Something beyond paycheque to boosting employee retention: evidence from a South Indian hospital

Abstract

Purpose

This paper aims to emphasize the need for a strategic approach to employee retention beyond financial benefits. This is directly proportional to employee retention. Bringing out the retention measures preferred by employees, depicting the relationship of demographic profile with employee retention tendency and exploring implications giving importance to beyond paycheque factors are the objectives of the study.

Design/methodology/approach

This study uses applied qualitative approach with a realistic view to collect the details of retention measures and practices from purposively selected 36 health-care experts by the conduct of interview using a one-to-one discussion with written notes. With quantitative approach, opinion survey was administered to receive the perceived opinion of randomly selected 350 health-care employees on paycheque and on beyond paycheque factors boosting their intention to stay. Bhattacharya and Ramachandran’s health-care study framework on retention was applied for the identification of the factors.

Findings

Both paycheque and beyond paycheque benefits are important for retention. Most respondents prefer beyond paycheque factors practiced at sampled hospital. Age, marital status and residence of employees are significantly associated with retention. The strategic initiatives of the sampled hospital to retention concerning motivational needs of employees in the workplace are thank you board, camp head, ad act camp, success corner and so forth.

Research limitations/implications

Addressing health-care work and relationship-related issues in terms of employee retention giving importance to beyond paycheque benefits – remedy for compassion fatigue health-care employees face in routine works, meeting promises made by management regarding paycheque or beyond paycheque benefits, employees participative in decisions in medical, clinical and in functional areas, reducing workload and role stress by the conduct of role analysis.

Originality/value

Many research studies are emphasizing the contribution of financial benefits to employee retention. Only a few studies have been carried out exploring and emphasizing the importance of beyond financial benefits motivating employee retention. This is the study of evidence from a hospital that gives strategic importance to beyond paycheque elements as well as paycheque elements.

Citation

Bharath, M. (2023), "Something beyond paycheque to boosting employee retention: evidence from a South Indian hospital", Vilakshan - XIMB Journal of Management, Vol. 20 No. 1, pp. 114-129. https://doi.org/10.1108/XJM-03-2021-0072

Introduction

Retaining employees is the toughest challenge to organizations in the globalized competitive labour market. Health-care organizations are not exempted from this competition. They are the organizations that are rigorously facing competition. Many research studies reported employee migration and turnover in the health-care industry are crucially increasing. Nowadays, it is becoming a big challenge for the management to not only manage the skilled employees but also keep them retained for a longer period. Health care is a labour-intensive sector (Latino, 2008). Human resource shortage has been realized in many countries, notably developing countries. They initiated to have a strategic approach to employee retention. The shortage was predicted by the World Health Organization as 12.9 million; a rise from the present number of 7.2 million in the next 20 years across the countries. Sen and Bhattacharya (2019) recommended the need for an innovative and global approach to tackle human resource shortage, talent development and retention issues in the Indian service sector. In the study of Mercer Webcast Series – 2016, Mahadi et al. (2020) identified the employee voluntary turnover rate is 9.1% globally, and around 15% turnover rate was found in countries like Indonesia, Philippines, Argentina and Romania. Because of skilled labour shortages in the health-care sector, employees expect more financial and non-financial benefits. Meeting the expectations will greatly influence the retention tendency of health-care employees. Though they are highly paid, but if they are poorly treated and if they are not recognized, they will quit their job. Frank et al. (2004) suggested a continuous discretionary effort has to be taken by the employer to retain their potential employees.

Employee retention

It is a systematic effort to create and foster an environment encouraging employees to remain employed by addressing their diverse needs. Bidisha and Mukulesh (2013) realized the retention of employees that requires a lengthy process that needs organizations all possible means. Das and Baruah (2013) suggested a need for a strategic process for implementing motivational tools is to be taken by organizations to sustain their employees. Employee retention was approached as taking initiatives to prevent the loss of proficient employees from leaving by researchers. Mita (2014) recommended the need for a technique to be used in organizations to make employees efficient to meet operational needs that enhance employee retention. Alshurideh (2019) stated in his study that retaining skilled employees significantly contributes to retaining the customers and enhances the operational cost efficiency of organizations.

