Predicting the Effect of Extrinsic andIntrinsic Job Satisfaction Factors onRecruitment and Retention ofRehabilitation ProfessionalsDiane Smith Randolph, Ph.D., OTR/L, assistant professor, department ofoccupational science and occupational therapy, Edward and Margaret DoisySchool of Allied Health Professions, St. Louis, Missouri

E X E C U T I V E S U M M A R YThe purpose of this study was to ascertain which extrinsic and intrinsic job satis-faction areas are most predictive of rehabilitation professionals' career satisfac-tion and desire to stay on the job. This article discusses the results of a surveyconducted on practicing occupational therapists, physical therapists, and speech-language pathologists regarding factors that contribute to career satisfaction anddesire to stay on the job. Five hundred surveys were mailed to each profession; 463were returned, of which 328 were able to be analyzed.

Results from regression analysis showed that intrinsic factors such as profes-sional growth and having a work environment in line with personal values aremore significant in predicting career satisfaction than are extrinsic factors such aspay and continuing education. These same intrinsic factors are also significant inpredicting the rehabilitation professional's desire to stay on the job. These find-ings are significant to healthcare managers desiring to recruit and retain qualifiedoccupational therapists, physical therapists, and speech-language pathologists. Inaddition to extrinsic benefits such as pay, healthcare managers need to focus onprovision of intrinsic factors such as opportunities for professional growth, recog-nition of accomplishments, and opportunities for departmental input to motivaterehabilitation professionals.

For more information on this article, please contact Dr. Smith Randolph at randolds@slu.edu.

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111 f you want to motivate the worker,I don't put in another water foun-tain; provide a bigger share of the jobitself" (Herzberg 1959). This quoteby Fredrick Herzberg succinctly sumsup his philosophy on creating andmaintaining employee motivationand satisfaction. Since enactment ofthe Balanced Budget Act of 1997 (PL-105-33), occupational therapists (OT),physical therapists (PT), and speech-language pathologists (SLP) have beenfaced with changes in the healthcaresystem that have affected their abilityto deliver rehabilitative services. Theamount of time these rehabilitationprofessionals can spend with clients,length of stay for which clients areable to qualify, and type of settings inwhich rehabilitation professionals typ-ically work are among these changes.Often, insurance companies, instead ofthe physician or rehabilitation profes-sional, are making the decision on howlong a patient may receive treatmentand what type of treatment the patientwill receive. These changes may in turncreate dissatisfaction for rehabilitationprofessionals.

In 1995, as part ofa master's de-gree thesis, the author completed asurvey of 500 OTs, 500 PTs, and 500SLPs to determine which extrinsic,intrinsic-context, and intrinsic-contentfactors were correlated with careersatisfaction and desire to stay on thejob (Barnes 1996). The choice of the-sis topic was in response to concernamong hospital administrators abouthow to best recruit and retain OTs, PTs,and SLPs. The sample was randomlychosen from membership lists fromthe American Occupational Therapy

Association (AOTA), American PhysicalTherapy Association (APTA), and Amer-ican Speech and Hearing Association(ASHA). The research design consistedof establishing frequencies of responsefor important factors as well as usingchi-square analysis to determine thesignificance of each factor to career sat-isfaction and desire to stay on the job.

Extrinsic factors were defined asthose external benefits provided to theprofessional by the facility or organi-zation. Such factors include flexibleschedule, competitive pay, and con-tinuing education. Intrinsic factorswere divided into intrinsic-contextand intrinsic-content. Intrinsic-contextfactors are less tangible but inherent tothe job; they are controlled by outsideforces but affect the professional'sinternal satisfaction. Factors includedare adequate staffing, realistic work-load, stable environment, and balancebetween work and home. Intrinsic-content factors are those controlledprimarily by the professional and affectthe professional's sense of self-efficacyand competence. These factors includehaving diversity in practice, providingdirect patient care, having meaningfulwork, and providing quality care.

