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Journal of Workplace LearningWork-related continuing education and training: participation and effectivenessHywel Thomas Tian Qiu

Article information:To cite this document:Hywel Thomas Tian Qiu, (2012),"Work-related continuing education and training: participation andeffectiveness", Journal of Workplace Learning, Vol. 24 Iss 3 pp. 157 - 176Permanent link to this document:http://dx.doi.org/10.1108/13665621211209258

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Work-related continuingeducation and training:

participation and effectivenessHywel Thomas and Tian Qiu

School of Education, University of Birmingham, Birmingham, UK

Abstract

Purpose Within the context of policies on developing the workforce of the government healthsector in England, this paper aims to investigate participation in work-related continuing educationand training (WRCET), its pedagogy and effectiveness. Individual and organizational characteristicsassociated with effective WRCET are examined.

Design/methodology/approach The paper employs a cross-sectional study, using data fromannual large-scale National Staff Surveys of 2006 and 2009. Based on detailed occupational groups, theauthors classify respondents to high- and low-skilled staff and develop four dependent variables thatcombine specific types of training with respondent assessments of the effectiveness of their trainingfor their professional development. Probit regressions models are estimated for both groups ofworkers, controlling for individual and organizational characteristics.

Findings Participation in WRCET increased between 2006 and 2009 for both groups withdifferential patterns of participation across four types of training. Applying an effectiveness criterioneliminates relative change in participation rates between the groups and results in only about a quarterof those who participated in WRCET rating it as effective. Appraisal and particularly membership ofpositively rated work teams are strongly associated with training being rated as effective.

Originality/value This is the first use of this large-scale data set to appraise health sector policieson WRCET. Distinguishing between participation alone and whether participation is perceived aseffective has benefits in appraising training policies and identifies appraisal and membership ofpositively rated teams as factors associated with effective WRCET. Use of an effectiveness criterionshows very large differences between participation alone and participation in effective WRCET.

Keywords Training, High- and low-skilled, Effectiveness, Teamwork, Appraisal, Health sector,Team working, Performance appraisal

Paper type Research paper

IntroductionHow effective is the work-related continuing education and training (WRCET) in whichworkers participate? We address this question by examining recent policies ondeveloping the workforce of the National Health Service (NHS), the government fundedand provided health sector in England and the countrys largest employer. With someof the most highly qualified and least qualified people in the country (NHS (InformationCentre Workforce and Facilities Team), 2010), attracting, retaining and developing thisworkforce are an essential component of the NHS ability to meet the demand for itsservices. In a national context of low growth in the workforce and where the way wedevelop skills and their contribution to productivity remains a serious weakness withparticular gaps in basic and intermediate skills (DfES, 2003), there is a premium on theNHS to develop its own workforce. It is a responsibility which is recognised throughpolicies on staff development both for healthcare professionals accustomed to receiving

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Work-relatededucation and

training

157

Received 12 August 2011Revised 29 September 2011

27 October 2011Accepted 8 November 2011

Journal of Workplace LearningVol. 24 No. 3, 2012

pp. 157-176q Emerald Group Publishing Limited

1366-5626DOI 10.1108/13665621211209258

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WRCET and those who do not have professional qualifications, including addressinggaps in adult literacy and numeracy (Department of Health, 2000, 2001a, b).

There are two sets of research questions. The first set examines participation,pedagogy and effectiveness: has the policy commitment towards lower skilled workershad an impact on access to training; what is the distribution of training betweendifferent pedagogies; and, crucially, its effectiveness in terms of doing the job betterand staying up-to-date? The second set of questions analyse the extent by whichindividual and organizational characteristics are associated with employeeassessments of effective WRCET. In examining these questions, we draw on datafrom the annual National Staff Surveys of 2006 and 2009, a period when the impact ofgreater emphasis on training the lower skilled should be evident.

We set our enquiry in the context of national and international evidence onrecipients of WRCET across the economy as a whole and then identify features ofWRCET specific to the health sector. The fourth section describes our data sources andresearch design; section five specifies the model and reports the empirical results; andsection six is the discussion followed by a brief conclusion and implications forresearch.

Recipients of WRCETAcross different sectors of the economy, UK and international studies show that themain recipients of WRCET are the more highly educated and highly skilled (Jenkinset al., 2002; Dolton et al., 2005; Arulampalam et al., 2004). Younger workers are alsomore likely beneficiaries (Oosterbeek, 1998; OConnell and Jungblut, 2008), althoughthis effect may increasingly be influenced by more rapid skills obsolescence(Arulampalam et al., 2004). Evidence on gender is less clear, although there is evidencethat women are more ready to pay for their training (Bassanini et al., 2005). Unlikeseveral other European countries, part-time workers in the UK are less likely to betrained (Arulampalam et al., 2004).