Determinants of employee retention

Employee retention is not determined by a single factor but by several factors (Fitz-enz, 1990). The factors that are commonly discussed are career development opportunities, supervision, work stress (Brown et al., 2002), management style and leadership (Andrews and Wan, 2009), autonomy, work-schedule flexibility, social support (Loan-Clarke, 2010), compensation (Spencer et al., 2016), crafted workload and work–life balance (Christeen, 2015):

• Compensation in the form of financial benefits has a relationship with employee retention. The commonly discussed compensation factors are performance-related pay (Tremblay et al., 2006), the number of pay hikes as extrinsic rewards (Hausknecht et al., 2009) and financial benefits coupled with the quality of work–life (Gifford et al., 2002; Hayes et al., 2006).

• Supportive work environment greatly contributes to influencing retention among health workers, as the environment enhances to meet patients every day that requires mutual relationship. The environment fosters to flexible atmosphere (Spence Laschinger et al., 2009), the availability of job and personal resources (Alexander et al., 1998), flexibility in work schedule and fun in work environment (Loan-Clarke et al., 2010) that makes health workers feel engaged.

• Social support: the satisfactory relationship with colleagues and fellow workers is to be the determinant factor of retention (Kossivi et al., 2016). The support from co-workers (Alexander et al., 1998; Tai et al., 1998), feelings of belongingness (Miller et al., 2001), manager–employee relationship (Jasper, 2007) and giving importance to individual needs (Ramlall, 2003) are greatly contributing to employee retention.

• Professional and career development opportunities significantly influence workers’ retention. Personal and professional growth (Horwitz et al., 2003; Armstrong, 2009), development opportunities (Arnold, 2005; Herman, 2005), promotions and proper training programs (Daniels et al., 2007), internal hiring and promotions, accurate career reviews (Prince, 2005) and perceived career success (Pitts, 2011) are the key determinants of employee retention.

• Other determinants of employee retention: apart from compensation, social support and environment, the rarely studied and discussed factors are the right fit work roles and responsibilities, creating teams more responsible, ensuring to balance the expectation of employees with realistic job features, need of third-party intervention to ensure registering voice of employees, making employees feeling job secured and performance evaluation based on outcomes reached rather than hours worked (Armstrong, 2009). Pillemer’s (1997) study among nurses regarding their intention to stay, recommended participative work culture as collaborative decisions in clinical and functional issues. Matongolo et al.’s (2018) and Jadon and Upadhyay’s (2018) study at private and public hospitals in Madhya Pradesh, India illustrated the relationship of participative work climate, role performance and retention. They recommended improving working environment fostering cooperation, empowerment, leadership style, job-specific proficiency, career role behaviour and team role behaviour would greatly affect the intention to stay. Alameddine et al. (2012) illustrated the reasons for creating turnover tendency among employees through their 81 health-care centres study around Lebanon are better job opportunities in the available labour market, lack of professional approach to work and workplace, lack of career development programs and poor financial benefits comparatively to the benefits available in the market.

Paradoxical views on employee retention: paycheque and beyond paycheque factors

Views have been found in previous studies about the relationship of rewards and employee retention. Stone et al.’s (2010) study discussed that all the employees are not always satisfied with financial benefits. They state that generally, the material incentives do not fulfil the psychological and self-esteem needs. Likely, Hill and Tande (2006) highlighted the main reasons for quitting organizations apart from monetary benefits are individual professional development opportunities being limited, discouragement with work management and poor treatment and recognition. Masango et al.’s (2008) study at the Swaziland health sector discussed the benefits of financial elements influencing the intention to stay. At the same time, they highlighted the importance of non-financial incentives such as improved working conditions and support of management. Stilwell’s (2001) study at Zimbabwe among health workers serving in remote areas discussed the nature of work and hard-working conditions make them motivated in health-care services though they do not have sufficient financial incentives. She highlighted non-financial benefits such as leadership style and supportive work culture can have a beneficial effect on motivation to retention even under adverse situations. Chinyio et al. (2018) identified the monetary rewards – bonus, incentives, gratuity and pension – motivate the employees to stay longer in the organization. At the same time, they consider and suggest that most of the employees are enthusiastic in applying their ability and in the challenging work tasks, they want to become competent and they want work-motivated leadership. They state that wages and financial benefits are not crucial factors in creating retention tendency. Gomathi and Mathew (2020) found in their study reviews that adopting non-monetary programmes greatly ensures the creation of retention tendency among employees than the monetary benefits did in the past.

