“What I thought was the dream job was a little different than I had expected”: A qualitative study exploring the turnover of IPS employment specialists
Abstract
BACKGROUND:
Individual Placement and Support (IPS) is an evidence-based vocational rehabilitation program that helps people with severe mental problems to obtain and maintain paid jobs. Turnover of IPS employment specialists is a scarcely studied subject that can undermine the effectiveness and implementation of the intervention.
OBJECTIVE:
This study aimed to explore and describe the experiential factors and processes that shape IPS employment specialists’ decisions to quit.
METHODS:
Braun and Clarke thematic analysis was used to analyze interviews of former IPS employment specialists, who worked during the early implementation phase in Northern Norway.
RESULTS:
A number of negative and positive experiential factors and processes were found to shape IPS employment specialists’ decisions to quit their jobs. A single theme captured our findings ‘The decision to quit for IPS employment specialists is a gradual process consisting of draining factors outweighing nourishing factors’.
CONCLUSION:
To retain IPS employment specialists in the early implementation phase, it is not enough to rely on hiring well-fitting individuals. Instead, prospectively developing interorganizational contexts, timely identifying and addressing work environment problems, while nurturing the strengths of individual workers can be helpful in decreasing turnover rates of IPS employment specialists.
1Introduction
The right to work is recognized as a fundamental human right by the United Nations General Assembly (United Nations, 1948). Nevertheless, a large number of people who suffer from mental health problems are marginalized from the workforce despite often viewing a return to work as a yardstick to their recovery (Dunn et al., 2008; Luciano & Meara, 2014; Waghorn et al., 2012). The Organization for Economic Co-operation and Development (OECD) states the unemployment rate for people who report mental health problems is on average 85% higher compared to those without, while those with severe mental health problems were 83% more likely to live in low-income households (OECD, 2021).
A variety of approaches to enabling people with mental health problems to gain and retain employment have been developed and tested (Elliott & Leung, 2005; Laws, 2011). The Individual Placement and Support (IPS) approach, a recognized evidence-based practice, has repeatedly demonstrated superiority over other vocational rehabilitation approaches in enabling people with mental health problems to gain and retain employment (Brinchmann et al., 2020; de Winter et al., 2022; Frederick & VanderWeele, 2019). IPS is both an individual and team level intervention that is integrated into mental health services. The key to delivery of the intervention is the IPS employment specialist who is integrated into mental health services and engages people with mental health problems who want to go back to work and helps them to achieve this goal (Drake et al., 2012). IPS employment specialists establish contacts within a local job market based on the IPS users preferences, integrate with healthcare and welfare services and continuously work with stakeholders representing these sectors (Kinn et al., 2021; Moen et al., 2021). Once an IPS user secures employment, the employment specialists’ role is to provide on-the-job support. In principle the role does not require a specific professional education or a background, instead, relevant knowledge and skills are developed through on-the-job training and supervision.
As countries around the world have begun national implementation and scale-up of IPS, a variety of barriers that can jeopardize the efforts have been reported in previous research (Bergmark et al., 2018; Moe et al., 2021; Rinaldi et al., 2010). One of these barriers is turnover of IPS employment specialists (Lindstrom, 2016; van Erp et al., 2007; Vukadin et al., 2021).
Turnover can be defined as “the voluntary cessation of membership of an organization by an employee of that organization” (Morrell et al., 2001). It can be classified as avoidable or unavoidable, desirable or undesirable. A variety of individual attributes, aspects of the job, job attitudes, organizational contextual factors and external economic forces have been found to have positive and negative effects on actual turnover and turnover intentions (Kim & Kao, 2014; Rubenstein et al., 2018). By understanding the factors and processes in the context of a particular job, some undesirable turnover can be avoided.
When turnover is high, it has varying negative effects for any human-resourced industry, including healthcare and welfare. A recent scoping review by Pascoe et al. found multiple negative effects on the sustainability of evidence-based programs (EBP). Specifically, staff turnover was found to have negative effects on funding stability, organizational capacity to provide the EBP, professional partnerships, service users’ trust, engagement and progress, and the organization’s capacity for strategic planning (Pascoe et al., 2021). A mixed-methods study investigated the role of staff turnover in the implementation of EBP in mental healthcare (including supported employment) and found that team turnover rates were a negative predictor of program fidelity and service penetration scores (Woltmann et al., 2008). In the literature on turnover of direct-support professionals there are also relevant evidence indicating that turnover is disruptive for people who depend on the service provision as they and their families lose opportunities for recovery “when stable and consistent supports cannot be located” (Pettingell et al., 2022). It is plausible to extrapolate the findings of these studies to IPS programs. We can assume that high turnover of IPS employment specialists causes increased operational costs, loss of organizational knowledge, disruptions in the service delivery and continuity of care, having a negative impact on employment outcomes of people with mental health problems. Despite the potential negative impact of turnover on the implementation of programs, to the best of our knowledge the topic of IPS employment specialist turnover has scarcely been researched.