Organizational factors also influence access to WRCET. Large firms are more likelyto provide training, although comparative European data shows the UK as a specialcase with training provision unaffected by organizational size (Bassanini et al., 2005,pp. 64-5). This may also relate to the nature of the training, i.e. it depends on whethertraining is mostly general or specific (Georgellis and Lange, 2007; Bougheas andGeorgellis, 2004). Ownership is also a factor with workers in the public sector morelikely to be recipients (Arulampalam et al., 2004). Recent work has also focused on thebenefits of teamwork and team members attitudes towards teamwork (Gallie et al.,2012; Kiffin-Petersen and Cordery, 2003). Studies find that the degree of autonomy andflexibility of teams influence learning and effectiveness at work (Felstead et al., 2010;Lantz, 2011; Procter and Burridge, 2008).

A recent appraisal of trends in UK adult training shows average levels ofjob-related training have declined through much of the 2000s and have now returned to1993 levels (Mason and Bishop, 2010). On the impact of government policies designedboth to improve economic competitiveness and enhance social cohesion, it showssome narrowing of the gap in training rates between low-qualified andhighly-qualified employees as a result of some increase in training rates for thelow-qualified. A characteristic of many of these studies is that they report whether ornot training has occurred rather than the amount of training, different types of training

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or its effectiveness. Yet, the modes of training used by firms are an important aspect ofhow workers learn and its perceived effectiveness.

In examining modes of training and their effectiveness, the distinction betweenlearning as acquisition and participation appears significant (Sfard, 1998), the formeremphasising content and the individual accumulation of knowledge and skills whilethe latter stresses the participative, active and situated nature of learning (Hagar, 2004;Lave and Wenger, 1991). Thus, a UK study combining worker self-report andobservation by researchers notes that learning as a by-product accounted for a veryhigh proportion of the reported learning of the people we interviewed (Eraut, 2007)and German data (Kuwan et al. 2003, p. 302, cited in Muller and Jacob, 2008) onworkers perceptions of means of learning, ranked self-learning in the workplace andexperiences from former workplaces as the most important, followed by instructionsby and learning from colleagues and supervisors at the workplace while formalfurther training provided in the firm or by outside suppliers only ranks at third place.The rest is private self-learning. An empirical development of the concepts ofacquisition and participation shows the positive effect of activities associated withparticipation, highlighting the contribution that the everyday experience of work canhave in enhancing work performance through activities such as doing the job, beingshown things, engaging in self-reflection and keeping ones eyes and ears open(Felstead et al., 2005). This has resonance with findings on communication, sharedresponsibility, flexibility, and coordination mechanisms in 107 Portuguese firms(Rebelo and Gomes, 2011) and a systematic review of the impact of collaborativecontinuing professional development on classroom teaching and learning whichidentified effective interventions likely to include: use of specialist expertise;opportunities for teachers to observe each other; peer support; and use of workshopsand seminars (Cordingley et al., 2005). Co-workers are also shown as influential inencouraging participation by lower educated workers (Sanders et al., 2011). As thesedifferent forms of pedagogic activity have prima facie differences in their resourceimplications, for example whether or not located in the work setting, our designattempts to link different forms of training with their likely resource implications.

WRCET in the NHSStrategyThe wider evidence provides a comparative basis for our analysis of WRCET in theNHS as there are developments specific to the sector. An Audit Commission report(Audit Commission, 2001) identified uneven participation in training, including groupswho typically receive less WRCET, such as part-timers, groups working unsocialhours and agency staff. Responding to these problems, NHS policy over the last decadehas sought to widen access to WRCET with particular emphasis on those withoutprofessional qualifications and doing so through an infrastructure of supervisors,mentors and an e-learning strategy (Department of Health, 2001a, passim, b, passim).

These policies are implemented through a nationally specified framework where,first, jobs are reviewed using a knowledge and skills framework developed to classifyjobs and create a new integrated salary structure. From this base, staff appraisal isintended to support progression to higher skilled jobs through access to WRCET(Department of Health, 2004a, b). This progression is represented in the skills escalator,a concept intended to facilitate and enable all levels of the workforce to renew existing


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skills and acquire new knowledge and skills. More recent reports continue to recognisethe potential of this strategy for developing existing members of the workforce and forrecruiting new staff where opportunities for a large scale skills escalator frameworkare immense (NWP, 2005; Robertson, 2007). We note, however, a report drawing ontwo qualitative studies of these initiatives which suggested their impact on skillsdevelopment for lower skilled staff was patchy (Cox et al., 2008). Nonetheless, theapproach clearly has potential benefits both for individuals and the NHS, and oneaspect of the success of the policy would be evidence of greater access to WRCET bylower skilled workers, and for such WRCET to be assessed as effective. The policy canalso assist in meeting the training implications of changing work processes.