Strategic and motivational elements of employee retention

Organizations, notably health-care organizations, started to realize the workforce shortage issues. They initiated to follow retention programs focusing motivational approach to employees retaining them for long period. Alzoubi et al. (2020) illustrated the importance of recognition, socialization in the workplace and creating a supportive work culture. Kurdi and Alshurideh (2020) in their study gave importance to employee retention drivers that are considered motivational factors as: psychological – fulfilling living needs for survival, feeling job secured, psychological security as suitable work environment and getting financial benefits; physical – physical needs; and affiliation – harmonious relationship and self-actualization – being skilled, potential and self-actualized. Jadon and Upadhyay’s (2018) study on private and public hospitals in Madhya Pradesh, India illustrated the relationship of participative work climate, role performance and retention. Zoeb-Ur-Rahman and Hussain (2020) identified critical elements as motivating factors such as the experience of employees in work schedule, working hours, socialization and feeling physically comfortable in the workplace influence the intention to stay.

Theoretical background

Relationship and connections of employees

With workplace and organization positively related to employees’ stay or leave. The health-care environment ensures a strong connection of employees physically (practicing profession and gaining experience, involving daily routines) and cognitively (job knowledge, experiencing skills and emotional relationship with workers community). Job embeddedness theory argues the connections of employees in terms of fit, links and sacrifice that assure employee retention. For example, the strategic practice concerning the job characteristics – nature of the job, work schedule, flexible work shifts, work–life balance, well-being to make employees strongly connect with workplace and organization.

Motivators and hygiene factors

Herzberg’s theory argues about satisfaction and dissatisfaction of employees influencing the intention to stay. This theory lists out the motivators factors (achievement, career growth, recognition, treatment and development) and hygiene (relationship with superiors and co-workers and salary benefits) are significantly associated with retention. In a health-care environment, both of the factors concerning satisfaction may prevail to sustain its employees. Most health-care employees may have a good perception of motivators. As health-care employees are highly professional and achievement-oriented, they expect equal treatment and recognition for their contribution. At the same time, they cannot sustain themselves without hygiene factors.

Fulfilment of needs

Maslow’s needs theory illustrates that when the needs of employees’ physical, biological, social, self-esteem and self-actualization are met, it leads to encouragement of retaining the employees with great values. The health-care work environment gives a huge space to the fulfilment of social and self-actualization needs. As the health-care employees are closely associated with people, their needs of mingling with people, interacting with workers and with patients and trusty relationships with stakeholders are sufficiently fulfilled by the effective socialization practice. Most of the time, they could feel self-actualized in their voluntary service to the physical and mental health of patients, in their professional excellence through experience.

Reviews on paycheque and beyond paycheque factors

Employee retention can be influenced by several factors. Benefits that the employees receive for what they contribute, notably health-care service workers, hugely influence their retention tendency. Among the benefits, financial benefits may fulfil economic needs and non-financial benefits may fulfil psychological, emotional and social needs. The health-care workplace environment naturally makes its employees closely associated with the workplace psychologically, emotionally and socially. So they mostly expect their psychological and emotional needs to be fulfilled.

Bhattacharya and Ramachandran’s (2015) cross-sectional study of 20 hospitals in urban areas of India studied the opinion of health-care professionals (physicians and nurses) and identified the factors which create health-care employees’ intention to stay in their organization for a long period. Compensation (financial benefits; 68%) including incentives, advances, loans, bonuses and gifts predicts the intention to stay. Non-financial benefits – co-workers support (70%), housing, conveyance and medical benefits (60%), facilities provided for effective working (67%), acceptable work schedule (66%), career advancement (62%), personal growth (55%), learning environment (61%), promotions (61%), training environment (51%), relationship with co-workers (78%), nature of job (65%), amicable behaviour (66%), self-esteem and feeling satisfied (59% and recognition (63%) – predict the intention of employees to stay.

Adzei and Atinga’s (2012) study at Ghana hospitals among health workers identified financial benefits and non-financial benefits hugely influence the intention of workers to stay. Among the benefits, the non-financial benefits such as opportunities for career development, leadership and supervision skill and facilities and resources available were preferred by the workers. Dhanpat et al. (2019) study at Gauteng public hospitals among nurses in South Africa and found out the retention factors such as job security, training and development programs and individual growth are the most preferable. T.F. Mahan et al. (2020), work institute study explored several factors regarding employee retention: financial factors – compensation benefits (incentives, allowances, bonus, gifts, equity sharing and so on); and non-financial factors – job characteristics, career advancement, manager behaviour, well-being, work environment and work–life balance. T.F. Mahan et al. (2020) have highlighted non-financial factors such as job characteristics, career growth, and schedule flexibility, support of co-workers, manager behaviour and competence among all other factors that have a significant relationship with the intention of employees to stay than financial benefits.

