS People Plan, which
urges flexibility of employment contracts within and between organisations.35 This concept of ‘shared human resource’ is also
gaining momentum through recent reviews of UK imaging and
radiotherapy services.4,36
The sampling strategy ensured that perspectives of radiographers from diagnostic and therapeutic radiography were captured.
While not all modalities were included, each profession/discipline
had unique perspectives on retention (Table 2). Ultrasound and
breast screening services have long-standing workforce shortages,8e11 translating into extensive patient lists with too little time
per patient. Sonographers’ work was ‘not valued’ by managers and
clinicians; this belief was reinforced by pay inequity between
different professional groups. Mammographers unanimously
expressed that they loved their job, and many wished to continue
working alongside caring responsibilities. Requests for flexibility
had been denied, resulting in their leaving, however several
expressed a desire to return to the service should flexible working
be offered in the future. Recent reports encourage the NHS to
consider flexible options such as ‘retire and return’ and ‘return to
practice’,34,35 and these are currently being rolled out within the
breast screening service.
General and rotational diagnostic radiographers were often
working in large departments in comparison to the ‘specialist’
radiographers working in smaller departments. Small departments
have been shown to offer a more positive experience, leading to
increased levels of job satisfaction.25 In a South African study of
radiography workplace cultures, early career radiographers
Conclusion
Reducing the mismatch between workforce supply and demand
cannot be achieved solely by increasing the number of new entrants to the service. It is much faster and less expensive to retain
staff than it is to recruit more people; retaining staff facilitates
continuity and allows improvements in experience and morale
which is likely to be passed on to patients in their care.
801
J. Nightingale, M. Burton, R. Appleyard et al.
Radiography 27 (2021) 795e802
This qualitative study aimed to identify why radiographers leave
the NHS, and what might incentivise them to stay. Three factors
influencing the decision to leave or remain were identified; challenging working patterns that had adverse effects on health and
wellbeing, a lack of flexibility in working terms and conditions, and
a lack of timely access to career progression and CPD opportunities.
While some variation was noted between the two different professions and the modalities, these three themes presented a common thread that linked the experiences of the radiographers
interviewed.
All radiographers interviewed were keen to confirm to the researchers that they loved ‘being a radiographer’ and that their interactions with patients and colleagues were rewarding. Several
radiographers who had left expressed a desire to return to a more
flexible role. With this in mind, small concessions and changes to
workplace culture and working patterns may tempt some radiographers to remain or return to the profession.
This is the first qualitative study to investigate retention across
the breadth of the radiography professions. While some of the
findings are unique to diagnostic and therapeutic radiography, they
nevertheless align very clearly to the wider workforce ambitions
set out in recent publications including the HEE People Plan35 and
the King’s Fund Closing the Gap34 report. Recommendations
relating to the findings presented in this article can be seen in
Table 3.
7. Society and College of Radiographers. Radiotherapy radiographic workforce
census. November 2017. ISBN: 978-1-909802-27-8.
8. The Centre for Workforce Intelligence. Securing the future workforce supply:
sonography workforce review. March 2017. www.cfwi.org.uk.
9. Society and College of Radiographers. Ultrasound workforce UK census 2019. July
2019. ISBN: 978-1-909802-43-8.
10. The Royal College of Radiologists. The breast imaging and diagnostic workforce
in the United Kingdom. BFCR 2016;(16):2.
11. Harrison G. Sonographer workforce developments. Synergy News August 2018:
12e3.
12. Sevens TJ, Reeves PJ. Professional protectionism; a barrier to employing a sonographer graduate? Radiography 2019;25(1):77e82.
13. Mitchell P, Nightingale J. Sonography culture: power and protectionism.
Radiography 2019;25(3):227e34. https://doi.org/10.1016/j.radi.2019.02.004.
14. Miller PK, Waring L, Bolton GC, Sloane C. Personnel flux and workplace anxiety:
personal and interpersonal consequences of understaffing in UK ultrasound
departments. Radiography 2018;25(1):46e50.
15. Probst H, Griffiths S. Retaining therapy radiographers: what’s so special about
us? J Radiother Pract 2007;6(1):21e32.
16. Probst H, Griffiths S. Job satisfaction of therapy radiographers in the UK: results
of a phase I qualitative study. Radiography 2009;15(2):146e57.
17. Probst H, Griffiths S, Adams R, Hill C. Burnout in therapy radiographers in the
UK. Br J Radiol 2012;85:e760e5.
18. Hutton D, Beardmore C, Patel I, Massey J, Wong H, Probst H. Audit of the job
satisfaction levels of the UK radiography and physics workforce in UK radiotherapy centres 2012. Br J Radiol 2014;83:20130742.
19. Halkett GKB, McKay J, Hegney DG, Breen LJ, Berg M, Ebert MA, et al. Radiation
therapists’ and radiation oncology medical physicists’ perceptions of work and
the working environment in Australia: a qualitative study. Eur J Canc Care
2016;26:e12511.
20. Hutton D, Eddy A. How was it for you? What factors influence job satisfaction for band 5 and 6 therapeutic radiographers. Radiography 2013;19(2):
97e103.
21. Lehmann P, Richli Meystre N, Mamboury N. Factors for lifelong job retention
among Swiss radiographers. Radiography 2015;21:181e7.
22. Williamson K, Mundy LA. Graduate radiographers’ expectations for role
development: the potential impact of misalignment of expectation and valence
on staff retention and service provision. Radiography 2010;16:40e7.
23. Johnson J, Arezina J, McGuinness A, Culpan AM, Hall L. Breaking bad and
difficult news in obstetric ultrasound and sonographer burnout: is training
helpful? Ultrasound 2019;27(1):55e63.
24. Singh N, Knight K, Wright C, Baird M, Akroyd D, Adams RD, et al. Occupational
burnout among radiographers, sonographers and radiologists in Australia and
New Zealand: findings from a national survey. J Med Imag Radiat Oncol
2017;61:304e10.
25. Lohikoski K, Roos M, Suominen T. Workplace culture assessed by radiographers
in Finland. Radiography 2019;25(4):e113e8.
26. Verrier W, Harvey J. An investigation into work related stressors on diagnostic
radiographers in a local district hospital. Radiography 2019;16(2):115e24.