Work processesChanges in work processes increasingly challenge role demarcation and stress theimportance of teamwork with changes occurring across health systems (Bach, 2000).On demarcation, an example at the higher skill end is the introduction of anaesthesiapractitioners who undertake a wide range of duties traditionally undertaken byanaesthetists, allowing one anaesthetist simultaneously to oversee the care of twopatients (Royal College of Anaesthetists, 2006). Another and more widespread exampleis the range of health care professionals who can now prescribe and supply medicines(Department of Health, 2000). Lower in the skill range is the use of nurse assistants inmonitoring vital signs (Royal College of Nursing, 2007).

Greater understanding internationally of the scale of medical errors and theirconsequence for patient safety is highlighting the inter-dependence of workers and,therefore, the importance of teamwork. These errors are increasingly understood interms of systemic problems rather than the failings of individuals (Kohn et al., 1999)and responses include seeking a better understanding of the organizational factors thatcontribute to errors and means of reducing them (Leape and Berwick, 2005, Leape et al.,2009; Benn et al., 2009) with several factors important for success, including:

[. . .] senior management and board commitment, fostering receptivity to change, engagingclinicians in quality improvement, implementing quality reporting processes, developingsafety culture and fostering staff-driven process improvement that engages the frontline.

Team work also influences the likelihood of learning occurring, a study of nurses inBelgium and The Netherlands showing how work location and the composition ofnursing teams are influential (Timmermans et al., 2011) while a large scale survey inthe Spanish health sector identified motivation and organizational support facilitatingtransfer into practice what is learned on training programmes (Pineda-Herrero et al.,2011). Many studies and interventions in the health sector focus on the high skilled, forexample in obstetric emergencies (Ellis et al., 2008) and emergency departments (Moreyet al., 2002; Shapiro et al., 2004; Wears et al., 2010), but lower skilled workers alsomatter:

I caught her [member of domestic staff] with a cloth wiping the floor and then wiping the teatrolley, but if you say something here youre made to look the big baddy (Healthcareassistant) (Dixon-Woods et al., 2009).

As well as illustrating the benefit of all health sector workers understanding risks frompoor hygiene, the comment also shows how organizational culture can affect patient

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safety through breakdowns such as this between different groups of workers,including the lower skilled.

Modes of education and trainingThe health sector has its own evidence base on effective modes of education andtraining, drawing upon systematic reviews of randomised controlled trials andquasi-experimental studies. Reviews of the continuing education of physicians indicatethat there are no magic bullets for improving the quality of health care (Oxman et al.,1995), but identify the value of: assessment of learning needs; interaction amongphysician-learners with opportunities to practice the skills learned; and sequencedmultifaceted educational activities (Mazmanian and Davis, 2002). A systematic reviewof studies of health professionals showed that interactive workshops rather thanrelying on lectures alone can improve professional practice (OBrien et al., 2008). Thisevidence on effective modes of education and training contributes to the researchdesign.

Data sources and research designData sourcesWhile the NHS is the generic name for the organization providing publicly fundedhealth care in the UK, each devolved administration within the UK has its ownorganization. Within each of these organizations, there are management andbudget-holding units known as Trusts, some of which are direct providers ofhealthcare (Acute Trusts and Mental Health Trusts) while Primary Care Trusts arelargely management units. This study is limited to England and these three types ofTrusts. All these Trusts are required to participate in an annual National Staff Surveyand the Surveys of 2006 and 2009 are our data sources, chosen because these two yearsinclude the longest available consistent questions on training[1]. All full- and part-timestaff directly employed by these Trusts are eligible to take part. Excluded from thesurvey are general practitioners (GPs) and their employees as they are not directlyemployees of the NHS, but contracted to provide their services. Also excluded areagency staff, who work in the NHS but whose employment contract is with anotheremployer. The response rates are 54 per cent and 53 per cent for 2009 and 2006respectively with no breakdown by occupational group. The survey capturesinformation on socio-demographic characteristics, organizational characteristics and arange of measures of staff satisfaction and opinion. It has detailed occupational groups(33 categories, including Others) and, for the focus of this paper, we classify thesegroups into high- and low-skilled staff.

High-skilled staff are: allied health professionals (AHPs)[2], Medical/Dental(consultant, in training and other), registered nurses and midwives[3], centralfunctions/corporate service (e.g. human resources, finance and IT) and generalmanagement (commissioning managers, social care managers and other managers);and the low-skilled are: nursing or healthcare assistants, administrative and clerical,maintenance/ancillary (e.g. housekeeping, domestic staff, facilities and estates) andgeneral support (support to AHPS, Scientific and technical, healthcare scientists, andsocial care). Ambulance-related staff and Other (please specify) are not included ineither of these specifications and later analysis. We also restrict our sample to


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respondents aged 21 to 65[4]. Table I shows the sample means for the raw occupationcategories across year.

DesignIn this section we describe how our four dependent variables have been constructedand list the independent variables included in the model.