The above-discussed study background related to the importance of employee retention, emphasizing need for the strategic approach to meet the psychological and emotional as motivational needs of health-care employees in workplace intent to stay, the study set the following objectives to produce evidence from a South Indian hospital – Mission Hospital and Research Centre (MHRC) – Tamil Nadu, India:

• To explore employee retention paycheque and beyond paycheque variables practiced in MHRC.

• To analyse the relationship of the demographic profile of sample respondents with their working years of experience, Pay Cheque Variables (PCVs) and Beyond Pay Cheque Variables (BPCVs) practiced in MHRC.

• To distinguish the preferences of sample respondents PCVs or BPCVs creating retention tendency among them.

• To bring out the strategic initiatives taken in MHRC and to bring out implications addressing work and relationship-related issues employees face in terms of intention to stay.

Methodology

The study produced the evidence of the opinion of randomly selected sample respondents working at MHRC, Tamil Nadu, India, which is “A1” graded and empanelled by the Department of Health and Family Welfare, Government of Tamil Nadu and listed in Prime Minister’s Comprehensive Insurance Scheme. A premier 800-bedded hospital functioning with multi-specialty and having around 1,500 workforce, and apart from specialties, it functions with many units such as palliative care unit, kidney transplantation unit, robotics surgery unit, heart transplantation unit, pharmaceutical institute and nursing training college. It has extended its preventive and curative services to the remote villages of South India at an affordable cost.

Data collection method

Applying a quantitative approach, the perceived opinion of MHRC employees who got satisfied by paycheque and beyond paycheque retention measures were collected. A survey questionnaire with a list of five-point scaled variables was administered and collected data from sample respondents.

Applying a qualitative approach, the details of retention measures practiced in MHRC were collected from 36 purposively selected experts working in MHRC. They are senior-level human resource managers, training and development managers and nursing superintendents. They were one-to-one interviewed using written notes.

Questionnaire preparation

During the interview, the selected words and terms related to retention measures and practices were placed before the experts. Repeatedly discussed words and terms with serious expressions were captured and used in the questionnaire. The support and guidance of the experts were received for selecting samples. While conducting frequency analysis on the words and terms repeatedly used by experts during one - on - one interviews, the following paycheque and beyond paycheque variables identified were used in the opinion survey questionnaire, tested reliability and used for data collection.

Reliability statistics

For the setting of variables, the study applied the framework of Bhattacharya and Ramachandran’s (2015) study at urban area Indian hospitals. The variables were taken and framed in the MHRC context. They were tested and used for the collection of data. For the scale of employee retention tendency creating variables, 30 items were used (M = 112.95, standard deviation [SD] = 8.029, V = 64.470, N = 30, Cronbach’s alpha = 0.866):

• (a) Paycheque variables (subscale of 10 items; M = 36.35, SD = 3.411, V = 11.633, α = 0.696): every year increment and allowances (M = 3.98, SD = 0.751, α = 0.706); educational and loan advances (M = 3.24, SD = 0.931, α = 0.629); leaves with pay (M = 3.82, SD = 0.602, α = 0.642); holidays with pay (M = 3.17, SD = 0.815, α = 0.640); incentives for group contribution (M = 3.04, SD = 0.602, α = 0.652); incentives for individual contribution (M = 3.60, SD = 0.566, α = 0.641); gifts (M = 3.59, SD = 0.531, α = 0.674); concession basis medical treatment offer for individuals (M = 3.94, SD = 0.316, α = 0.679); concession basis medical treatment for family members (M = 3.55, SD = 0.583, α = 0.721); and free hostel stay and discounts for canteen products (M = 4.41, SD = 0.699, α = 0.717).