In our previous quantitative study, we found that turnover rate of IPS employment specialists (45.0%) was statistically significantly higher than the average turnover rate of other occupations in the public sector (27.1%) in the same geographical regions (Butenko et al., 2022a). We also found higher turnover intentions of IPS employment specialists to be associated with lower job satisfaction, work meaningfulness, satisfaction with supervision and current work. In addition, we have previously found that Big 5 personality traits Extraversion and Negative emotionality, and male gender were longitudinally associated with general job satisfaction of IPS employment specialists (Butenko et al., 2022b). These findings warrant further investigation of the job factors and work-related processes that affect job satisfaction and turnover intentions. Additionally, as turnover is typically seen as a process of interaction between factors that inhibit and catalyze it (Morrell et al., 2001), there is a need to explore the positive factors and processes that make IPS employment specialists want to retain their jobs by making the role meaningful and satisfactory. Of special importance, it is to expand the exploration of turnover beyond understanding factors associated with job quitting ideation among still employed by incorporating the perspective on the process of quitting from those who actually quit the job. Such exploration can help in identifying possible vulnerabilities in the design of the occupation, as well as personal and environmental factors that affect the service providers and, as a possible consequence, affect the health state of the employees and quality of the IPS service provision. In order to bridge these knowledge gaps, we conducted a qualitative study that aimed to explore and describe the experiential factors and processes that shape IPS employment specialists’ decisions to quit their jobs.
2Methods
2.1Study design
In this qualitative study the lived experiences of IPS employment specialists who voluntarily quit their jobs were explored using semi-structured in-depth individual interviews. The desire to expand understanding of the turnover phenomenon among IPS employment specialists beyond previously identified quantitative antecedents (Butenko et al., 2022a) has led the authors to the decision to draw upon the conscious subjective experiences of representatives of this occupation after they have quit their job. Collecting data via semi-structured in-depth individual interviews for this purpose provided with a desired degree of flexibility, needed to reassure that study participants would be enabled, but also guided to recall and share relevant experiences (Dicicco-Bloom & Crabtree, 2006). At the same time, such choice of the data collection method aimed to reassure production of a sufficiently rich amount of material for the following analysis (Creswell & Creswell, 2018). In order to be able to holistically approach the heterogeneous body made of various interviews and explore overarching factors and processes that shaped IPS employment specialists’ decisions to quit their jobs, thematic analysis as described by Braun and Clarke (ref) has been chosen. The study followed the standards for reporting qualitative research (SRQR).
2.2Study context
This qualitative study was conducted during 2020– 2022 in the counties of Finnmark, Nordland and Troms in Norway as a part of the IPSNOR project. At the time of the study, IPS employment specialists and the teams they worked in were predominantly established within the public welfare agency ‘Norwegian Labour and Welfare Administration’ (NAV). Several teams were also established in municipal primary healthcare teams and specialist mental health services. As such, some IPS employment specialists had an office and line managers in either NAV or in health, or both. IPS employment specialists were trained by being able to attend a 2-day IPS course delivered in collaboration between NAV and the Health directorate, along with shadowing existing IPS employment specialists to further build their competence and experience.
At the time of the study the total number of IPS employment specialists positions was 45, though the actual number of employees varied due to turnover and recruitment.
2.3Interview guide
A semi-structured interview guide was developed (Appendix 1). The first draft of the interview guide was developed by the first author, then revised and edited with the IPSNOR research team. The development of questions for the interview guide was informed by the team’s expertise in employment specialists’ job, knowledge of the theory on the process and antecedents of turnover and preliminary findings from the previous quantitative research on turnover and job satisfaction of IPS employment specialists (Butenko et al., 2022a; Butenko et al., 2022b). Before the data collection, the interview guide was reviewed by an IPS supervisor, who worked in Northern Norway.
2.4Recruitment and qualitative interviews procedures
As mentioned earlier, this qualitative paper is a result of a sub-study of IPS employment specialists in the IPSNOR project. A total of 40 IPS employment specialists were recruited to the study by signing informed consent forms. From the initial sample, twelve IPS employment specialists were interviewed after they left their jobs.