27. Chipere TGA, Motaung T, Nkosi B. Structuring improved work environments
for newly-qualified radiographers. Radiography 2020;26(1):e14e7.
28. Gale NK, Heath G, Cameron E, Rashid S, Redwood S. Using the framework
method for the analysis of qualitative data in multi-disciplinary health
research. BMC Med Res Methodol 2013;13:117. https://doi.org/10.1186/14712288-13-117.
29. Elliott J, Williamson K. The radiology impact of healthcare errors during shift
work.
Radiography
2020;61:248e53.
https://doi.org/10.1016/
j.radi.2019.12.007.
30. European Society of Radiology (ESR) and European Federation of Radiographer
Societies (EFRS). Patient safety in medical imaging: a joint paper of the European society of radiology (ESR) and the European federation of radiographer
societies (EFRS). Radiography 2019;25(2). e26ee3.
31. Harrison G, Harris A. Work-related musculoskeletal disorders in ultrasound:
can you reduce risk? Ultrasound 2015;23:224e30.
32. Public Health England Screening. Breast screening mammography: ergonomics
good practice. 22 October 2018. https://www.gov.uk/government/publications/
breast-screening-ergonomics-in-screening-mammography.
33. Maslach C, Schaufeli WB, Leiter MP. Job burnout. Annu Rev Psychol 2001;52:
397e422.
34. Beech J, Bottery S, Charlesworth A, Evans H, Gershlick B, Hemmings N, et al.
Closing the Gap – key areas for action on the health and care workforce. Report by
the health foundation, King’s fund and Nuffield health. March 2019. https://www.
kingsfund.org.uk/publications/closing-gap-health-care-workforce.
35. NHS England We Are The NHS. People Plan for 2020/21 – action for us all. July
2020. www.england.nhs.uk/ournhspeople Publishing approval reference:
0067.
36. NHS England and NHS Improvement. Transforming imaging services in England:
a national strategy for imaging networks. November 2019. NHS Improvement
publication
code:
CG
51/19,
https://improvement.nhs.uk/resources/
transforming-imaging-services-in-england-a-national-strategy-for-imagingnetworks/.
Declaration of conflict of interest
The corresponding author (JN) is the Editor-in-Chief (EiC) of the
Radiography journal. This submission was handled by another editor and JN was blinded to all editorial and reviewer
correspondence.
Ethics approval
Sheffield Hallam University Research Ethics Committee [no.
ER15453637].
Acknowledgements
We wish to thank Health Education England for funding this
research and the Society and College of Radiographers for their
support in the research delivery. Thank you also to Prof Heidi Probst
for advice and guidance. We are grateful to all of the radiographers
and managers for giving their time to participate in the study, and
to many others who expressed an interest in participating.
References
1. Cancer Research UK. Securing a cancer workforce for the best outcomes.
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files/documents/Cancer-Workforce-Document_FINAL%20for%20web.pdf.
4. Richards M. Diagnostics: recovery and renewal. Independent Review of Diagnostic Services for NHS England; Oct 2020. Accessed 23.10.2020, https://www.
england.nhs.uk/wp-content/uploads/2020/10/BM2025Pu-item-5-diagnosticsrecovery-and-renewal.pdf.
5. George J, Gkousis E, Feast A, Morris S, Pollard J, Vohra J. Estimating the cost of growing
the NHS cancer workforce in England by 2029. Oct 2020. https://www.
cancerresearchuk.org/sites/default/files/estimating_the_cost_of_growing_the_
nhs_cancer_workforce_in_england_by_2029_-_full_report.pdf Accessed23.10.20.
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Radiography 29 (2023) 76e83
Contents lists available at ScienceDirect
Radiography
journal homepage: www.elsevier.com/locate/radi
Retention of radiographers in the NHS: Influencing factors across the
career trajectory
J. Nightingale a, *, T. Sevens a, R. Appleyard a, S. Campbell b, M. Burton a
a
b
Dept of Allied Health Professions, Sheffield Hallam University, United Kingdom
Breast Imaging Department, Yeovil District Hospital NHS Foundation Trust, United Kingdom
a r t i c l e i n f o
A b s t r a c t
Article history:
Received 11 June 2022
Received in revised form
14 September 2022
Accepted 10 October 2022
Available online 27 October 2022
Introduction: In order to meet the rising demands for imaging and radiotherapy services, the chronic
workforce deficits experienced in many countries must be addressed. Improving workforce retention is
essential; factors influencing radiographer attrition from the NHS have been previously reported as
challenging working patterns, lack of flexibility in working patterns and lack of timely career progression
and CPD. This article explores how these influencing factors for radiographers to leave the NHS change at
different stages of the career trajectory.
Methods: A qualitative research design using framework analysis explored via semi-structured telephone
interviews (n ¼ 44) the perspectives of radiography managers, radiographers who have left the NHS, and
those considering leaving. Purposive sampling ensured representation across radiography disciplines,
geographical and organisational diversity, and stages of career.
Results: The application of Generation Theory revealed how the emphasis on the influencing factors to
leave or remain within the NHS changes across the working life of radiographers. Early career radiographers were found to be a more transient workforce leaving for increased career opportunities, midcareer radiographers were more likely to leave due to the lack of progression and CPD and late career
radiographers due to the inflexibility of working patterns and conditions. It is imperative managers
consider the needs and requirements of each generation of radiographers to improve radiographer
retention.
Conclusions: The different needs between the generations of radiographers should be viewed in terms of
the strengths that they may bring to the workplace, rather than the challenges that they may pose. This
generational timeline does not stand still and the learning is a continuous process.
Impact on practice: Recommendations are presented which will be a catalyst for sharing of best practice
between radiology and radiotherapy centres.
© 2022 The Author(s). Published by Elsevier Ltd on behalf of The College of Radiographers. This is an
open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).
Keywords:
Workforce Retention
Flexible working
Generational theory
Career progression
Continuing professional development
Introduction
Rising demand for radiology and radiotherapy services worldwide, coupled with persistent radiographer shortages and high
vacancy rates, present an urgent workforce issue.1e4 Workforce
strategies have traditionally focussed on increasing entrants to the
profession, yet their effectiveness may be counter-balanced by loss
of existing radiographers.5e8 Within the United Kingdom, predicting attrition due to retirement is relatively straight forwards,
Abbreviations: CPD, Continuing professional development; NHS, National
Health Service (UK).