• (b) Beyond paycheque variables (subscale of 20 items; M = 76.59, SD = 5.321, V = 28.317, α = 0.824) – job characteristics (M = 4.18, SD = 0.592, α = 0.822); work practicing ways (M = 4.17, SD = 0.754, α = 0.821); ability to adhere to systematic work plan (M = 4.06, SD = 0.595, α = 0.823); work shift flexibility for nurses (M = 3.66, SD = 0.593, α = 0.808); work shift flexibility for administrative employees (M = 3.93, SD = 0.376, α = 0.806); work attitude creating workplace (M = 3.97, SD = 0.306, α = 0.812); co-workers supportive behaviour (M = 3.53, SD = 0.575, α = 0.818); respectful behaviour of colleagues (M = 3.81, SD = 0.473, α = 0.814); treatment of immediate superiors (M = 3.75, SD = 0.475, α = 0.811); career growth (M = 3.45, SD = 0.542, α = 0.819); internal promotions (M = 3.58, SD = 0.580, α = 0.819); camp and training programs (M = 3.54, SD = 0.527, α = 0.822); importance to individual and family care (M = 3.97, SD = 0.271, α = 0.813); guidance in work (M = 3.74, SD = 0.596, α = 0.813); session for meeting emergency situation (M = 4.41, SD = 0.662, α = 0.814); sessions for improving social and emotional intelligence (M = 3.54, SD = 0.527, α = 0.825); sessions for improving morale (M = 3.72, SD = 0.511, α = 0.817); listening to the opinion while decision taking (M = 3.68, SD = 0.514, α = 0.820); feedback for individual growth (M = 3.59, SD = 0.504, α = 0.821); and self pride on rendering health-care service (M = 4.31, SD = 0.818, α = 0.814).

Respondents

The experts supported and guided to select the suitable samples for the conduct of the questionnaire survey. A total of 430 sample respondents working in MHRC at different in-patient wards and departments including 200 medical respondents [senior nursing superintendents, trained diploma in nursing and midwifery (DNM) and axillary nurse midwife (ANM) nurses] and 230 non-medical respondents (middle-level managers, executives, assistants and ward secretaries) were randomly selected. Out of 430 respondents met, 410 responses (95%) were received and 350 responses (86%) were taken for analysis, and the rest of the 60 responses (14%) were not filled properly and were repeatedly answered, so they were removed. The collected data were analysed using multivariate analysis techniques in SPSS 20 version.

Demographic frequency

Of the respondents (N = 350), 282 belong to 31–40 years of age group, 53 respondents belong to 21–30 years of age group and 15 respondents belong to 41–50 years of age group. A total of 228 respondents are female (M = 35.29, SD = 3.443, V = 11.853) and 122 respondents are male (M = 1.65, SD = 0.477, V = 0.228); 296 respondents got married and 54 respondents remain unmarried (M = 1.15, SD = 0.362, V = 0.131); 263 respondents are living within 25 km of distance from the location of study organization and 87 respondents are living within 26–50 km of distance from the location (M = 1.25, SD = 0.433, V = 0.187); 141 respondents have diploma (DNM) qualification, 110 respondents have under graduation qualification, 90 respondents have post-graduation degree and 9 respondents have ANM qualification (M = 2.20, SD = 0.852, V = 0.726); 200 respondents are medical employees and 150 respondents are non-medical employees (M = 1.43, SD = 0.496, V = 0.246); and 273 respondents are working for 6–10 years and 77 respondents are working for 11–15 years (M = 8.53, SD = 1.960, V = 3.843).

Thus, the study produced evidence from MHRC respondents most of them who got married. They are in an average of 35 years of age, female medical and non-medical respondents. They have diploma and graduation qualifications with a sufficient amount of training experience. They live nearby the workplace and they work with an average of 8–9 years of experience retained at MHRC. They evidenced and preferred beyond paycheque variables influencing intention to stay.

Results

PCVs and BPCVs practiced at MHRC significantly contribute to creating retention tendency among respondents. PCVs are important factors to fulfil the basic economic, physiological and biological needs of employees. Without which employees cannot survive and retain in the workplace. BPCVs are much more important to fulfil the social, psychological and esteem needs of employees, preferably health-care employees. Without this, the employee cannot survive and retain in the workplace for a long period:

R1.

Whether MHRC employees prefer paycheque or beyond paycheque elements creating retention tendency?

Yes, most of the respondents (234 respondents, 67%) prefer BPCVs. They have a high level of opinion on retention measures practiced at MHRC. This preference shows that they want to fulfil their social, esteem and psychological needs.