Results showed that the only ex-trinsic factors that were significantwere productivity expectations, whichnegatively correlated with career satis-faction, and flexible scheduling, whichpositively correlated with desire to stayon the job. Intrinsic-context factorssuch as a stable work environment,opportunity for professional growth,input into departmental decisions, andpracticing in an environment that wasin line with the professional's values

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THE EFFECT OF EXTRINSIC AND INTRINSIC JOB SATISFACTION FACTORS

were significantly positively correlatedwith career satisfaction and desire tostay on the job. Intrinsic-content factorssuch as opportunity for direct patientcare, feeling competent, accomplishingcareer objectives, and meaningful workwere significantly correlated with careersatisfaction. Intrinsic-content factorssuch as fair policies, accomplishingcareer objectives, and closeness withcoworkers were significantly correlatedwith desire to stay on the job.

A second survey was conducted in2000 to determine if differences hadoccurred in career satisfaction anddesire to stay on the job since 1995.It was determined that a second surveymight reveal changes because of in-creased managed care in rehabilitationservices. Therefore, the purpose of thissecond study was to ascertain whichextrinsic and intrinsic job satisfactionareas were most predictive of rehabili-tation professionals' career satisfactionand desire to stay on the job. A com-parison could then be made with theearlier survey to see if changes haveoccurred since the increase in man-aged care. Rehabilitation professionalsincluded in this study were OTs, PTs,and SLPs. This information is felt to beimportant for healthcare managers andhuman resources personnel desiring toattract and retain qualified rehabilita-tion professionals.

R E V I E W OF L I T E R A T U R ERehabilitation ProfessionalsStudies of OTs show that general work-ing conditions and task autonomy aresignificant predictors of commitment inambulatory care settings (Painter andAkroyd 1998; Painter et al. 1995). In

addition, communication and coopera-tion among team members, managerialfeedback, the patient's influence oncare, and the relatives' influence oncare are significant for job satisfaction(Eklund and Hallberg 2000). Anotherstudy shows that issues such as lack ofrespect, excessive paperwork, limitedadvancement, stress, and overload arefactors in attrition of female OTs (Bai-ley 1990). Lastly, a study examiningretention of OT staff in rehabilitationsettings shows that issues change withyears of experience, with less experi-enced therapists leaving because ofproductivity expectations and increasedpaperwork and more experienced ther-apists leaving because of interpersonalconflict and disillusionment with de-partmental management (Freda 1992).

PTs identify feeling satisfied withtheir profession when they experiencefreedom on the job and developmentof skills. Pay and benefits and oppor-tunities for career development arethe major determinants of retention(Okerlund, Jackson, and Parsons 1994;Noh and Beggs 1993).

NursingStudies have revealed issues of taskrequirements, stress, and organizationalpolicies as causing discontentmentwith nursing staff. Positive relation-ships, autonomy, participative decision-making management styles, salary,and job status positively affect jobsatisfaction (Finn 2001). Another studyreveals five coherent factors definingjob satisfaction: interpersonal contact,pace of work, meaning of work, au-tonomy, and control of work (Murray1988). Intrinsic factors are identified as

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sources of job satisfaction, and in anethnographic study the opportunity to"make a difference in people's lives,"the challenges of being the "patient'sadvocate," financial stability, and flex-ibility of schedules and work settingswere identified as the most appeal-ing aspects ofthe job (Chiara 1993;Koebel, Fuller, and Misener 1991).Studies also indicate that job satisfac-tion factors differ within levels of nurs-ing, with higher-level nurses valuingintrinsic factors more and lower-levelnurses valuing extrinsic factors more(Bell 1993; Malkin 1993; Robertsonet al. 1999).

Theoretical FrameworkSeveral theories of motivation focus onissues facing management of profes-sional employees. McGregor's (1960)Theory X and Theory Y form the basisfor concepts of authoritarian and par-ticipative management. Ouchi (1981)describes Theory Z, which focuses onclosely linking work and the worker'slife. Morse and Lorsch's (1970) con-tingency theory contends that "Theproper fit among task, organization,and people seem[s] to develop a strong'competence motivation' in individualsregardless of organizational style."Herzberg (1959) identifies two factorsthat are operative in motivation: satis-fiers and dissatisfiers. Factors such ascompany policy, supervisors, and workconditions, if perceived as negativeor lacking, are dissatisfiers. If they arepresent and perceived as good, they aresatisfiers but not motivators. Motivatorsinclude such things as opportunity foradvancement and promotion, greater

responsibility, opportunity for growth,and interesting work.