In the context of the established contact network with IPS sites in Northern Norway, one of the research team members was informed when some of the IPS employment specialists quit their job. They were then contacted by phone to check their willingness to be interviewed and a time and date for an interview was confirmed. All study participants provided informed consent to participate in the study and for the results to be scientifically disseminated. The interviewing process took place in 2020–2022.
On average, a one-to-one phone interview lasted for 40 minutes, during which participants responded to the interview guide questions. Interviewers encouraged participants to provide extensive answers to the questions, and through follow-up questions prompted their reflections and any additional information relevant to the study.
2.5Translation of the interviews
The first author does not speak Norwegian and a decision was made to offer participants the option of being interviewed in Norwegian or English. Nine interviews were conducted in Norwegian and three in English.
To be able to work with the data, the transcribed Norwegian interviews were translated into English by a research team member proficient in both Norwegian and English.
2.6Study participants
Twelve IPS employment specialists who voluntarily quit their job were invited to participate in this study and all accepted. They had been working during the early phase of national roll out of IPS in northern Norway. There were no known cases of involuntary quitting. Two interviews were excluded from the analysis as it was established that the participants did not quit – they were promoted within the service. As such, these two cases did not fit within the definition of turnover and the aim of the study. Ten interviews were included in the analysis.
2.7Analysis
Thematic analysis following the 6 phases was used for identifying and analyzing categories and themes from the initial interview material (Braun & Clarke, 2006). As the authors were not able to obtain license for NVivo qualitative data analysis software, the data analysis was conducted in Microsoft Word and Excel. In the first step of the analysis the first and the second authors familiarized themselves with the transcribed interviews and made a tentative list of initial topics the study participants spoke of. In the second step the first author coded the text in Microsoft Word. After all interviews had been coded, all codes along with quotes were transferred into Microsoft Excel. A decision to use spreadsheets in the latter software was made to be able to easily access, systematize and operationalize the data. In the third and fourth steps, themes and subthemes which united codes were defined and refined in a series of discussions with the research team. In the fifth step the first author conducted a final revision of the themes, finalizing them in clear semantic forms as presented in this article. Once themes and subthemes were established, they were added to a Microsoft Excel spreadsheet that contained quotes and categories. In the sixth step the first author wrote the initial draft of the results section and unfolded the narrative behind the established theme. The draft was then revised in discussion with co-authors. The results section was structured in the following way: a theme is marked in bold italics, subtheme in plain italics, and a narrative supplied with quotes in plain italics.
A number of methodological decisions were made during the analysis as suggested by Braun and Clarke: 1) theme and subthemes were established with consideration of author’s judgments on the prevalence of the investigated phenomenon across the entire dataset; 2) the analysis was conducted to investigate in detail and provide a meticulous account of a particular topic within the dataset, as such not all the collected data was used to establish themes and subthemes; 3) the analysis was predominantly deductive as coding was undertaken to fulfill a specific objective with respect to the findings of the previous phase of the study and general turnover theory. However, there was no pre-made code list for the analysis, instead codes were developed during the analysis, which is more typical of an inductive approach; 4) themes and subthemes were identified based on explicit semantic meaning of participants’ words, without intention to interpret latent meanings; 5) epistemologically, the analysis was undertaken within a pragmatic philosophical paradigm, meaning that the experiences of participants were understood as being both context-specific and context-dependent, a result of subjective interactions with the external reality.
The research team included researchers with extensive expertise in IPS and comprehensive qualitative methodological knowledge and skills, specifically in the theory and application of thematic analysis.
3Results
Of the ten included participants, eight study participants were women and two were men. Their age ranged between 32–58 years. Eight people were employed by NAV, one by a specialist mental health service, one by a municipality primary healthcare team.
The analysis revealed that the majority of IPS employment specialists quit their jobs due to contextual work environment problems. For several, quitting ideation began with a particular incident that we refer to as a ‘shock event’. One person started thinking about quitting due to work-life conflict due to life circumstances, another due to a managerial decision to transition IPS delivery from Healthcare to NAV and two due to having short-term employment contracts. Overall, there was no noticeable difference in the experiences related to the decision to quit by those employed by NAV or health.
One core theme emerged in the analysis: the decision to quit for IPS employment specialists is a gradual process consisting of draining factors outweighing nourishing factors.
This theme covers the following subthemes: a) Draining factors; b) Nourishing factors.