Dependent variables. The range of questions on training has allowed us to developfour variables that combine information on specific types of training with respondentassessments of the effect of training for their professional development. As with otherlarge data sets that include questions on training (e.g. the Labour Force Survey) thequestions ask whether the respondent has experienced a certain type of training ratherthan its volume.

On the type of training, a question asks: In the last 12 months, have you taken partin any of the following types of training, learning or development, paid for or providedby your Trust? Six yes/no options are provided:

(1) Taught courses (internal or external).

(2) Any supervised on-the-job training.

(3) Having a mentor.

(4) Shadowing someone.

(5) E-learning/online training.

(6) Keeping up-to-date with developments in your type of work (e.g. by readingbooks or journals, or by attending seminars or workshops).

(7) Other methods of training, learning or development (please specify).

We have created four categories from these options, combining supervision, mentoringand shadowing into one and ignoring other methods. This approach was informedby the literature cited earlier on learning by acquisition (e.g. formal learning) andparticipation (e.g. informal learning) and its situated nature (Sfard, 1998; Lave andWenger, 1991) and, more substantially, by a set of learning processes at or near theworkplace identified by Eraut (2007) in a typology of early career learning. We usedthese as the basis for our own classification in Table II, where, within the context of

2009 2006 All

High-skilled 0.667 0.637 0.654AHPs 0.178 0.164 0.172Medical/dental 0.058 0.071 0.064Registered nurses and midwives 0.312 0.330 0.320Central functions/corporate service 0.069 0.046 0.059General management 0.050 0.026 0.039Low-skilled 0.333 0.363 0.346Nursing or healthcare assistants 0.079 0.080 0.080Administrative and clerical 0.173 0.203 0.187Maintenance/ancillary 0.043 0.043 0.043General support 0.038 0.036 0.037n 123,330 100,586 223,916

Table I.Sample means for the rawoccupation categoriesacross year

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these other frameworks, we have sought to take account of the possible resource andeconomic significance of the different forms of learning processes.

Formal learning, such as taught courses, has the greatest immediate economicimpact as it takes people away from their work and involves some amount of resourceprovision by employers. Informal learning, such as being supervised, mentored orshadowing, includes activities that occur in the immediate workplace and, as morelikely to be part of the daily routine and integrated with work processes, are likely toincur a lower loss of productive activity than formal learning. E-learning may or maynot occur in employer time and, in the case of the latter, incurs no direct cost forproductive activity. The examples of Keeping up-to-date seem to suggestindependent learning or personally chosen activities and, as such, are more likely tobe done in a workers own time. While this classifies items by their likely immediatecost, however, it is not a comment on their effectiveness, although we note someparallel between this grouping both in terms of worker perceptions and evidence on theeffectiveness of different learning activities cited earlier (Eraut, 2007; Mazmanian andDavis, 2002; Kuwan et al. 2003, p. 302, cited in Muller and Jacob, 2008; OBrien et al.,2008). Table III shows the percentages of these four categories between the high- andlow-skilled across years.

From Table III, we see that participation rates increased between 2006 and 2009 inalmost all categories and for both groups, the exception being no change in keepingup-to-date for the high-skilled. Formal training and keeping up-to-date are the highestpercentages in 2006 and 2009 with online training/e-learning showing the biggestincrease. Across all four types of training, the high-skilled have higher levels ofparticipation but, between 2006 and 2009, the difference between the high and lowskilled narrows for formal, informal training and keeping up-to-date, while, for onlinelearning, the difference widens from 0.06 to 0.15.

The training reported in Table III undoubtedly includes certain routine NHS healthand safety training, such as fire, lifting or resuscitation. We have, therefore, tried tonarrow the scope of training by adding evaluations that respondents provided on

2009 2006High-skilled Low-skilled Dif. High-skilled Low-skilled Dif.

Formal training 0.80 0.61 0.19 0.77 0.54 0.23Informal training 0.47 0.38 0.09 0.44 0.32 0.12Online training/e-learning 0.49 0.33 0.15 0.24 0.18 0.06Keeping up-to-date 0.84 0.44 0.40 0.84 0.39 0.45n 84,528 42,799 67,111 38,673

Table III.Training between thehigh- and low-skilled

across year

Formal learning processesInformal learningprocesses

Independent learningprocesses

Independent learningprocesses

(a) Taught courses (internalor external)

(b) Being supervised(c) Being mentored(d) Shadowing

(e) E-learning (f) Keeping up-to-date Table II.Learning processes and

economic activity


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whether their training contributes to their continuing development. The questions onthe effect of training asks respondents to consider their reply to the earlier question ontypes of training received, asking:

Thinking of any training, learning or development that you have done in the last 12 months(paid for or provided by your Trust), to what extent do you agree or disagree with thefollowing statements?a. My training, learning and development has helped me to do my jobbetter; b. It has helped me stay up-to-date with my job; and c. It has helped me stay up-to-datewith professional requirements. Respondents are asked to choose on a five-point scale fromstrongly disagree to strongly agree.