* Corresponding author.
E-mail address: J.Nightingale@shu.ac.uk (J. Nightingale).
with an estimated 9% of leavers expected from the diagnostic
radiography workforce between 2016 and 2021, and 6% of leavers
expected from the therapeutic radiography workforce in the same
period.9 However accurately predicting the number of leavers due
to early retirement, or other non-retirement reasons, is more
challenging. These predictions are concerning, with Health Education England workforce figures indicating that 28% of diagnostic
and therapeutic radiographers are likely to leave the NHS in this
same five year period for non-retirement reasons.9
The 2019 King’s Fund ‘Closing the Gap’ report10 calls on the NHS
to review workforce practices to improve staff retention in later
career stages. These staff often wish to continue to work, “but the
rigid structure of NHS employment and rostering means that there can
be an ‘all-or-nothing’ approach, with long shifts and undesirable
work-life balance” [p. 39].10 There could be untapped potential to
https://doi.org/10.1016/j.radi.2022.10.003
1078-8174/© 2022 The Author(s). Published by Elsevier Ltd on behalf of The College of Radiographers. This is an open access article under the CC BY license (http://
creativecommons.org/licenses/by/4.0/).
J. Nightingale, T. Sevens, R. Appleyard et al.
Radiography 29 (2023) 76e83
aiming to assist managers in providing a more nuanced support
package to improve retention in their workforce.
retain their expertise up to and beyond statutory retirement age
through more flexible working practices.6,10 However high vacancy
rates are not only a consequence of early retirements; radiographers may divert their careers to the independent sector or leave
the profession to pursue other life choices.11
To better understand this leaver profile, this qualitative study
aimed to identify why radiographers leave the NHS early, and what
incentives are important in their decision to stay.11 In an earlier
publication, Nightingale et al (2021) identified three over-arching
factors influencing these decisions (Fig. 1), providing service managers with a broad understanding of the stressors impacting on
their workforce and informing targeted interventions to improve
radiographer retention.11
When considering the career span of a radiographer (up to 45
years), it is reasonable to assume that the factors impacting upon
the decision to leave or remain may change in their emphasis over
time. Early career radiographers [preceptorship to five years postregistration] are establishing themselves as autonomous professionals and determining early career choices. Mid-career radiographers may be developing specialist expertise, working whilst
studying postgraduate education, and may have a major role in
managing teams and supporting career development of others. Late
career radiographers include senior leadership positions, and are
within 5e10 years of retirement. These career stages each bring
with them unique professional challenges as well as changing
personal circumstances that may impact on morale, wellbeing and
retention.11,12
Overlapping with these career stages is the notion of generational cohorts, with four generations of the workforce now working
and learning within imaging and radiotherapy services.13 Generational Cohort Theory, first described by Edmunds and Turner in
2005,14 proposes that people with similar birth years have a shared
history and life experiences, and therefore develop similar beliefs
and values; this may promote similar attitudes towards their professional world and working life. This theory is based on an
assumption that any differences are created by experiences of the
social world around them, rather than purely due to their age or
their maturity.14 Understanding these generational differences and
how they impact on radiographer career stages is important as
generational attitudes play a major role in people’s experiences of
work and study, influencing morale and retention.13
This article will explore the range of factors influencing radiographers to ‘remain or leave’ at different stages of their careers,
Methods
A qualitative research design within a pragmatic framework
methodology15 was utilised; framework analysis is appropriate for
research with some a priori (known) issues, undertaken within a
short time frame and by multiple researchers. Following ethical
approval [Sheffield Hallam University Research Ethics Committee
no. ER15453637], diagnostic and therapeutic radiographers (who
had left the NHS or were considering leaving) and service managers
were recruited through a multi-faceted advertising campaign. A
purposive, maximum variation approach to sampling was adopted
to ensure adequate representation of radiography disciplines,
geographical spread, career stages and organisations.
The interview topic guide was informed by the literature review
and included the following a priori questions:
– What are the reasons for leaving/considering leaving the NHS
and/or radiography?
– Where do people go when they leave or plan to leave?
– Are there different factors affecting radiographers at different
career stages, or working in different modalities?
– What would make a difference to staff (incentives to stay), and
what are managers doing to address the issues?
The topic guide was piloted with two recently retired radiographers before semi structured interviews were undertaken by
telephone, audio recorded, professionally transcribed verbatim and
anonymised. The interviews were undertaken by the research team
which included four researchers with radiography backgrounds
[three diagnostic and one therapeutic radiographer] and one
qualitative health researcher. The team were assigned interviews
which most closely aligned to their areas of knowledge and
expertise within four specific discipline groups. The first two disciplines were therapeutic radiography (to include managers and
radiographer roles in radiotherapy planning/pre-treatment, radiotherapy treatment and radiotherapy review) [undertaken by RA],
and diagnostic radiography (to include managers and radiographer
roles in general radiography, CT, MRI, interventional/fluoroscopy,
and radiographer reporting) [undertaken by JN and MB]. Interviews
with radiographers and managers working in mammography and
Figure 1. Influencing factors in the decision for radiographers to leave or remain within the NHS (Nightingale et al, 202111).
77
J. Nightingale, T. Sevens, R. Appleyard et al.
Radiography 29 (2023) 76e83
out they need a three or a four bedroom house, and then they can’t
afford one here. [DR/manager]
sonography roles were undertaken and analysed separately by
discipline experts [SC and TS respectively] as they were known to
represent a unique working environment with specific workforce
challenges. Data collection continued until data saturation was
reached. Framework analysis was guided by the a priori interview
topics.15 Transcripts were initially analysed within the discipline
groups, and then two reviewers with significant qualitative analysis
expertise [MB and JN] reviewed the emerging framework to
enhance rigour, credibility and trustworthiness.
These patterns of life events appear to be drivers which combine
with professional and career factors which are both seen to change
across the different career stages and generations, posing different
risks for radiographer wellbeing and retention at each stage (Fig. 3).
The findings are now presented aligned to early, mid and late career
radiographer stages.
Results
Early career
Forty-four interviews were undertaken, including service
managers (n ¼ 12) and radiographers who recently left (n ¼ 23) or
were considering leaving the profession (n ¼ 9). The purposive
sampling enabled a spread of experiences to be captured across
four professional groupings and across different career stages
(Fig. 2), including those in early career roles (n ¼ 9), mid-career
roles (n ¼ 15) and late career roles (n ¼ 10).