Comparing mean scores of the respondents assigned to BPCVs, the study found out that they have assigned high scores for job characteristics (M = 4.18) (involving caring mental and physical health activities and practices), feeling satisfied with the way work practiced (M = 4.17) (the way of health-care activities systematically practiced routinely), confident on their ability to adhere to systematic work plan (M = 4.06) (skill sets and abilities to involve in health-care activities and adhering to work plan and schedules), sessions for meeting emergencies (M = 4.41) (training sessions to meet emergencies) and having self-pride on health-care service (M = 4.31) (contribution to life-saving and health-care service). The study also found out that the rest of the 116 respondents (33%) expressed low-level opinions and stressed the following to be practiced with strategic importance: career growth (M = 3.45) (fostering career advancement programs), internal promotions (M = 3.58) (promotional activities based on experience and performance), flexible work shifts for nurses (M = 3.66) (adjustment in work timings and shifts), co-workers supportive behaviour (M = 3.53) (motivated positive work supportive culture), sessions for improving social and emotional intelligence (M = 3.54) (training sessions for maintaining good rapport with patients and with their relatives, peers and superiors) and feedback for individual growth (M = 3.59) (feedback for individual growth to better performance delivery not for hurting).

Comparing mean scores of the respondents assigned to PCVs, the study found out that 105 respondents (30%) expressed a high-level opinion on PCVs creating retention tendency as every year increment and allowances (M = 3.98), leaves with pay (M = 3.82), incentives for individual contribution (M = 3.60), gifts (M = 3.59) and concession in canteen and hostel stay (M = 4.41). The study also found out that the rest of 245 respondents (70%) expressed low-level opinion and addressed the followings to be practiced, being requested by them as holidays with pay (M = 3.17), incentives for group contribution (M = 3.04) (for example, incentives for performance of group of nurses in in-patient wards) and free medical treatment (M = 3.94) (medical treatment for individual and for family members based on type and seriousness of diseases).

Thus, the respondents shared their opinion and registered their preference to getting satisfied resulting in retention tendency. Besides the fulfilment of economic needs, being the health-care employees, knowledgeable, skilled professionals, dedicated and committed to caring service, they mostly prefer to fulfilment of social, psychological and self-esteem needs:

R2.

Does MHRC practice retention measures with strategic importance aligned with the association of demographic factors influencing retention tendency?

Yes, MHRC practice retention measures with strategic importance aligned with demographic factors. During the one-to-one discussion with experts, the study explored the retention practice of MHRC with strategic importance. This gives keen attention to demographic factors age, marital status and distance from residence to workplace and its relationship with retention tendency.

Relationship of demographic factors with work experience

The study resulted significant association of demographic factors age (χ² = 1174.004, Df = 153, Phi = 1.831, Cramer V = 0.610, p-value < 0.05), marital status (χ² = 113.238, Df = 9, Phi = 0.569, Cramer V = 0.569, p-value < 0.05) and distance of residence from workplace (χ² = 22.635, Df = 9, Phi = 0.254, Cramer V = 0.254, p-value < 0.05) with working years of experience in MHRC. The study also explored these factors are independent and significant with medium to large effect size predicting retention tendency. When the age of employees increases (Mahadi et al., 2020), they are emotionally and socially getting connected with co-workers and with the workplace. They will not switch over the workplaces (T.F. Mahan et al., 2020). As married employees are leading family life and they are closely associated with the workplace for many years in the same organization, they will not change their work often and they mostly wish to retain themselves (T. F. Mahan et al., 2020). Dedicated and committed employees, who travel from distance residence to workplace, generally want to get back the benefits for what they contributed. In the case of aged and experienced, married and travelling from distant places to the workplace, they expect their social, psychological, self-esteem needs and economic needs also to be fulfilled.

Retention practice of Mission Hospital and Research Centre with strategic importance

Giving importance to age factor in terms of maintaining mutual relationship among employees, the aged and experienced employees are rightly identified and placed in required right places. On this point, educational qualification is not given much importance compared to the experience, age and expertise factors of employees. For example, at MHRC, besides the nurses working in in-patient wards, an excellent patient caretaker is being placed in every in-patient ward. This role is mostly played by senior trained nurses who are generally skilled in caretaking, not in qualification. Recognizing the contribution of married employees, flexible work shifts, works sharing culture, concession basis treatment offers for parents and children of employees as well, food canteen with discounts and separate hostel provisions are practiced. Coverage of distance of workplace and residence, transport facilities and work time adjustments to long-distance travellers are provided to aged and married employees. The provision of a sufficient amount of parking lots in the hospital premises is arranged. This pragmatic and strategic approach of MHRC greatly influenced its employees.