The decision to quit for IPS employment specialists is a gradual process consisting of draining factors outweighing nourishing factors
All participants revealed that the decision to quit their job was a gradual process where draining factors eventually outweighed nourishing factors. For the majority there was no particular starting point that initiated quitting ideation except the few who experienced a ‘shock’ event. For example, one participant shared that: “There were some very challenging situations, yes. But I can’t point out a single situation that made me make the decision”. The majority of participants experienced a gradual loss of motivation that came with a feeling of growing distress, frustration and exhaustion under the pressure of the work environment they could not improve despite continuous efforts: “I believed and was aware that when you get there [into the job] it takes some time to get into a new place and sort everything out. I then spent some time trying to solve it. But it becomes clear when you try, try and try and there is no solution to it. Would call it a gradual process where you just give up a little by little”. In words of other participants: “The process and system overshadowed my enthusiasm and commitment” and “I felt eventually I can’t handle this. It became too hard”.
3.1Draining factors
The semantic label ‘draining’ is applied to describe job factors that were negatively impacting participants’ ability and willingness to occupy the job. The analysis identified a multitude of draining factors that were classified in two categories: unprepared inter-organizational contexts and negative person-context interactions.
Participants experienced the inter-organizational context of the intersection of healthcare and welfare as unprepared for them to carry out their roles. Participants emphasized their sense of betrayed expectancy of there being systems and processes already in place: “There were things that should have been in place long before I was hired” and “Nothing was in place when I started working. I believe the workplace should have been prepared!”.
A participant described there was little knowledge and understanding of IPS, its processes and the overall approach among all stakeholders1 involved on all inter-organizational levels, making the role more demanding and ambiguous. The lack of knowledge and understanding manifested itself across a variety of situations – during the hiring process: “I did not know what I went to, not at all. I thought the job advertisement was unspecific” and whilst carrying out their job duties: “There was little information about how the employment specialist job was supposed to be working”. The managers of participants at times seemed to have limited knowledge of IPS: “I know my manager tried, but they had too little knowledge of IPS. And the other manager in the NAV office had even less”. While some healthcare teams were not informed about the implementation of IPS: “I came to a place where the treatment team did not even know that I was coming”. Another participant shared that: “They [clinicians] were not trained. They did not know what IPS was about. [. . .] It was very tiring to stand alone against an entire treatment team that does not really know what it is about. You are there by yourself, you do not know how to do things yet”.
The participants experienced the healthcare and NAV settings to be rigid in adapting to the services needs and lacking effective communication systems between them. For example, the participants employed by NAV experienced problems with accessing clinical records of IPS users which had implications for risk management processes and procedures: “They [healthcare workers] did this screening for violence and they would put it in the clinical system, and they would forget that I can’t read those documents. So I made arrangements with IPS users without healthcare people knowing. While [healthcare workers] assumed that I’m reading what is in the system . . . I missed a lot of information they assumed I knew”. Another participant reported signs of system-rigidity and centralized power. They experienced having little power in terms of decision making about how the service was organized: “It was very difficult to be heard. I was not involved in any decision-making processes, everything was just decided over my head”. In some cases such power dynamics resulted in IPS employment specialists excluding their managers from decisions: “In the end, I did not take the manager seriously”.
The unprepared inter-organizational context resulted in several negative person-context interactions. These were described as unexpected difficulties of interaction with different stakeholders, role conflict situations, lack of leadership and guidance and professional isolation. Unexpected difficulties in the interaction mainly concerned work with mental healthcare teams. Several participants experienced conceptual disagreements in relation to the place of IPS within healthcare. In particular, some experienced that clinicians and clinical leaders did not see helping people with mental health problems to gain and retain employment as an outcome of interest to healthcare: “[Clinicians] did not understand that now they had to come in and give us lots of support”. Some participants felt that leaders of clinical teams saw IPS and the employment specialists as a burden for their work. Participants also experienced difficulties in interactions with some employers who were not open-minded toward the idea of employing people with mental health problems along with rejecting and dismissive behaviors: “It could sometimes feel that [employers] were dismissive without having talked about or reflected on the potential of people who might have dropped out of working life. That is, that they had a residual resource, or had a strong motivation”. Some participants found it unexpectedly difficult to support IPS users with severe mental health problems, whose mental state fluctuated: “The heaviest part was when some job seekers have rather heavy diagnoses, where things go very up and down in their lives. [. . .] In one moment everything is fine, we arrange a job, everything is in place [. . .] and then it collapses. They do not pick up the phone, they avoid you for 1– 2 weeks, and you are not able to contact them [. . .]. And then I must somehow go crawling back to the employer, explain myself and the situation, and hope the job seeker will get another chance”.