Bandura (1986) explains self-efficacy as people's judgment of theirown capabilities and standards. Hestates that people take pride in theiraccomplishments when they ascribetheir successes to their own abilityand effort. Bush, Powell, and Herzberg(1993) looked at self-efficacy related tomotivation in OTs and determined thatOTs are leaving the profession becauseof unmet career expectations.

The theoretical approach used indesigning the present study was that ofself-efficacy and Herzberg's two-factortheory. The study determined whichfactors are dissatisfying, satisfying, andmotivating. In addition, many of theintrinsic-context and intrinsic-contentfactors surveyed focused on issues ofself-efficacy. These theories assisted inexamining the results and determininga focus for the future.

Reviews of rehabilitation andnursing literature reveal that multiplefactors affect motivation, career satis-faction, and desire to stay on the job. Avast amount of research has been doneon these factors with regard to nursing,but less so with regard to rehabilitationprofessionals. Although it could beargued that many of the factors aresimilar with regard to recruitment andretention, practice areas and foci aredifferent enough to warrant furtherexamination specific to rehabilitationprofessionals. In addition, the contin-ually changing healthcare environmentmay potentially have an effect on ca-reer satisfaction and retention issuesfor all health professionals. Therefore,understanding which factors are most

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THE EFFECT OF EXTRINSIC AND INTRINSIC IOB SATISFACTION FACTORS

predictive of career satisfaction anddesire to stay would be helpful formanagers and human relations per-sonnel for recruitment and retentionissues.

METHODS

SubjectsParticipants were selected from ran-dom samples of currently practicingOTs, PTs, and SLPs—chosen from themembership files of AOTA, APTA,and ASHA—who work with clientsat least 60 percent of their time. Re-habilitation professionals who workprimarily as administrators, researchers,and academicians were excluded. Thissample was chosen similarly to thesample analyzed in the 1995 survey.Because the participants were randomlyselected, some of the participants mayhave answered both surveys, but forthe most part the samples did notcontain the same participants. How-ever, because the study used the samemembership organizations and becauseof the random sampling, the authoris confident that strong comparisonscan be made between surveys. Biasmay be a factor, as not all OTs, PTs,and SLPs belong to their respectivemembership organizations. Therefore,results are not generalizable to thosewho do not belong to the membershiporganizations.

ProceduresThere were 1,500 surveys mailed (500to each profession), with a cover letterexplaining the purpose of the surveyand a self-addressed, stamped enve-lope for return to the investigator.Participants were asked to complete

the survey within a two-week period;463 surveys were returned, and 328were usable. The initial survey in 1995had a response rate of 830, with 620in usable form. Surveys that were notusable were mostly from professionalswho had been in a clinical positionless than 60 percent of the time. Othersurveys were deemed unusable becauseof incompleteness.

Survey InstrumentThe survey instrument was developedfrom the review of literature prior tothe first survey conducted in 1995(Barnes 1996). The survey was de-veloped by the author and her thesiscommittee. Participants identified theirlevel of career satisfaction and desireto stay on the job on a five-point scale.They were then asked to identify theavailability and importance of intrinsicand extrinsic job factors. Extrinsicfactors are those that are traditionallyprovided by the employer, includingthe following:

• Family leave

• Flexible schedule

• Cafeteria-type benefits

• Employer-provided child care

• Competitive pay

• Continuing education

• Tuition reimbursement

• Productivity expectations

• Use of extender personnel

• Clinical ladder

Intrinsic-context factors are less tangi-ble but inherent to the job; they are

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controlled by outside forces but affect aparticipant's internal motivation:

• Adequate staffing

• Realistic workload

• Facility reputation

• Adequate support staff

• Career advancement

• Stable environment

• Professional growth opportunities

• Support by physicians

• Support by other healthcareprofessionals

• Support by administration

• Communication with management

• Input into departmental decisions

• Recognition for accomplishments

• Feeling valued as an employee

• Environment in line with values

• Input into professional growth

• Balance between work and home

• Adequate guidance

• Quality supervision

Intrinsic-content factors are those con-trolled mostly by the professional andaffecting the professional's sense ofself-efficacy:

• Program development

• Opportunity to conduct clinicalresearch

• Interdisciplinary team participation

• Diversity of practice

• Role conflict with other professionals

• Direct patient care

• Fair policies

• Helping people become well

• Feeling close with coworkers

• Helping people prevent disabilities

• Helping people overcome disabilities

• Feelings of competency

• Proper training

• Meaningful work

• Accomplishing career objectives

• Providing quality care

Importance was rated on a seven-point Likert-type scale. Open-endedquestions were asked to identify anyadditional factors that affected careersatisfaction or desire to stay on thejob. The final section of the surveywas a series of questions identifyingdemographic factors.