Relationship of demographic factors with PCVs and with BPCVs practiced at Mission Hospital and Research Centre

Chi square test of independence results a significant association of age (χ² = 494.133, Df = 373, Phi = 1.188, Cramer V = 0.288, p-value < 0.05), marital status (χ² = 47.424, Df = 22, Phi = 0.368, Cramer V = 0.386, p-value < 0.05), residence (χ² = 41.886, Df = 22, Phi = 0.346, Cramer V = 0.346, p-value < 0.05) and working years of experience (χ² = 212.829, Df =198, Phi = 0.780, Cramer V = 0.260, p-value 0.223 > 0.05) with paycheque variables practiced at MHRC. As there is no significant relationship of working years of experience with PCVs practiced, working years of experience are not dependent on PCVs. Chi square test of independence results a significant association of age (χ² = 742.378, Df = 578, Phi = 1.456, Cramer V = 0.353, p-value < 0.05), marital status (χ² = 87.683, Df = 34, Phi = 0.501, Cramer V = 0.501, p-value <0.05), residence (χ² = 59.525, Df = 34, Phi = 0.412, Cramer V = 0.412, p-value < 0.05) and working years of experience (χ² = 413.325, Df = 306, Phi = 1.087, Cramer V = 0.362, p-value < 0.05), with beyond paycheque variables practiced. This shows working years of experience are dependent on the BPCVs practiced at MHRC with large effect size:

R3.

Whether MHRC has any strategic initiatives for employee retention? What are they?

Yes, MHRC has strategic initiatives giving importance to the preference of respondents to BPCVs. The study found out a significant difference between the groups of respondents who got satisfied and preferred to paycheque and beyond paycheque factors.

Difference in preference

Paired sample test statistics results a significant mean variance between the groups got satisfied by PCVs (M = 3.4909, SD = 0.39339, V = 0.155) and BPCVs practiced (M = 3.6951, SD = 0.33934, V = 0.115), creating retention tendency among the work experience groups: M = −0.20429, SD = 0.32308, SE = 0.01727, t (349) = −11.829, p = 0.000 < 0.001, Cohen’s d = 0.63, clinical informatics lower bound = −0.23825 and upper bound = −0.17032 at 95% confidence level. A total of 273 out of 350 sample respondents are working for 6-10 years of experience retained at MHRC (M = 8.53, SD = 1.960, V = 3.843) evidenced the significant variance. This difference evidences the preference of respondents to BPCVs. These respondents are middle aged, married, female trained qualified respondents working for in an average 8.5 years of experience. They encourage retention by looking beyond paycheque elements.

Strategic initiatives of Mission Hospital and Research Centre

These were illustrated by the experts during one-to-one discussions. To giving importance to employee attrition issue, practicing communal recruitment programs:

1. (a) Referrals active – A recruitment program for recruiting the potentially suitable candidates through relatives, friends and neighbours working at MHRC. For the recognition of the contribution of employees and for giving importance to relationship.

2. (b) Thank you board – A feedback mechanism receiving feedback directly from patients or their relatives on service received, placed in the board in their handwritings or drawings and photos; the board will be placed in the visible areas of the floors, near the in-patient wards. For recognizing the contribution of employees and for feedback.

3. (c) Success corner – The success stories of patient treatments and cases will be displayed with the names who consulted the patients, the success stories of hospital and new technology advancements will be placed in the corner.

4. (d) Ad actor camp – Giving chance to the employees who received healthy feedback from patients and from superiors to act in the advertisement of hospital representing technological advancement in medication and treatments. Forgiving importance to leadership and relationship of superiors.

5. (e) Camp head – The experienced employees (executives, managers, nursing heads and ward head secretary) will take part in the role of head, conducting sessions to the subordinate co-workers, and a group of employees including physician, nurses, assistants and executives will involve forming a health camp service to remote villages notably hilly tracks. For getting connected with work and workplace.

6. (e) Facility update – The updated facility requirement requests can be directly placed in the facility update corner – mostly the nurses, ward secretaries, beginners, workers who are posting their requests; this is frequently checked and the needs are immediately fulfilled.