The participants did not have a shared understanding of the structure of IPS leadership. Participants referred, at times with confusion, to different positions within the hierarchies of the organizations – local NAV line managers, responsible for supported employment in general or IPS specifically, IPS method supervisors, and healthcare team leaders. However, the majority of participants experienced a similar absence of supportive and accessible leaders. Some felt that leaders were not available to the degree needed: “It was very difficult and time consuming to reach out to the leader”. Others felt that the IPS service was poorly anchored due to the lack of visible management to drive the implementation forward, resolve ongoing challenges and guide participants: “If there had been a project manager who fought those battles against the systems, instead of the employment specialist, it would have been better. It would have been more anchored”. Participants were disappointed with the lack of follow-up of concerns and challenges voiced during meetings with management: “You have those meetings, and when those meetings are over and that door is closed again, then you know that they [management] do not think about your problems until the next meeting”.
In addition to difficulties with IPS leadership there was a shared feeling of professional isolation. Some participants struggled with being the only employment specialist during the early implementation and lacked professional support: “In such an early phase to only have one employment specialist is crazy, especially it should not be allowed to have just one employment specialist in smaller places. Because you need a strong professional backing. You need team support”. Others, while having colleagues around them, felt uncomfortable being isolated from both NAV and health: “What was bad about the job is that we were very much left to ourselves from the very beginning. We both were new and we were supposed to establish a completely new service”.
Finally, a variety of role conflict situations were reported. There were several experiences of mismatch between expected and scheduled working hours in being available to provide support to IPS users when needed: “We are expected to have an 8-4 job. But we don’t, because we have job seekers, or participants about to start a job. Sometimes they do not have t an 8-4 job or they work weekends. So one feels that one must always be available, to be able to fulfil expectations of what IPS stands for”. Some participants also experienced conflicting information from different stakeholders on access to users’ clinical records: “Method leader says that you can’t read notes, while health team says that you should read notes [. . .]. They say one thing at one place and another thing at the other”. Several participants concluded that they would not have taken the job if they had known about the difficulties they would experience in the job: “If I had known then what I know today, then I would never have taken that job, it’s that simple. Would have said no, this is notfor me”.
The draining factors had a negative personal impact on the wellbeing of participants. Professional isolation, absence of available and supportive leaders, needing to carry out implementation in an unprepared inter-organizational context on top of regular duties caused distress and frustration. Eventually, as their personal resources were drained, some experienced low self-esteem and felt exhausted: “I got very, very tired of that job. Well, what I thought was the dream job was a little different than I had expected”. This negative emotional impact seems to be a mediator between the draining factors and participants’ decisions to quit.
3.2Nourishing factors
The semantic label ‘nourishing’ is applied to describe the personal and job related factors that were positively impacting on participants’ ability and willingness to occupy the job.
Despite little initial knowledge of the IPS method and an ambiguous understanding of the tasks of the job, all participants willingly and readily applied for the position, wanting to explore the role: “When I started, I had never heard of IPS before. I’ve never heard of employment specialists before. And not many of my colleagues had heard either. So there was very little knowledge about it. So when I started, I had to explore what it was”. All participants exhibited a recovery-oriented mindset by talking in unison about their wish to offer IPS users an opportunity to improve their quality of life and achieve more control over it. They wanted to help users to take on new role as contributors and active agents in their lives as opposed to being passive receivers of health and welfare services: “[I appreciate] being allowed to give people a second chance, and a new opportunity to build their life and a future, to become a contributor instead of a recipient”. As participants became familiar with the IPS method, they developed an appreciation of it and a faith in its ideology: “I really liked the method. [. . .] I liked the way one worked with the job seekers. This was shaped by their wishes. It was all about them”. Person-centered, close follow-up and the possibility to work with IPS users outside of the office in the community were features of IPS that participants appreciated.
Over the course of their employment participants experienced a variety of positive person-context interactions that were nourishing their readiness and willingness to continue their work. All appreciated and found the idea of working with IPS users, NAV frontline workers, employers and healthcare workers exciting. However, the actual experiences of interacting with these groups varied – positive experiences in interactions with healthcare workers were mentioned the least. Most often study participants had positive experiences of interacting with IPS users, emphasizing their appreciation of being able to motivate, to help increase self-esteem and encourage IPS users on the way to acquiring a job: “[I liked] discovering their capability, because very many have low self-esteem. To see how their spark ignites, to see what they can accomplish. To look at what they have managed. And make them feel safe with me so they feel like trying and dare to try”. Most of the participants spoke in a positive way about interactions with NAV frontline workers, describing how helpful and available they were in assisting with IPS users’ welfare matters. The participants also revealed positive experiences of meeting employers who were open-minded towards the idea of employing people with mental health problems. Those participants who had positive experiences of working with mental healthcare workers emphasized the crucial role of an interdisciplinary approach to users’ cases: “Interdisciplinarity is absolutely fantastic. I absolutely believe that it is very, very important in order to achieve a comprehensive follow-up of job applicants. The therapists supported us with challenges and we were informed and aware about it, so we could set up the job with consideration to those challenges. Yes, I mean it is very, very, very, very important and very positive when it has worked”.