Data AnalysisData were examined using frequency ofresponse to identify the population ofrespondents. Linear regression analyseswere performed to assist in identifyingfactors significant in predicting careersatisfaction and desire to stay on thejob. Hair et al. (1998) define linearregression analysis as "a statisticaltechnique that can be used to analyzethe relationship between a single de-pendent (criterion) variable and severalindependent (predictor) variables." Themost direct interpretation of the regres-sion variate is a determination of therelative importance of each indepen-dent variable in the prediction of thedependent measure. Linear regressionwas chosen for this analysis, insteadof the chi-square analysis performedon the initial survey, because of theimproved ability of logistic regressionanalysis to predict job satisfaction and

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THE EFFECT OF EXTRINSIC AND INTRINSIC IOB SATISFACTION FACTORS

desire to stay on the job, as opposedto reporting significant correlationsthrough chi-square analysis.

RESULTSDescription of SampleSimilar to the survey conducted in1995, the percentage of each profes-sion (OTs, PTs, and SLPs) was fairlyeven (31 percent, 43 percent, and 26percent, respectively). The mean agewas 38, with 12 years of experience.The average hours worked were 36,with 84 percent of the time spent inclinical work. The mean years spentwith the current employer were 5.8,with 5.7 of them in the same position.Eighty-one percent of the rehabilitationprofessionals stated that they werevery or somewhat satisfied with theircareers, compared to 89 percent on thefirst survey. Seventy-six percent statedthat they definitely or probably wouldstay at their current job, compared to81 percent on the initial survey.

Regression AnalysisLogistic regression analyses were runwith career satisfaction as the depen-dent variable, considering the rehabil-itation professionals in total and thenseparately. Results in Table 1 show thathaving an environment in line withthe professional's values and havingopportunities for professional growthwere significant predictors of careersatisfaction for the professions in totaland for OTs and PTs separately. Close-ness with coworkers and providingquality care were also significant withregard to predicting career satisfac-tion for OTs. Helping people becomewell was significant for PTs, and team

participation was negatively correlatedwith career satisfaction.

Accomplishing career objectives,having a realistic workload, havingan adequate support staff, achievinga balance between work and home,having a flexible schedule, and helpingpeople overcome disabilities were pre-dictive of career satisfaction for SLPs.The adjusted R^ showed a predictivevalue of these factors of 39 percent forrehabilitation professionals in total,77 percent for OTs, 32 percent for PTs,and 62 percent for SLPs.

Results in Table 2 show that pro-fessional growth and having an envi-ronment in line with the professional'svalues continued to be predictive ofdesire to stay on the job for the pro-fessions in total and for OTs and PTs.Having adequate support staff wasalso predictive of desire to stay onthe job for OTs, and accomplishingcareer objectives was predictive forPTs and SLPs. In addition, havinga flexible schedule, proper training,absence of role conflict, and having arealistic workload were predictive ofthe desire to stay on the job for SLPs.The adjusted R^ showed a predictivevalue of these factors of 27 percent forrehabilitation professionals in total, 65percent for OTs, 21 percent for PTs, and49 percent for SLPs.

D I S C U S S I O NRecruitment and retention of qualifiedrehabilitation professionals is an im-portant issue for healthcare managers.Knowledge of those factors that providecareer satisfaction and desire to stayon the job can assist the healthcare

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louRNAL OF HEALTHCARE MANAGEMENT 50:1 JANUARY/FEBRUARY 2005

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manager in obtaining and maintain-ing a competent rehabilitation staff.According to the survey conducted in2000, career satisfaction and desireto stay on the job remain high forrehabihtation professionals, althoughdecreased from the initial survey con-ducted in 1995. Intrinsic factors, suchas having an environment in line withthe professional's values, continue todominate as predictive factors for bothcareer satisfaction and desire to stayon the job for all three rehabilitationprofessions. Extrinsic factors, such ascompetitive pay, were weaker in signif-icance for predicting career satisfactionand desire to stay on the job.