Table IV shows the distribution of responses. As most respondents reported more thanone type of training, the results represent their composite assessment of all forms oftraining and, among these, the most frequent combinations are formal training andkeeping up-to-date and formal and informal training and keeping up-to-date,Our assessment is that as all these questions were related to their development in work,it was valid to combine the results into a single measure that represented their overallassessment of the effectiveness of their training for their progress at work. To specifythis single measure of effectiveness, the scores of respondents, from 1 (stronglydisagree) to 5 (strongly agree) were aggregated for all three questions, so that amaximum score would be 15. In defining a standard for effective training, we then settwo restrictions. A response is treated as positive (coded 1) only if a respondent hadreported some training; and (restriction 1) the sum of answers to the three statementson effectiveness were equal to or greater than 12 and (restriction 2) at least oneresponse was strongly agree. Our reasoning in relation to these restrictions has threeelements: requiring one of the statements to be scored at the highest level ensures onevery positive response to training; a minimum of 12 points requires a high overall

2009 2006High-skilled Low-skilled High-skilled Low-skilled

To do the job betterStrongly disagree (5) 0.03 0.03 0.04 0.05Disagree (4) 0.05 0.07 0.06 0.09Neither A nor D (3) 0.20 0.31 0.22 0.32Agree (2) 0.55 0.47 0.53 0.44Strongly agree (1) 0.17 0.12 0.15 0.10To stay up-to-date with jobStrongly disagree 0.03 0.03 0.04 0.06Disagree 0.05 0.08 0.06 0.11Neither A nor D 0.16 0.29 0.17 0.30Agree 0.58 0.49 0.59 0.46Strongly agree 0.18 0.11 0.14 0.08To stay up-to-date with prof devStrongly Disagree 0.03 0.03 0.04 0.06Disagree 0.05 0.07 0.05 0.11Neither A nor D 0.15 0.35 0.16 0.38Agree 0.58 0.44 0.59 0.38Strongly agree 0.19 0.10 0.15 0.07n 83,354 41,045 65,572 35,636

Table IV.Effect of training

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response but still allows some disagreement (e.g. 5, 5 and 2); and it omits those whoselect agree (4) to all three statements, a decision that makes the outcomes oneffectiveness substantially more discriminating. Table V shows the effect of theserestrictions: restriction 1 reduces the percentage of the high-skilled rating their formaltraining in 2009 as effective from 80 per cent to 58 per cent and adding restriction 2reduces it to 20 per cent. When the levels of participation in WRCET shown in Table IIIare adjusted by applying the effectiveness criterion, the results in Table VI show a verylarge fall, only about a quarter of those who participated in WRCET rating it aseffective.

It is the responses based on these two restrictions that provide us with the fourdependent variables shown in Table VI. As with the data on overall participation, inboth years there is an increase in levels of participation with the high-skilled reportinggreater levels of effective training. There is, however, little change in differencesbetween both groups when 2006 is compared with 2009, the largest being a widening to6 per cent in relation to e-learning.

Independent variables. The independent variables selected reflect the widerliterature but also relevant aspects of NHS policy discussed earlier, such as theimportance attached to appraisal and teamwork. The survey collects information ongender, age, ethnicity, length of employment in the Trust, working hours per week,whether or not a line manager within the Trust, the size and quality of the work teamand whether respondents have had an appraisal in the last 12 months. We also havedata on the size and type of Trust in which they are employed. The first columns ofTables VII and VIII present the sample means of independent variables included in theregression models for the high- and low-skilled in 2006 and 2009 respectively.

Personal characteristics. Around 80 per cent of respondents are women, which isconsistent with the percentage of women in the NHS labour force[5]. Age is captured byfour dummy variables: 21-30, 31-40, 41-50 and 51-65. Ethnic background is groupedinto seven dummy variables: White (British and Irish), Other White, Asian/Asian

2009 2006High-skilled Low-skilled Dif. High-skilled Low-skilled Dif.

Formal training 0.20 0.12 0.08 0.18 0.10 0.08Informal training 0.14 0.09 0.05 0.12 0.07 0.04Online training/e-learning 0.13 0.07 0.06 0.06 0.03 0.03Keeping up-to-date 0.21 0.11 0.11 0.19 0.09 0.10n 81,283 35,119 63,922 28,837

Table VI.Distribution of dependant

variables

2009 2006High-skilled Low-skilled High-skilled Low-skilled

Formal training (no restriction) 0.80 0.61 0.77 0.23Formal training (with restriction 1) 0.58 0.39 0.52 0.31Formal training (with restrictions 1 and 2) 0.20 0.12 0.18 0.10Dif. (between res 1 and res 1 and 2) 0.38 0.27 0.34 0.21

Table V.Formal training

(comparison)


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Table VII.Average marginal effectfor Probit regressions ontraining participation in2006

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Table VIII.Average marginal effect

for Probit regressions ontraining participation in

2009


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British (Indian, Pakistani, Bangladeshi and other Asian background), Black/BlackBritish (Caribbean, African and other Black background), Mixed (White and BlackCaribbean, White and Black African, White and Asian and Any other mixedbackground), Chinese and Other. More than 80 per cent of the respondents are WhiteBritish.