Early career radiographers are often a younger and more transient workforce who are less likely to have ties to a particular region
or hospital. While most move to other radiography posts, a small
number become disillusioned with the profession at an early point
in their career. In therapeutic radiography, potentially influenced
by a high proportion of mature entrants, the radiographers interviewed in this study rapidly became bored with a lack of career
progression. These participants were frustrated that their skills and
knowledge were not exploited or appreciated; they were demoralised by the prospect of ‘years of service’ before promotion opportunities were realised.
Influence of life events
Three primary influencing factors for the decision to leave or
remain in the NHS have been previously reported (Fig. 1).11 The
managers interviewed within this study could identify how significant life events (marriage, birth of children, elderly caring responsibilities) impacted on their radiographers at different career
stages, and this would make them vulnerable to leaving either their
hospital, their profession or the NHS at different points in their
working lives.
One manager explains how he/she noted a pattern of life events
which appears to regularly impact on retention of staff, particularly
as their hospital is situated in a ‘desirable’ location:
I was really career driven, and I felt very blocked at band 6 level …
in most of the cancer centres that we have there isn’t that progression. I think people have to literally leave or come to the end of
their retirement before you can get a band 7. And so I had itchy feet
for that, and I … think those were times when I thought right I’ll go
and do something else. [TR/left]
You were just kind of factory workers, and that wasn’t the buzz for
the job, and I struggled doing the same thing, and working on the
same machine day in day out for the year. It wasn’t for me. [TR/left]
We’ve had one or two go to relocate geographically … it is
expensive to live here. So typically a lot of our workforce lives about
an hour’s drive away … people will do that for two or three years
and then they get tired of it, especially as home or family dynamic
changes … and then they start to have a family and then they figure
I felt like I was contributing a massive amount to the department
and I wasn’t getting what I deserved as a result of that contribution.
And I think that if that contribution was at least acknowledged by
anyone I would have felt better about things, I would have
Figure 2. Participant career stages and radiographer disciplines. Early career radiographers were not expected to be found within the mammography and sonography groups. Some
managers within these two groups held dual roles where they were also undertaking regular clinical practice.
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J. Nightingale, T. Sevens, R. Appleyard et al.
Radiography 29 (2023) 76e83
Figure 3. Primary reasons for radiographers to leave the NHS or the profession at different career stages aligned to generations.
the old on-call systems went and we now have a more structured
shift pattern of working. With that there was a loss of income for
many radiographers … if a new radiographer wanted to save a
deposit for a house, it’s quite difficult for them to do that as a band 5
radiographer if there’s a lack of overtime. So it’s attractive to newer
radiographers to go locum and work for an agency …” [DR/
Manager]
definitely felt better about staying. But there was no appreciation
for all the hard work that I and other people had put in from
management in itself. The lack of appreciation was quite stark
really; it was quite annoying. [TR/left]
Private healthcare and public health related opportunities
became increasingly attractive; not necessarily for more pay, but
facilitating roles that spanned their full scope of practice. A private
sector imaging manager reaffirmed this expectation:
[Agency poaching] tends to be one of the things that leads to an
instability in your staffing, if they feel the need to rush off and
moonlight at St Elsewhere … then St Elsewhere will make them an
offer they can’t refuse and then you end up losing your staff. [DR
(MRI)/Manager]
… even though they do MR and CT, they are expected to also do
general radiography … They’re multi-skilled and are expected to do
that. So, because we are small and we have to remain flexible, I
can’t have someone saying ‘oh I’m an MR radiographer’, when I’m
saying ‘no you’re going to theatre’. [DR/Manager]
Early career radiographers also recognised that their working
patterns often left them little time for home life, making private
healthcare opportunities more attractive:
While few early career radiographers directly cited pay as an
issue, one sonographer who was considering leaving expressed
concerns about their pay in relation to the responsibility that they
held:
The shift pattern was quite bad. I found myself working a lot of
hours per week. I’d say it was probably averaging out towards
45e50, a lot of weekends. There wasn’t much scope for progression
and I’d say that’s, from my experience that’s across the board really.
[DR/left]
It’s quite a responsible job when you don’t get recognition or
payment. I’m getting paid £8 per scan when you’ve taken tax off for
looking in detail at a foetal heart. And that could mean a big difference to a mum and a baby, but I’m paid £8. [Sonog/leaving]
Mid-career
Mid-career radiographers who often occupied higher pay
bandings also outlined frustrations with a lack of opportunity to
earn beyond their basic pay, resulting in some sonographers and
reporting radiographers also working additional shifts with
agencies.
Several participants cited frustrations at a lack of additional
earning potential beyond their basic pay, particularly when they
were saving for significant life expenses such as a house deposit,
wedding or car. Several had registered with radiography agencies
and bank work at other hospitals, working additional shifts around
their standard working hours. Over time several began to appreciate the flexibility of agency work, leaving the NHS to concentrate
on agency employment:
The pay for the work we do is not very … I get double the pay now
where I work now. [Sonog/left]
I don’t think it’s as simple as money, although obviously that’s the
first thing that springs into your head is pay rises that are equal to
how much the cost of living’s going up. [Sonog/leaving]
I actually get paid less than I used to, because I don’t do all the
enhanced shifts anymore and that’s an irony in itself. [DR/leaving]
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Radiography 29 (2023) 76e83
A massive challenge is a lot of my advanced practitioners are
working for private companies doing private reporting as a sideline for extra income … With regards to leaving to agencies
there’s been an increase in that. [DR/Manager]
Mid-career radiographers of all disciplines complained about
limited opportunities for CPD underpinned by insufficient funding
and staffing; planned CPD was often withdrawn at short notice.
Managers also highlighted recent CPD funding restrictions, made
more challenging by having to negotiate with Directors of Nursing
for access to essential funding.
Many mid-career radiographers highlighted a disappointing
lack of progression into advanced practice roles, likening it to ‘dead
man’s shoes’ where radiographers were trapped in a band 6 role for
a number of years. They became gradually more cynical which
went against their initial love of the profession:
I don’t think there’s a lot of incentive for a lot of the younger
sonographers because of the lack of money and lack of training; the
workload and the lack of support. [Sonog/left]
I actually think the funding streams and the way they’re currently
working needs … to come directly into radiology as opposed to one
specific directorate within in a trust. Sometimes it feels like a battle.