When examined separately, issuesbetween OTs, PTs, and SLPs had somedifferences. OTs and PTs agreed moreregarding factors important for careersatisfaction and desire to stay on thejob than OTs and SLPs or PTs andSLPs. Much of the literature regardinghealth professionals' career satisfactionand desire to stay on the job has fo-cused on availability of extrinsic factorssuch as pay, continuing education, andclinical ladders, with autonomy beingone of the few intrinsic factors men-tioned. It appears, however, from thisand the previous analysis, that health-care managers should focus efforts onintrinsic factors such as professionalgrowth, provision of an environment inline with the professional's values, andrecognition for achievements as muchas or more than on extrinsic factorssuch as pay.

C O N C L U S I O NA survey of currently practicing OTs,PTs, and SLPs revealed factors that

are predictive of career satisfactionand desire to stay on the job. Resultsrevealed that intrinsic factors, ratherthan extrinsic factors such as pay, tendto be predictive of career satisfactionand desire to stay on the job. Strengthsof this study are the large sample sizeas well as a fairly equal distributionof professions. Another strength isthat the findings corroborate earliersurveys. A limitation of the study isthat the sample was not controlledby age or level of experience. Anotherlimitation is that the sample was drawnfrom rehabilitation professionals whoare members of their respective mem-bership organizations. Perhaps thoseprofessionals who are not memberswould have different responses thanthe sample chosen. It was also impos-sible to compare the same participantsfrom survey to survey, limiting con-clusions that could be drawn betweenthe two surveys. There was also nosorting or sampling based on region,which would provide a more repre-sentative sample of the rehabilitationprofessions.

The implication for managers isthat if facilities desire to attract andretain rehabilitation professionals,they will need to find ways to providethese intrinsic factors as well as thosetraditional benefits. Providing the re-habilitation professional with not onlythe traditional benefits they need butalso the intrinsic benefits they desirewill improve career satisfaction, reduceattrition, and retain qualified personnelneeded to provide services for thecurrent and emerging healthcare envi-ronment. Mechanisms to address issuesof recognition for accomplishments.

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THE EFFECT OF EXTRINSIC AND INTRINSIC JOB SATISFACTION FACTORS

opportunity for input into departmen-tal decisions, and maintenance of arealistic workload in a stable environ-ment are potential areas for managerfocus. Ideally, management and therehabilitation professional should worktogether to design a career satisfactionand job retention program that wouldbe the most mutually beneficial.

A c k n o w l e d g m e n t sThe author would like to acknowledgeRandy R. Richter, Ph.D., P.T., for helpingset up the database; St. Louis UniversityResearch Services for funding the Sum-mer Research Grant; and Carolyn Baum,Ph.D., OTR/L, FAOTA; Ron Gribbins,Ph.D.; and Jan Duchek, Ph.D., for assist-ing with the creation of the survey usedin the initial and follow-up research.

R e f e r e n c e sBailey, D. 1990. "Reasons for Attrition from

Occupational Therapy." American Journalof Occupational Therapy 44 (1): 23-29.

Bandura, A. 1986. Social Learning Theory.Englewood Cliffs, NJ: Prentice-Hall.

Barnes, D. 1996. "Job Satisfaction and the Re-habilitation Professional." Thesis, Wash-ington University School of Medicine, St.Louis, Missouri.

Bell, P. L. 1993. "Nurse's Perception oftheClinical Ladder's Contributions to TheirLevels of Job Satisfaction and Dissatisfac-tion." Dissertation, University of Virginia,Charlottesville.

Bush, J. V., N. J. Powell, and G. Herzberg.1993. "Career Self-Efficacy in Occupa-tional Therapy Practice." American Joumalof Occupational Therapy 47: 927-33.

Chiara, M. 1993. "Making a Difference: AnEthnography of Women's Career Moti-vations, Values and Work Satisfactionin Nursing." Dissertation, NorthwesternUniversity, Evanston, Illinois.

Eklund, M., and I. Hallberg. 2000. "Fac-tors Influencing Job Satisfaction AmongSwedish Occupational Therapists in

Psychiatric Care." Scandinavian Joumal ofCaring Sciences 14 (3): 162-71.

Finn, C. P. 2001. "Autonomy: An ImportantComponent for Nurses' Job Satisfaction."Intemational Joumal of Nursing Studies 38(3): 349-57.