Job tenure is captured by five dummy variables: Less than one year, one to twoyears, three to five years, five to ten years, 11-15 years and more than 15 years.Contracted-hours per week are identified with a dummy variable taking the value of 1if people work 30 or more hours per week.

Organizational characteristics. Three types of Trust are included in the analysis[6]:Acute Trust (including acute specialist), Primary Care Trust (PCT) and Mental Healthand Learning Disability (MHLD) Trust. Trust size is measured by five dummyvariables: Less than 1,000 staff, 1,000-1,999, 2,000-2,999, 3,000-3,999 and 4,000 or more.

There are two types of teamwork variables: one for size and the other for quality.The variables on size result from combining an affirmative reply to the question Doyou work in a team? with replies to: How many core members are there in yourteam? From these, five dummy variables are created: not in a team, 2-5, 6-9, 10-15 andmore than 15. Respondent views on the quality of their team is created from affirmativereplies to the three statements: Does your team have clear objectives?, Do you haveto work closely with other team members to achieve the teams objectives? and Doesthe team meet regularly and discuss its effectiveness and how it could be improved?.Another two dummy variables are whether a line manager within the Trust and hadan appraisal (both Knowledge and Skill Framework (KSF) development review andother type of appraisal, performance development review) in the last 12 months. Thepercentage of line managers among the high-skilled is approximately 30 per cent morethan among the low-skilled in both 2006 and 2009.

Empirical resultsBased on the above data specifications, we begin by estimating separate Probit modelsfor both the high- and low-skilled and for 2006 and 2009, respectively, controlling forindividual and organizational characteristics. We find generally a consistent impact ofthese characteristics on effective training in both years and with the wider literature.

For ease of interpretation, Tables VII and VIII present the average marginal effect(AME)[7] of the Probit regressions for the high-skilled and low-skilled, and for 2006and 2009 respectively. Gender is a significant predictor for training participation.High-skilled men are less likely to engage in formal training, informal training and inkeeping up-to-date with developments compared to high-skilled women, and thisrelationship weakened slightly from 2006 (approximately 2-3 per cent less) to 2009(approximately 1-2 per cent less). For the low-skilled, the opposite is the case with menmore likely to have these three types of training. We do not find any gender impact ononline learning for both high- and low-skilled for both years. Our results also show thatthe age effect on the probability of training is important and consistent with theliterature: people are less likely to engage in training as they get older. We find thisclear trend for formal, informal training and keeping up-to-date for both the high- andlow-skilled in 2006. In 2009, the same trend occurs for the high-skilled for all four typesof training; for the low-skilled, however, this is mainly for taught courses and online

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learning. The most noticeable change from 2006 to 2009 is for online learning; in 2006there is no clear age effect but, in 2009, the relationship is significantly negative.

As for the impact of ethnic background, compared to the reference group of OtherWhite, high-skilled White British are less likely to engage in all four types of trainingin 2006, and this relationship strengthened in 2009. Low-skilled White British are alsoless likely to engage in online learning and keeping up-to-date in 2006 and, in 2009, thisapplies to formal, informal training and keeping up-to-date. Both high- and low-skilledBlack/Black British are more likely to engage in formal training, informal training andkeeping up-to-date in both 2006 and 2009, although the size of the impact declinesslightly for the high-skilled from 2006 and 2009. We also find that high-skilledAsian/Asian British, Mixed and Chinese are less likely to engage in taught courses andkeeping up-to-date in 2009.

The type of Trust has an effect on training participation but the pattern is notconsistent. In 2009, compared to MHLD Trusts, both the high- and low-skilled in PCTsare less likely to engage in formal training, online learning and keeping up-to-date. Anexception to this is among the high-skilled in PCTs who are 2 per cent more likely tohave informal learning in 2006, a relationship that disappears in 2009. The high-skilledin Acute Trusts are less likely to engage in taught courses, online learning and keepingup-to-date in 2009 but both the high- and low-skilled in these Trusts are more likely tohave informal learning compared with MHLD in both 2006 and 2009.

The relationship of job tenure and informal learning is consistent with theexpectation that, compared to the reference group of those working less than 1 year, thelonger people work in a Trust, such training is less likely. We also find a similar butsmaller negative relationship for online learning and keeping up-to-date; the latter ismore consistent for the low-skilled in both 2006 and 2009. For formal training, whilethe overall pattern for the low-skilled is consistent with informal training, thehigh-skilled with 1-2 years tenure are more likely to participate in formal training andkeeping up-to-date in 2006 but not in 2009. On contracted hours of work, there is astrong link with training, those working 30 or more hours per week generally morelikely to engage in all four types of training in both 2006 and 2009, although the impactis more noticeable for the high-skilled (approx. 2-3 per cent more) than for thelow-skilled (approximately 1-2 per cent more). Our results confirm that part-timeworkers are generally less likely to be trained in the NHS trusts.