[DR/manager]
the hospital I was at I was there for 12 years in that role [Band 6].
And I really just got to a stage where I felt there was lack of progression. There was no opportunities for me and I didn’t get recognised for the knowledge and experience that I had. [DR (MRI/
CT)/Left]
While some mid-career radiographers had left to take up or test
out new careers, several believed that they may return to radiography in the future, and wished to maintain their Health and Care
Professions Council (HCPC) registration.
Several mid-career radiographers who had progressed to
advanced practice roles also reported feeling ‘stuck’ at their grade
with several years of their career still remaining. Their desire to
remain in clinical practice, alongside limited opportunities for
consultant practice appointments, were highlighted.
It annoyed me that I would have to wait that long [for promotion]
just because they say, oh, you need a minimum of 5 years for this or
a minimum of 10 years for that … that’s what upset me the most
and I thought to myself, well, you know what, I’m going to keep my
registration but use my Masters and try something different. [TR/
Left]
She [manager] said my hands are tied, you know, you’re NHS,
you’ve come in from a different trust, you go up one and across and
then you have to work your way up to the top of the pay scale.
[Mammo/leaving]
… it’s the career progression side from [radiographer] reporting in
particular that is a challenge … Is there something else we can
develop an individual into such as a clinical specialist? And so we
can give them a higher banding for an extra level of responsibility
within their role, rather than them thinking that the only next step
on the ladder for them is consultant practice. [DR/manager]
Late career
Later career radiographers cited a lack of flexible working
options as a major catalyst for them leaving the NHS earlier than
planned. Diagnostic radiographers frequently highlighted the
physical demands of shift working, with mammographers and
sonographers describing the long term effects of repetitive
strain.
Consultant radiographers also felt limited and unchallenged
with lack of opportunity to fulfil all four pillars of their role (clinical,
education, research and leadership). This resulted in them
exploring opportunities for secondments within academia and
commissioning organisations, thus reducing their NHS component
over time.
I think we’re more prone to injury, we’re more prone to slowing
down, and I don’t think the system allows for that at all. It doesn’t
accept the fact that you are getting older. [Sonog/leaving]
The physical side of it scares me. What will my shoulder be like at
68? [Sonog/leaving]
I feel like I’m so far stuck down a hole as a consultant practitioner
that I can’t see a viable way upwards or outwards … [Mammo/
leaving]
Staff in senior appointments, including managers and
consultant radiographers, identified with the potential for
‘burnout’; combinations of long working hours, workplace stress,
feelings of isolation and in some cases a lack of support from
colleagues.
Many mid-career radiographers were frustrated as they were
unable to advance their careers by applying for positions in other
locations due to family or elder caring responsibilities. Their frustrations were exacerbated when requests for flexible working to
accommodate caring responsibilities were turned down.
… unfortunately a lot of consultant radiographers do head towards
burnout and if you get to the point of burnout then there’s obviously a high risk of you leaving that job. [DR/leaving]
when I applied for flexible working at the trust I had gone to, they
said no. And at that point I just thought I’ll just hand my notice in
then. [Sonog/leaving]
when you work 55 hours a week and you’re still doing that the
following week and the following week and you just wear yourself
out … I’m mad carrying on like this. It’s time to leave. If it means I
need to work at the local private hospital for a couple of days a
week, I’ll do that. But I’m not going to carry on the way I am. It’s too
much. [Sonog/leaving]
I was given it [reduced hours] for a few months and then I was told
right after six months you’ve got to go back to occupational health
now if you want to carry on working two days. Or you can resign
and reapply for your own job. [Mammo/left]
I’d applied to drop my days to three but they said, no, band 7 you’ve
got to do four … that was kind of the last straw really … it was
financially a huge drop in pay [leaving the NHS] but the fact that it’s
so much more flexible was a bonus. [TR/left]
you’re quite alone being a consultant practitioner [Mammo/
leaving]
… actually I don’t really feel valued … [Mammo/leaving]
80
J. Nightingale, T. Sevens, R. Appleyard et al.
Radiography 29 (2023) 76e83
their entire career to their chosen profession.16 Unlike Baby
Boomers and Generation X, they may not feel tied to any one
employer, role or profession, and will change employers if their
needs are not met. They value flexibility to achieve a work-life
balance, with Gen Z valuing professional and personal freedom
above all.16
More importantly, their expectations, values and motivations
may not be the same as the managers and supervisors of their
work who are from different generations. Workforce stability will
be positively influenced by managers with an understanding and
respect for these differences; the generations’ different approaches to working and learning should be ‘harnessed and
celebrated’.13 There are a number of parallels from the Jones et al.
study16 with the testimonies and themes emerging from this
study of radiographers.
Baby Boomers and Generation X (Fig. 4) were estimated in Jones
et al.,’s 2015 study to make up approximately 65% of the NHS
workforce16 although this proportion is reducing every year as
more staff in these categories retire. Radiographers from these
generational groups are commensurate with ‘late career’ radiographers in our study, and may occupy many of the senior leadership
and management positions. The radiography profession will have
changed immeasurably during the course of their careers. This
generational cohort are said to be independent and self-reliant,
motivated and hard-working, but may also be ‘workaholics’ who
succumb to a poor work-life balance.13 Between 2011 and 2018
more than 56,000 people left NHS employment citing a poor worklife balance6; the loss of these experienced radiographers to early
retirement is inevitable if they are unable to source a less
demanding working pattern.
Others in the later stages of their career found that their clinical
role no longer stretched them, and they sought opportunities to
develop other aspects of their role such as education or research.