Freda, M. 1992. "Retaining OccupationalTherapists in Rehabilitation Settings:Influential Factors." American Joumal ofOccupational Therapy 46: 240-45.

Hair, J. F., R. E. Anderson, R. L. Tatham, andW. C. Black. 1998. Multivariate DataAnalysis, 5th ed. Englewood Cliffs, NJ:Prentice-Hall.

Herzberg, P. 1959. The Motivation to Work.New York: John Wiley & Sons, Inc.

Koebel, P. W., S. C. Fuller, and T R. Misener.1991. "Job Satisfaction of Nurse Prac-titioners: An Analysis Using Herzberg'sTheory." Nurse Practitioner 16 (4): 43-48.

Malkin, K. 1993. "Primary Nursing: Job Sat-isfaction and Staff Retention." Joumal ofNursing Management 1 (3): 119-24.

McCregor, D. 1960. The Human Side of Enter-prise. New York: McCraw-Hill.

Morse, ). ]., and J. W. Lorsch. 1970. "BeyondTheory Y." Harvard Business Review 48 (3):61-68.

Murray, K. H. 1988. "Intrinsic, Extrinsic andContextual Work Variables InfluencingJob Satisfaction/Turnover Among Reg-istered Nurses in Selected New JerseyHospitals." Dissertation, Seton Hall Uni-versity, South Orange, New Jersey.

Noh, S., and C. Beggs. 1993. "Job Turnoverand Regional Attrition Among Physiother-apists in Northern Ontario." PhysiotherapyCanada 45 (4): 239-44.

Okerlund, V. W., P. B. Jackson, and R. J. Par-sons. 1994. "Factors Affecting Recruit-ment of Physical Therapy Personnel inUtah." Physical Therapy 74 (2): 177-84.

Ouchi, W. 1981. Theory Z: How AmericanBusiness Can Meet the Japanese Challenge.Reading, MA: Addison-Wesley.

Painter, J., and D. Akroyd. 1998. "Predictorsof Organizational Commitment AmongOccupational Therapists." OccupationalTherapy in Health Care 11 (2): 1-15.

Painter, J., D. Akroyd, S. Wilson, andC. Figuers. 1995. 'The Predictive Valueof Selected Job Rewards on OccupationalTherapists' Job Satisfaction in Ambulatory

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Care Settings." Occupational Therapy inHealth Care 9 (4): 21-37.

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P R A C T A P P L I C A T

Steven P. Johnson, Ph.D., president, SSM Rehab, St. Louis, Missouri

E very healthcare executive has been focusing on what attracts and retains profes-sionals inside the organization, and this study reveals additional understand-

ing of the key satisfaction factors by examining occupational therapists, physicaltherapists, and speech-language pathologists. As described by Smith Randolph,the intrinsic factors—complementing extrinsic items such as pay or benefits—are not significantly unlike those that have also been identified as key retentionmotivators for nurses and others. The study is a great guide for the administratorsof rehabilitation units or any facility that requires the services of one or more ofthese professionals.

Each of the three professions appears regularly over time on the list of difficultto find or retain personnel, and each has inspired some form of emergency recruit-ment strategy. In an ever-tightening healthcare workforce, this study of the satis-faction priorities can help executives to determine what needs to be emphasizedor changed in their organizational environment to alleviate turnover. This workstrongly points to the importance of personal grov^^h, organizational values, andrecognition. Similar to other health professionals, clinicians in these groups aremore satisfied and more likely to stay in the organization when they believe theyhave a say in what happens in the work setting. These intrinsic satisfiers, accordingto the study, are more important than pay.

The research included a good sample of professionals. As this study reveals,compelling to healthcare decision makers, whether attempting to attract or retainone or another kind of clinician (occupational therapists, physical therapists, orspeech-language pathologists), is the finding that more collegiality and recognitionin the organization are critical to rehabilitation professionals. This contrasts witha traditional command-and-control hierarchy, which often has existed in hospitalsand other health organizations, or the expedient and short-lived staffing strategiesthat only focus on pay or sign-on bonuses to offset staff shortages.

This article realistically identifies that a complex set of stress factors in theenvironment is the enemy of satisfiers for clinicians, and it helps to point directlyto policies and practices that can have a long-lasting positive effect in areas wherepay and benefits are not enough.

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