Implications

Considering the results and preference of MHRC respondents regarding beyond paycheque factors, though they have a high level of perceived opinion on some of the factors, they expressed a low-level opinion on some of the factors such as career growth, flexibility in work shifts, feedback for individual growth, training sessions and promotions based on performance. They addressed these to concern with strategic importance. This low level of opinion is resulted because of the issues they face in the workplace environment such as compassion fatigue because of doing works repeatedly, role stress because of overload, treatment of superiors and peers, no proper response to their ideas, opinion related to the medical and functional decision because of lack of recognition and respect. So they may feel disconnected from the workplace. The following should be intensely addressed something beyond paycheque in MHRC.

MHRC employees have shared high opinions on work nature, work practice, work schedule and confidence in their ability for work doing. They do their work routinely and repeatedly, which may make them compassion fatigue – physical, psychological and emotional state of exhaustion and dysfunction, because of compassion stress (Figley, 1995). Many research studies reported health-care workers to face this issue. This a form of burnout faced by care-giving professionals, emergency rescue personnel and mental health professionals (Joinson, 1992). The study of Masango et al. (2008) at the Swaziland health-care sector, found that compassion fatigue and compassion stress greatly influence the intention of employees to leave their organization. Understanding the compassion fatigue of health-care employees – notably nurses, workers and emergency rescue personnel – creating work environment fostering to encourage non-work relationships, self-care activities (Abernathy and Martin (2019), psychological and peer support, maintaining a sense of humour and free interactions with co-workers, would be a significant remedy for compassion fatigue and make them socially connected with workplace.

Moreover, naturally, health-care workers render care services to patients wholeheartedly. They are closely associated with work and organization physically, emotionally and psychologically. They are generally expecting the promises made by management as either financial (incentives, bonuses and advances) or non-financial benefits (treatment, promotions, flexibility in work schedule and so on) to be fulfilled. Masango et al.’s (2008) study at Swaziland health sector on the issue of equality and treatment of employer identified the issue of fulfilling the promises made by management significantly influence the intention of health-care employees to leave the organization. They stressed not fulfilling the promises leads to breaking the psychological contract between employer and employee.

Further, the respondents expressed a low level of opinion on lack of flexibility in working hours, work shifts and sometimes overload. This may be the consequence of handling multiple task activities or work overload in every functional role. This is routinely and repeatedly faced by them. This is significantly influencing the intention of health-care employees to leave. For example, a nurse is playing different roles like a caretaker, counsellor, record keeper and physician assistance. The study of Dasgupta (2015) on the turnover intention of nurses from private hospitals in Kolkata, identified the nurse role stress significantly influences turnover intention. He identified playing multiple roles and multiple functions make them confused and stressful. The study of Hemingway and Smith (1999) showed the stress of nurses because of playing different roles is associated with turnover intention. Baernholdt and Mark (2009) illustrated the reason for workload and role stress leading to nursing turnover is the inadequacy of resources providing to work done. By conducting role analysis (Udai and Rao, 2003) and defining the roles and functional activities for every role of health-care employees will considerably support reducing the workload and support encouraging work-sharing culture among employees.

Finally, being a dedicated and committed workforce, health-care employees generally expect more from the organization for what they contribute. Service workers, notably health-care workers are value creators who are the competitive advantage to the organization. Such value creators whose responses in decision-making related to medical, clinical, emergency service, equipment and technology update and technical advancements should be taken into account and they should be known that their responses are most valuable. This kind of participative decision makes them closely associated with the organization and leads them to feel their contribution most valuable. The study of Jadon and Upadhyay (2018) among nurses illustrated the positive relationship between participative work culture and employee retention. Further, the study of Pillemer (1997) among nurses recommended participative collaborative decisions in medical functional areas. Thus, recognizing participative decisions in medical, clinical and functional areas, focusing to improve work-related proficiency and importance to professionalism would create a great influence on the intention of health-care employees to stay.

Conclusion

Giving importance to paycheque and beyond paycheque factors to create retention tendency among health-care employees, we need to give much more importance to such dedicated and committed workers engaged in life-saving and health-care activities, who are facing everyday work and relationship-related issues such as work–life balance, well-being, treatment of superiors and peers, avoidance, fatigue, role stress, inability and lack of competence. These are something beyond paycheque factors still to be seriously addressed by health-care organizations.

Direction for further research

The study explored paycheque and beyond paycheque employee retention variables practiced in a health-care organization. It depicted the relationship of demographic factors such as age, marital status and distance of workplace with retention tendency. Further study on the relationship of health issues, perceived organizational support, leadership style, supportive work behaviour and nurses’ role stress, with health-care employee retention tendency may be studied.