The loss of this highly experienced generation of radiographers will
compromise the support available for the mid-career ‘Millenial’
(Generation Y) radiographers. Estimated to make up about 35% of
the NHS workforce in the Jones et al., 2015 study,16 Gen Y are noted
to be passionate, highly committed and hard working. They often
expect structured career progression, flexible job roles and plenty
of feedback, guidance and support.13,16 In our study, frustration was
expressed when this is lacking, jeopardising retention as Generation Y are more likely to change employer, role or even profession if
these values are not met.16
Generation Z too expect to specialise and progress quickly,
changing jobs to achieve this.19 The early career Gen Z radiographers in our study articulated frustrations with an apparent lack of
career progression, stating that their skills and abilities were not
recognised within a ‘time served’ mentality. Some made the decision to leave the NHS at this early stage of their career, moving into
the private sector or other health-related roles. This also paralleled
the nursing study which identified that Gen Y and Z nurses were
more likely to view their career in the short term, with Gen Z unsure about devoting their entire career to their chosen profession.16
Unlike Baby Boomers and Generation X, they are a more transient
workforce,10 valuing flexibility to achieve a work-life balance and
professional and personal freedom.10,16 There are a number of
parallels from several previous studies16,19,20 with the testimonies
and themes emerging from this study of radiographers.
Over the next few years the radiography profession will lose the
Baby Boomer generation to retirement, and will need to offer
stimulating and flexible roles for experienced Generation X radiographers to minimise early retirements. Generation Y radiographers (Millenials) will soon become the greater proportion of the
radiographer workforce, and they will need to implement
One experienced manager had taken the decision to leave the
profession to pursue a wider hospital management role as he/she
no longer felt challenged in the role:
But you never got to do project stuff, you never got to step back and
have time to actually deliver an improvement project … the aspects
of line management as well, managing at one stage up to 70 people
under me. Trying to do appraisals for 15 people is quite tough as
well while you’re trying to do your clinical role. So I think I was in
the loop of the same … you end up just doing day to day firefighting
and actually not doing anything strategic … I got immune to doing
my job, I could just do it with my eyes closed. And then I lost the
desire in it. [DR/left]
However physical demands and burnout were less prominent
reasons for leaving Therapeutic Radiography; significant staffing
shortages was more a contributory factor. One radiotherapy manager had been unable to retain staff intending to retire early despite
adjustments to less physically challenging roles whilst exploiting
their specific skillsets and maintaining their pay banding.
Many of our late career participants had requested flexible
working to accommodate their changing needs, and they reiterated
the need for ‘wind down’ roles (perhaps with a focus on passing on
their extensive knowledge through training) as radiographers
approach retirement.
I went to management, because I thought well 55, flexible retirement plan. You can’t have it. Can I go part-time? No. Oh right, well
can you just give me a couple of months career break then, just let
me get myself sorted out? No. And it became the only option I had
was leave. [DR/Left]
Discussion
The range of influencing factors on radiographer decisions to
leave or remain in the NHS appear to change across the career span.
A more nuanced understanding of these changing influences across
career trajectories will support managers in their efforts to motivate staff, maintain morale and improve retention. However while
the length of time in a career will have some impact on decisions to
leave or stay, a compounding influence is generational differences,
increasingly recognised as having impacts on the workplace.16 We
purposively sampled representatives from early, mid and late
career radiographers, and found evidence to support one of the
premises of the Interim NHS People Plan that ‘different generations
want different things from their working lives’ [p49].17
“Generational cohort theory” assumes that people with similar
birth years have a shared history and life experiences, along with
similar attitudes, beliefs, values and preferences.14 While caution
should be applied when generalising based solely on birth date, it is
nevertheless important to acknowledge that different generations
have experienced life in a different way. For example, we have
experienced technology very differently through the generations as
demonstrated in Fig. 4.18
Four generational cohorts are likely to be working and learning
together in radiology and radiotherapy departments. Each generation develops a collective personality that may exhibit particular
attitudes toward authority and organisations, work expectations,
and professional aspirations. These attitudes play a major role in
people’s experiences at work, and in staff morale and retention of
staff.
In their study of generational differences in nursing, Jones
et al.16 identified that Gen Y and Z nurses were more likely to view
their career in the short term, with Gen Z unsure about devoting
81
J. Nightingale, T. Sevens, R. Appleyard et al.
Radiography 29 (2023) 76e83
Figure 4. Generational map showing four generations: Baby Boomers; Generation X; Generation Y (Millennials) and Generation Z. In this model Gen Y and Z are sub-divided. NPD
Group Inc.18
Interim People Plan (2019).17 Collaboration between Trusts and
across Imaging Networks will increase the potential for meaningful
CPD opportunities that can be offered at lower costs.
Limitations of this study included low participation of Therapeutic Radiographer late career and manager respondents; early
and mid-career representatives were prominent. Inevitably, the
project attracted radiographers with strong feelings about retention, many of whom had experienced difficult and unresolved situations, raising the potential for recruitment bias. We aimed to
purposively sample across a wide geographical area incorporating
all parts of the United Kingdom, however those responding to the
adverts were predominantly from England. Notably the participants represented a range of healthcare organisations, including
large teaching hospitals, specialist centres, smaller ‘district’ hospitals and private healthcare centres. Similarly they were based in
both urban, semi-rural and more remote locations, providing a
wide range of working environments and contexts.
strategies to nurture and support the new Generation Z students
and staff. Estimated to be less than 5% of the NHS workforce in
Jones et al.,’s 2015 study,16 this proportion is increasing rapidly as
new entrants enter the workforce. While the most ideal strategies
are not yet clear, radiography authors have begun to identify
management approaches to working with Gen Z radiographers
including effective onboarding, preceptorship and career development planning.13,19,21,22 This new generation may not see radiography as a career for life, but enabling them to try out new roles and
even leave and return may be effective in maintaining workforce
supply as recognised within the Interim NHS People Plan.17
From the analysis of interviews with the service managers, there
was clear evidence of a range of innovative strategies being devised
and implemented to address recruitment and retention challenges.
These included new leadership roles to focus on staff CPD and
retention, transparent competency frameworks between Bands 5
and 7, and widened responsibilities for experienced Band 6 radiographers. Rather than seeing local Trusts as competitors, several
managers advocated cross organisational collaboration for CPD,
bank working and integrated care system working aligned with
national strategy.23,24
The findings of this research highlight the importance of
radiotherapy and imaging service managers gaining an understanding of generational cohort theory and how it applies to their
early, mid and late career workforce. However we need to
acknowledge that all radiographers are individuals and some,
including many mature entrants to the profession, may not align
neatly into the generational theoretical framework.25 Strategies to
enable flexibility and timely career progression at all career stages
is fundamental to good morale. Creative strategies to provide opportunities for flexibility may include establishing cross system
staff banks (rather than out-sourcing to agencies), and streamlining processes for staff to move efficiently between organisations could help.6,24 This might include radiographers working
flexibly across different Trusts, working from home, retiring and
returning, or occupying ‘wind down’ roles as advocated in the
Conclusion
From the perspective of radiography managers and educators,
recognising that the expectations, values and motivations of employees (or students) may not be the same as your own is an
important step in tailoring interventions to improve retention.