While the wider literature shows large firms typically offering more training to theiremployees (and all these Trusts would be defined as large), the effect of NHS Trust sizeon training is less clear. The results generally show a positive relationship for thehigh-skilled with informal learning in 2006 and, in 2009, online learning for both thehigh- and low-skilled. Compared to Trusts with fewer than 1,000 staff, the high-skilledin Trusts sized 3,000-3,999 were (2 per cent) more likely to engage in taught courses in2006, similar to the low-skilled in Trusts sized 1000-2999. The probability of engagingin formal, informal training and keeping up-to-date in 2009 is not associated with thesize of Trust.

Given the increased emphasis on the importance of team working in the NHS andevidence on positive relationships between teamwork and performance, we includeassessments of team quality and team size in the analysis. We ran the analysis threetimes, the first two included the quality and team size variables separately and thethird included both variables in the model. In the separate analyses, we find a


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significant positive impact of quality and team size on the four types of training and forboth the high- and low-skilled. We do not report the results here but they are availableon request. When both variables are included in the model, the positive impact of teamquality remains for all four types of training and in both years, the magnitude of thecoefficients is larger for the high-skilled than for the low-skilled, but the impact of teamsize changes. As shown in Tables VII and VIII, for the high-skilled and compared withnot in a team, in both years team size is negatively related to the probability ofparticipation in taught courses, online learning and keeping up-to-date. For thelow-skilled who work in a team with more than ten people, a positive impact remainsfor taught courses, informal learning, and keeping up-to-date but for online learningonly in 2009. Our results indicate that where respondents rate their team positively interms of quality they are significantly more likely to give a positive assessment of theeffectiveness of their training. This applies to both groups and both years but theimpact is greater on the high-skilled.

In 2006 and 2009, there are strong links between whether a line manager within theTrust and all four modes of training. Being a line manager is positively related toformal training, online learning and keeping up-to-date but negatively related toinformal training at the workplace. Whether or not staff have had an appraisal in thelast 12 months is also strongly related to a greater likelihood of engaging in all fourmodes of training in both 2006 and 2009 and, for each mode, the relationshipstrengthens between these years (from approximately 1-3 per cent more in 2006 to 3-6per cent more in 2009). It is a finding that provides support that staff appraisal (e.g.KSF review) may be fulfilling its intention in support of progression at work throughaccess to WRCET that is rated as effective.

DiscussionData for 2006 and 2009 from the NHS National Staff Survey are used to provideevidence on participation in different forms of training by high- and low-skilledworkers and to examine the impact of individual and organizational characteristics onhow the effectiveness of this training is assessed in terms of doing my job better andkeeping up-to-date. As far as we are aware, this is the first time these data sourceshave been used in this context. The discussion is structured in relation to the researchquestions itemised in the introduction.

In terms of the NHS strategic commitment for greater access to training andprofessional development for its-low skilled staff, the basic data on access (Table III)show that participation for both groups increased between 2006 and 2009 and acrossall four types of training; they also show the high-skilled had higher levels ofparticipation. However, the difference in participation between these groups in formaltraining, informal training and keeping up-to-date was smaller in 2009 compared with2006 but, for online learning, the difference increased. When the effectiveness criterionis included in the data, the overall pattern still shows greater participation in 2009compared with 2006 and higher levels of participation by the high-skilled remain.These results are ambiguous in terms of policy achievement. Whilst there is growth intraining participation by the low-skilled, it has also increased for the high-skilled. Ifpolicy is appraised in terms of narrowing the difference in WRCET between the high-and low-skilled, the basic access data shows participation by the low-skilled hasincreased at a faster rate for formal training, informal training and keeping up-to-date

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but the larger rate of increase in e-learning by the high-skilled prevents a clearconclusion on the overall distribution of growth between both groups. When theeffectiveness restriction is applied, however, the difference between the two groupsshows almost no change, and such change as occurs shows a widening gap betweenthe high- and low-skilled.

In terms of individual and organizational factors that influence participation ineffective training, our overall results on individual characteristics are consistent withkey features of the wider international literature, a finding more significant becausethese data incorporate respondent views on effectiveness, whereas the bulk of existingstudies are largely confined to measures of participation. Across all types of trainingand in both years, the high skilled participated in more training than the low-skilled.We also found that the young are more likely to participate in training and there is anegative relationship with training and length of job tenure and part-time working. Ongender, like the wider literature, the evidence lacks consistency: gender is shown to bea significant predictor but differing between skill levels. Compared with their femalecounterparts, high-skilled men are less likely to engage in formal training, informaltraining and keeping up-to-date, although these relationships weakened slightlybetween 2006 and 2009. The opposite is the case for low-skilled men. The impact oftrust size on training is less clear with the high-skilled working in larger trusts morelikely to have informal learning in 2006 and online learning for both the high- andlow-skilled in 2009. We find evidence of less access to training by White British butgreater participation by Black/Black British into almost all modes of training.