A few participants had positive experiences of leadership and supervision. Those who were satisfied emphasized the importance of leaders being available, supportive and quick to follow-up: “I thought I had a good collaboration with the supervisors who were at NAV. If there were things that had to be taken care of, I just had to ask and right away it was taken care of. That was really good. I feel that they were very supportive”.
Finally, those participants who were not working alone valued being part of a team. They emphasized the importance of having reliable and supportive colleagues with whom they could have professional discussions about user cases and work environment challenges. Those who had positive experiences of interacting with mental healthcare workers described their appreciation of being taken seriously, professionally and being regarded as colleagues: “I felt incredibly included both as a colleague and professionally. I was allowed to come along to the professional meetings, some of them had nothing to do with IPS. I was allowed to be a professional person with my opinions and ideas”.
Overall, the interviews show that higher job satisfaction was experienced among those who worked in teams, who had clearly defined, supportive and accessible leaders, and who experienced IPS as being established and integrated across the organizations. The process of working with IPS users, teamwork with other IPS employment specialists and welcoming, respectful attitudes of mental healthcare workers were nourishing the participants. Moments of success of IPS users – whether it was a strong motivated decision to find a job, or the actual triumph in getting a job, – were desired rewards for the participants’ work, which had a powerful motivating impact on them: “We often see that [IPS users] fail, but having the pleasure of succeeding, that’s what makes it a really fun job. It’s absolutely amazing. That’s what motivates us”.
Figure 1 visualizes our findings of the gradual process of draining factors outweighing nourishing factors and resulting in negative personal impact.
Fig. 1
The gradual process of draining factors outweighing nourishing over time and resulting in negative personal impact.
4Discussion
The aim of this study was to explore and describe the experiential factors and processes that shape the decisions of IPS employment specialists to quit their jobs. For several participants, quitting ideation began with a particular incident whilst the majority quit their jobs due to work environment problems. All participants experienced quitting ideation as a gradual process characterized by the imbalance between ‘nourishing’ and ‘draining’ factors. Exposure to draining factors appeared to have a negative impact on participants’ wellbeing who reported feelings of distress, frustration, loss of motivation, tiredness and exhaustion. Those participants who had more positive interactions with the work environment, specifically – being part of a team, supportive and available leadership, and respectful welcoming attitudes of healthcare personnel, experienced a less negative personal impact. To comprehensively capture and describe the complexity of participants’ experiences a single theme was established: ‘The decision to quit for IPS employment specialists is a gradual process consisting of draining factors outweighing nourishing factors’.
As far as we are aware this is the first qualitative study to explore IPS employment specialists’ decisions to quit their jobs. We believe the findings of this study are relevant to providers of IPS services where the employment specialists are employed by an organization external to healthcare but need to integrate into healthcare to deliver the intervention (for example, Voluntary, Community and Social Enterprise sector organizations).
Factors revealed in the analysis related to the participants’ decisions to quit correspond with the wider literature on antecedents of turnover: internal motivation, discrepancy between job expectations and reality, role ambiguity, role conflict, teamwork, quality of leadership, organizational support, centralization of power within an industry and job insecurity (Rubenstein et al., 2018). Interestingly, findings of this study correspond with our previous quantitative survey-based findings that satisfaction with salary had little to no impact on the participants’ decision to quit (Butenko et al., 2022a). This finding stands out from the common narrative that wages are key to employee retention (Houseworth et al., 2020; Pettingell et al., 2022). One possible explanation is that IPS employment specialists’ salary in northern Norway at the time was around 526,000 – 573,800 Norwegian kroner per year (Brinchmann B., personal communication, April 14, 2023), while the average income for all households in 2019 was 547,200 NOK (∼53,455 €) (Statbank Norway, November 12, 2022). As such, a transition to another job would be unlikely to result in a significant increase in salary and so motivation to retain or change the job would mainly concern factors related to the fit between character and quality of the work environment and personal preferences.