Different drivers for the decision to leave or remain in the NHS or
the radiography profession are articulated by participants from
each of the early, mid and late career categories; these differences
appear to closely resemble the descriptors for the generational
cohorts.
Acknowledging the dangers of stereo-typing and of misconceptions related to generational cohort theory, understanding
generational differences can improve communication between
generations. The generational differences between managers and
their teams, and between early, mid and late career radiographers
should be viewed in terms of the strengths that they may bring to
the workplace, rather than the challenges that they may pose. This
82
J. Nightingale, T. Sevens, R. Appleyard et al.
Radiography 29 (2023) 76e83
generational timeline does not stand still and the learning is a
continuous process; the next phase to enter the workplace is Gen
Alpha which will certainly create new opportunities and challenges
for the workplace.
10. Beech J, Bottery S, Charlesworth A, Evans H, Gershlick B, Hemmings N, et al.
Closing the Gap e Key areas for action on the health and care workforce. Report by
the health foundation, king’s Fund and nuffield health. https://www.kingsfund.
org.uk/publications/closing-gap-health-care-workforce; 2019.
11. Nightingale J, Burton M, Appleyard R, Sevens T, Campbell S. Retention of
radiographers: A qualitative exploration of factors influencing decisions to
leave or remain within the NHS. Radiography 2021;27(3):795e802.
12. Caulfield L. A literature review exploring the perceived impact, challenges and
barriers of advanced and consultant practice in therapeutic radiography.
Radiography 2021;27(3):950e5.
13. Coggins J, St John-Matthews J, Gibbs V. Welcoming generation Z: understanding multi-generational working and learning within radiography. In:
Imaging and therapy practice. Society and College of Radiographers; 2019.
14. Edmunds J, Turner B. Global generations: social change in the twentieth century. Br J Sociol 2005;56:559e77.
15. Gale NK, Heath G, Cameron E, Rashid S, Redwood S. Using the framework
method for the analysis of qualitative data in multi-disciplinary health
research. BMC Med Res Methodol 2013;13:117.
16. Jones K, Warren A, Davies A. Mind the Gap. Exploring the needs of early career
nurses and midwives in the workplace. Summary report from Birmingham and
Solihull local education and training Council every student counts project. 2015.
17. National Health Service. Interim NHS people plan. https://www.longtermplan.
nhs.uk/wp-content/uploads/2019/05/Interim-NHS-People-Plan_June2019.pdf;
2019.
18. NPD Group Inc. Guide to gen Z: debunking the myths of our youngest generation.
https://www.npd.com/wp-content/uploads/2021/06/guide-to-gen-z.pdf;
2018. Accessed 20.07.21.
19. Williamson K, Mundy LA. Graduate radiographers’ expectations for role
development: the potential impact of misalignment of expectation and valence
on staff retention and service provision. Radiography 2010;16:40ee47.
20. Lehmann P, Richli Meystre N, Mamboury N. Factors for lifelong job retention
among Swiss radiographers. Radiography 2015;21:181e7.
21. Tay YX, Wei YM, Aw LP, Lai C. The strategy to develop newly joined radiographers in a COVID-19 world: a curated orientation programme. Commentary.
J Med Imag Radiat Sci 2021;52(3):345e9.
22. Harvey-Lloyd J, Morris J. Supporting newly qualified diagnostic radiographers:
are we getting it right? Int J Pract-Based Learn Health Social Care 2020;8(2):
57e67.
23. Richards M. Diagnostics: recovery and renewal. Independent Review of Diagnostic Services for NHS England; 2020. https://www.england.nhs.uk/wpcontent/uploads/2020/10/BM2025Pu-item-5-diagnostics-recovery-andrenewal.pdf. Accessed 23.10.2020.
24. NHS England and NHS Improvement. Transforming imaging services in England:
a national strategy for imaging networks. NHS Improvement publication code:
CG
51/19,
https://improvement.nhs.uk/resources/transforming-imagingservices-in-england-a-national-strategy-for-imaging-networks/; 2019.
25. Mawson JA, Miller PK, Booth L. Stress, a reflective self and an internal locus of
control: on the everyday clinical placement experiences of older undergraduate radiographers in the UK. Radiography 2021;28(1):55e60.
Conflict of interest statement
None.
Acknowledgements
We wish to thank Health Education England for funding this
research [award date 15.04.19] and the Society and College of Radiographers for their support in the research delivery. We are grateful
to all of the radiographers and managers for giving their time to
participate in the study, and to many others who expressed an interest in participating.
References
1. College of Radiographers. Diagnostic radiography workforce report. https://
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2. College of Radiographers. Radiotherapy radiographic workforce census. https://
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documents-and-publications/reports-and-surveys/radiotherapy-radiographicworkforce-uk-census-(1); 2020.
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Available at: www.england.nhs.uk/ournhspeople; 2020.
7. NHS England. NHS staff survey 2019 national results briefing. 2020.
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83
The Joint Commission Journal on Quality and Patient Safety 2021; 47:76–85
Physician Task Load and the Risk of Burnout Among US
Physicians in a National Survey
Elizabeth Harry, MD; Christine Sinsky, MD; Lotte N. Dyrbye, MD, MHPE; Maryam S. Makowski, PhD;
Mickey Trockel, MD, PhD; Michael Tutty, PhD; Lindsey E. Carlasare, MBA; Colin P. West, MD, PhD;
Tait D. Shanafelt, MD
Background: Cognitive task load can affect providers’ ability to perform their job well and may contribute to burnout.
Methods: The researchers evaluated whether task load, measured by the National Aeronautics and Space Administration
(NASA) Task Load Index (TLX), correlated with burnout scores in a large national study of US physicians between October
2017 and March 2018 with a 17.1% response rate. Burnout was measured using the Emotional Exhaustion and Depersonalization scales of the Maslach Burnout Inventory, and a high score on either score was considered a manifestation of
professional burnout. The NASA-TLX was chosen to evaluate physician task load (PTL) due to its robust validation and
use across many industries, including health care, over the past 30 years. The domains included in the PTL were mental,
physical, and temporal demands, and perception of effort.