In relation to factors that influence the probability of participating in trainingassessed as effective, there is a positive relationship with having had an appraisal.This is encouraging in terms of NHS policy on developing low-skill workers, as oneaspect is developing staff through appraisals linked to the knowledge and skillsframework, job review and the skills escalator. It may be a matter of concern, however,that in 2009, 26 per cent and 36 per cent, respectively, of high- and low-skilled staff hadnot been appraised in the last 12 months. It is also pertinent to studies elsewhereshowing the importance of supportive organizational behaviour.

There is also evidence relevant to the policy of changing work processes and itsincreased emphasis on teamwork. For both the high- and low-skilled, the results showa strong positive relationship between participation in effective training andrespondents being in a team they rate positively in terms of quality, a findingconsistent with other studies. Evidence on effective training and team size is lessconsistent: there is a positive relationship for the low-skilled working in a team withmore than ten people but the high-skilled are less likely to report effective training ifthey work in a team and, if they are part of a team, the smaller the team, the lower thebenefit. Being a line manager is positively related to participation in effectivetraining, except for informal training which is negatively related.

On pedagogic practice, the literature indicates greater effectiveness for less didacticforms of teaching and the value of workshops and peer support; there is also evidencethat workers perceive these more informal modes of learning as more effective. Inrelation to this, the evidence shows e-learning with the strongest growth and formaltraining next with informal learning and keeping up-to-date. While we should not infertoo much into these results, they do not suggest a major shift towards the forms ofpedagogies that the extant evidence suggests are the more effective.


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Finally, we consider the strengths and limitations of introducing an effectivenesscriterion into the analysis. Making a distinction between participation alone andwhether participation was viewed as effective has clear benefits in appraising trainingpolicies, and the criterion we have applied shows a very large difference betweenparticipation alone and participation in effective WRCET; for example, in the case offormal training alone, participation levels for the high-skilled were 80 per cent in 2009but this falls to 20 per cent when our effectiveness criterion is included. These changesconvey a specific message about training quality in the NHS and a more generalmessage on the need for studies to include ways of taking account of quality inassessing WRCET. Set against this, is the weaknesses that the question on theeffectiveness of training covers all training and makes no distinction between thedifferent types. The restrictions we apply in defining what counts as effective mayalso be controversial, although we suggest that a high overall score and one stronglyagree response is a reasonable benchmark.

ConclusionBetween 2006 and 2009 there was greater participation in training across high- andlow-skilled staff but a differential pattern of participation across the four types oftraining results in limited clarity as to whether the relative access of the low-skilledimproved. The use of an effectiveness criterion effectively eliminates relative change inparticipation rates between these two groups. Among those who participated inWRCET, only about a quarter rated it as effective.

Appraisal and, in particular, membership of positively rated work teams arestrongly associated with training being rated positively, reflecting findings in studiescited earlier from a number of countries. However, when we included both quality andsize of team in the model, we found that the high-skilled are less likely to reporteffective training if they work in a team. What might explain this relationship? Is itbecause more training occurs in teams and, for various (unknown) reasons, the highskilled are negative about this training? Conversely, does it reflect a response arisingfrom too little training in teams, hence dissatisfaction with what they regard astraining ill-matched to the needs of their team? It is an area requiring further researchthat has implications for practice at a time when the role of teams in the health sectorand elsewhere are increasingly important.

Notes

1. The NHS National Staff Survey was launched in 2003 and has been run each year between2003 and 2009. Given our main interest in the effectiveness of WRCET, the questionnairesbefore 2006 do not include the effect of training.

2. Allied Health Professionals in the questionnaires include Occupational Therapy,Physiotherapy, Radiography, Pharmacy, Arts Therapy (e.g. art, music and dramatherapy), Other AHPs (e.g. chiropody/podiatry, dietetics, speech and language therapy andcomplementary therapy), Other qualified Scientific and Technical or Healthcare Scientist(e.g. haematology, clinical biochemistry and microbiology).

3. These include Adult/general, Mental health, Learning disabilities, Children, Midwives,Health visitors, District/community and Other registered nurses.

4. The percentages for those aged 16-20 and more than 66 are 0.5 per cent and 0.6 per centrespectively.

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5. Approximately 79.5 per cent in 2009, and this is calculated based on figures of NHS Statistics& data collections: www.ic.nhs.uk/statistics-and-data-collections/workforce/nhs-staff-numbers

6. Ambulance Trusts are included in the survey but we do not include them in our analysis dueto the limited numbers of observations.

7. For detailed discussions of AME see Bartus (2005).

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