The experiences of quitting as a gradual process characterized by the imbalance between nourishing and draining job factors correspond with the processual theoretical models of turnover. These models emphasize turnover being a phenomenon that is the result of a deliberate decision-making process (Lee et al., 1999; Mobley et al., 1979; Price, 1986). Broadly speaking, these models describe a decision to quit as a process of a failed balance between a variety of factors, internal and external to the employee contributing to fluctuations in turnover intentions. Within Lee and Mitchell’s ‘unfolding’ model of turnover which emphasizes the multi-pathway nature of voluntary turnover, it argues that some turnover cases start with a ‘shock’ – an event that initiates quitting ideation (Lee et al., 1999). Similarly, we found for some participants in our study, turnover ideation started with a shock event (e.g. work-lifeconflict).
It was previously shown that general job satisfaction and its facets are associated with turnover intentions of IPS employment specialists (Butenko et al., 2022a). However, it was not clear which work environment factors are important to job satisfaction. The present study addresses this knowledge gap by revealing factors, which tap into established antecedents of job satisfaction – subjective perceptions of job characteristics, role clarity, role conflict, job insecurity, perceived supervisor support and leadership (Judge et al., 2020).
It is interesting to note that some of the draining factors described in this study have been previously reported as barriers to IPS implementation. Research from Sweden, Norway and England identify similar barriers of unprepared inter-organizational environments, a lack of managerial and leadership support, poor communication between welfare and healthcare agencies and sometimes conflicting workplace policies and procedures (Bergmark et al., 2018; Hillborg et al., 2021; Moe et al., 2021; Rinaldi et al., 2010). To date, these barriers have not been linked to the turnover of IPS employment specialists.
This study was undertaken during the early period of IPS implementation. It is recognized that for an effective new intervention to deliver and sustain the outcomes as expected, it requires effective implementation strategies and drivers (competence, organizational and leadership) resulting in organizations changing their existing systems to support the effectiveness of the new intervention (Bertram et al., 2015). This study reveals that those IPS employment specialists who quit their jobs experienced work environment problems related to organizational and leadership drivers and implementation readiness. For example, the experienced conflicting policies, procedures and legislation, and poor communication networks for inter-sectoral working between NAV and health indicate a lack of organizational drivers. While insufficient knowledge and understanding of IPS among frontline healthcare personnel, and also leaders in health and NAV indicate a lack of leadership drivers and readiness for implementation. Though it was encouraging to find that interactions with frontline NAV workers was a positive experience, which aligns with previous research showing from the perspective of the frontline workers similar experiences (Brinchmann et al., 2022). All together our findings suggest that both NAV and health may not have been sufficiently ready or prepared for the implementation of IPS and that systems, processes and the drivers for effective inter-organizational working had either not been established or were not changed to support the implementationof IPS.
4.1Practical implications
This study shows there is both a possibility and a need for IPS managers and leaders to address work environment problems that IPS employment specialists’ experience. This could increase job retention of IPS employment specialists, ensure the operational continuity of an IPS service and ultimately increase the number of people accessing the service and achieving their goal of returning back to work. Our analysis also revealed the nourishing factors of being an IPS employment specialist that seem important for managers to recognize and encourage: intrinsic motivation, resilience and a recovery-oriented mindset.
Additionally, in light of the findings it is apparent that during the recruitment of IPS employment specialists candidates should be extensively informed about the job’s tasks, goals, work setting, and challenges that should be expected during an implementation phase. Such efforts will set reasonable expectations for the role and enable candidates to have an informed understanding of the role. The establishment of IPS teams with more than one employment specialist along with a supervisor who leads the implementation and integration within healthcare services might also have had a positive effect on retaining IPS employment specialists.
Furthermore, our findings concerning poor inter-organizational readiness and communication highlight the need for tailored actions aimed at enhancing communication and collaboration among the relevant organizations. These improvements should extend to having a clear operational policy which defines responsibilities, accountabilities, governance and decision-making, and leadership. Besides, additional initiatives are required to enhance awareness among local mental healthcare providers regarding the goals, principles and implementation efforts of IPS. This is essential to expedite the integration of services necessary for the efficient operation of IPS employment specialists.
Finally, research shows there is a clear association between poor work environment conditions and the impact on the health and wellbeing of staff (Harvey et al., 2017). It was concerning to find participants describing the lasting negative impact of their former work environment on their emotional state. As such, further research that addresses the negative impact of the work environment on the wellbeing of IPS employment specialists with a specific focus on burnout is warranted.