Results: Mean score in task load dimension varied by specialty. In aggregate, high emotional exhaustion, depersonalization, and one symptom of burnout was seen in 38.8%, 27.4%, and 44.0% of participants, respectively. The mean PTL
score was 260.9/400 (standard deviation = 71.4). The specialties with the highest PTL score were emergency medicine,
urology, anesthesiology, general surgery subspecialties, radiology, and internal medicine subspecialties. A dose response relationship between PTL and burnout was observed. For every 40-point (10%) decrease in PTL there was 33% lower odds of
experiencing burnout (odds ratio = 0.67, 95% confidence interval = 0.65–0.70, p < 0.0001).
Conclusion: The relationship between PTL and burnout may suggest areas of particular focus to improve the practice
environment and reduce physician burnout.
H
ealth care is an intrinsically complex field, and in the
wake of policy changes, an aging population with increasingly complex comorbidities, health care reform, advances in medical knowledge, and electronic health record
adoption, it has been cited as one of the most complex industries ever created.1 , 2 This complexity is increasing at an
alarming pace and directly affects the day-to-day work of
physicians as they care for patients. There is no centralized
process to monitor the volume and impact of the increasing
administrative and cognitive burden on physicians,3 and
the mounting complexity of their work may contribute to
the increased risk of burnout in physicians relative to workers in other fields.4–7 The Quadruple Aim of health care
seeks to improve the work life of health care providers and
enable professional fulfillment and meaning in work. Despite this, and the evidence that workload stressors increase
burnout and intent to leave, little formal measurement has
been done to evaluate the degree and impact of this increasing complexity and resultant cognitive workload, although
informal and colloquial discussions related to workload and
burnout have been described.8–11
1553-7250/$-see front matter
© 2021 The Authors. Published by Elsevier Inc. on behalf of The Joint Commission. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/)
https://doi.org/10.1016/j.jcjq.2020.09.011
In 1973 Daniel Kahneman, the Nobel Prize–winning
psychologist known for his work in judgment, decision
making, and behavioral economics, posited that human beings have limited cognitive resources available for attention.12 Cognitive load theory, popularized by Australian
psychologist Jonathan Sweller, added to this framework by
identifying limitations in working memory that humans depend on to perform cognitive tasks.13 Working memory, a
fundamentally limited cognitive resource, is attenuated in
the presence of physiologic or emotional stress.14–16 The
availability of working memory depends on external physiologic or emotional stressors, the type of information being
processed, and the method of information delivery.
Cognitive load refers to the amount of working memory
used and has three components: intrinsic load, extraneous
load, and germane load (Figure 1). Intrinsic load refers to the
inherent complexity of the task. With the ever-increasing
complexity of patient care, this load is increasing. This load
is immutable. Extraneous load refers to the load imposed
by the way in which information is presented. Information
presented in a disorganized, redundant, or incomplete manner presents high extraneous load and uses more working
memory. In contrast, standardization, lack of redundancy,
and synthesizing all pertinent data pieces to one location
and type of presentation reduces extraneous load. Germane
load is the workload of making mental models or learning.
Volume 47, No. 2, February 2021
77
the correlation between perception of these dimensions in
health care professionals.3 In the present study, we evaluated the cognitive load of a clinical workday in a national
sample of US physicians and its relationship with burnout
and professional satisfaction.
METHODS
Figure 1: Working memory is the available awareness necessary to complete any cognitive task. It is reversibly depleted by three types of cognitive load: intrinsic, germane,
and extraneous.
This is the working memory devoted to synthesizing novel
information and expanding current mental models to incorporate new information. The workload imposed by germane load is highest for learners and those early in their
career, although it remains a critical feature for all lifelong
learners in the age of ever-evolving medical knowledge. Understanding these types of loads as well as the impact of
stressors on available working memory is critical because
when cognitive resources are overwhelmed, new information cannot be acquired or integrated, and critical data can
be lost.17
Although a potential link between cognitive load and
burnout is intuitive, no large-scale study has evaluated
The aim of this study was to evaluate the relationship between physician task load (PTL) and burnout scores. We
conducted a national survey of US physicians between October 2017 and March 2018. A description of the survey administration process, participation rates, and demographic
characteristics of the overall sample was similar to prior
studies4 , 5 and has been previously reported.18 The physician sample for the survey was assembled using the American Medical Association (AMA) Physician Masterfile, a
nearly complete record of all US physicians independent of
AMA membership, and included physicians of all specialty
disciplines. Participation was voluntary, and all responses
were anonymous. As previously reported, 5,197 (17.1%)
of the 30,456 physicians who opened at least one invitation e-mail and/or received a paper mailing of the survey
participated in the study.
An intensive secondary survey was sent to a random sample of 500 physicians who did not respond to the initial
electronic survey.19 These individuals were mailed a paper copy of the survey with a $20 incentive to participate.
Physicians who did not respond to the initial mailing of the
secondary survey were sent a second mailing without additional compensation three weeks later. Twenty-four mailed
surveys were returned as undeliverable, yielding a final sample of 476. A total of 248 (52.1%) responded to the secondary survey. As previously reported, we found no statistically significant differences in age, years in practice, mean
or median burnout scores, or satisfaction with work-life
integration (WLI) among participants in the initial electronic survey and the secondary survey with a higher response rate. These findings support the absence of response
bias in the electronic survey respondents with respect to
burnout and satisfaction with WLI, which suggests that
participants were generally representative of US physicians
in these domains. Given this consistency with respect to
the experience of burnout and WLI, all responders were
pooled into a sample of 5,445 physicians for further analysis. Of these 5,445 physicians, the 5,276 (96.9%) who
were actively practicing at the time of the survey were included in the present analysis evaluating PTL in practicing
physicians.
Burnout Measurement
Responding physicians provided information on demographics (age, gender) and professional characteristics (specialty, practice setting, hours worked per week, nights on
call per week). Burnout was measured using the Emotional
78
Elizabeth Harry, MD, et al.
Physician Task Load and the Risk of Burnout Among US Physicians
Figure 2: Four domains of PTL based on presence or absence of burnout symptoms. Significant difference between those
with and without burnout for all domains (p
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