4.2Future perspectives
While this study has contributed to laying the groundwork for understanding the turnover of IPS employment specialists during the implementation phase of the evidence-based practice in Norway, there are multiple knowledge lacunas left that need to be addressed. In particular, future research should examine turnover experiences among IPS employment specialists in different countries and at various stages of IPS operation. Additionally, research should explore factors contributing to a pleasant and functional working environment, as well as investigate and measure the repercussions of turnover on key service outcomes, implementation quality, and sustainability on different structural levels (e.g. IPS site). Finally, we assume that the process of deciding to quit is not a straightforward cascade of events, but rather it is akin our visual metaphor presented in the Fig. 1 – a process where different factors are weighed over time until a critical point is reached, and the choice is made, with some or perhaps even the majority of the deliberation stages being unconscious. This hypothetical model also requires further empirical investigation as acquired knowledge can be helpful for designing effective retention interventions.
4.3Strengths and limitations
The present study has a number of strengths and limitations. Instead of studying turnover by relying on a proxy (i.e. quitting ideation), this study interviewed people who actually quit their jobs. As such, our analysis revealed work environment problems that were directly related to IPS employment specialists’ decisions to quit – findings that could be used to improve the work environment and subsequently reduce turnover rates. The methodological choice allowed us to produce an experiential holistic composition of factors that were found to have draining and nourishing effects on IPS employment specialists’ capacity and willingness to occupy the job, instead of handpicking factors that we would hypothesize to be relevant. The first limitation of our study is the modest number of study participants. However, after 8 interviews saturation was achieved with only a few substantially new codes were established in the remaining two interviews. This assured authors that a sufficient amount of primary data was collected. The study was also conducted during the timeframe of Covid-19 where we know that IPS employment specialists reported less collaborative engagement with clinical teams and employers (Wittlund et al., 2022). However, we do not believe this directly impacted on turnover ideation in our sample as none of the participants spoke of Covid-19 or its impact.
It is also important to note that the study was conducted within an implementation setting in Northern Norway. As such, generalization of findings to other stages of the IPS operation in different geographic areas should be approached with caution.
Another matter worth emphasizing is that the findings have been shaped by the decision to be predominantly deductive (i.e., theory-driven) in the development of the interview guide and data analysis. In particular, our work has been driven by understanding turnover from the ‘psychological school’ perspective as a consequence of an individual subjective decision, shaped by the dynamic process of interaction between catalyst and inhibitor factors (Morrell et al., 2001).
Finally, the interviews had to be translated from Norwegian to English for authors to be able to conduct the analysis. However, as the aim of the study concerned subjective conscious lived experiences, and not linguistic features or unconscious content that would be expected to be hidden behind and in-between the lines, we do not believe that translation decreased the quality of the analysis. Additionally, in order to minimize the possibility of content loss, translation was carried out by a native English speaker, fluent in Norwegian.
5Conclusion
This study revealed that the imbalance between factors that drain and nourish the wish of IPS employment specialists to stay in their role gradually caused the majority to quit. As these factors mainly concern the work environment, corresponding improvements could be made by the IPS leadership with a goal of preventing future undesired turnover.
Acknowledgments
We express our gratitude to the IPS employment specialists who agreed to participate in the present study. We are also most grateful to Unni Kolstad for helping with communications and to Line Rasmussen for conducting some of the interviews.
Ethics statement
This study received ethics approval from The Regional Committee for Medical and Health Research Ethics Region North, Norway (#123711). A data protection officer from Nordland Hospital HF approved the GDPR application for the study (case number 2019/5454).
Conflict of interest
There are no financial or non-financial competing interests from the authors of this article.
Funding
The study is funded by research grants from the Research Council of Norway (#273665 and #280589).
Informed consent
All study participants provided informed consent to participate in the study and for the results to be scientifically disseminated.
Availability of data and materials
Data is not available due to the GDPR regulations and conditions of ethics approval.
Author contributions
DB: Design, Interview guide development, Data collection, Analysis, Writing – original draft, Writing – review & editing. MR: Design, Interview guide development, Analysis, Writing – review & editing. CF: Design, Writing – review & editing, Supervision. BB: Funding acquisition, Data collection, Writing – review & editing. SW: translation of interviews. EK: Design, Writing – review & editing. MB: Design, Writing – review & editing, Supervision. AM: Funding acquisition, Design, Interview guide development, PI of the project.
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Notes
1 ‘Stakeholders’ refers to staff in NAV and healthcare sector, who interact with IPS.
