Introduction
The average age of British National Health Service (NHS) employees currently stands at 43, and is rising year on year (Weyman, Meadows and Buckingham Reference Weyman, Meadows and Buckingham2013). This profile, combined with the recent alignment of public-sector and state pension age (Hutton Reference Hutton2011), has led to concerns about how an older workforce will cope with the high physiological and psychological demands of their jobs in the NHS and how this might impact upon staff and patient safety, productivity and service standards (Griffiths and Long Reference Griffiths and Long2013). Such concerns are justified, given that prolonged exposure to job stress has already been found to be associated with increased heart disease in the general working population, and particularly on older workers (Nuñez Reference Nuñez2010). Allied health-care professionals such as physiotherapists, paramedics and occupational therapists who make up 12 per cent of the NHS workforce, and like nurses and doctors, face the prospect of working well beyond 60 if they wish to avoid losing a sizeable percentage of their occupational pension (Weyman, Meadows and Buckingham Reference Weyman, Meadows and Buckingham2013). Saying that, while all health-care professions face occupational risks such as work-related injuries, high psychological demands and working night shifts, some of these risks can in theory be mitigated by experience and expertise (Nicholson et al. Reference Nicholson, Mayho, Robson and Sharp2016).
A more speculative issue, however, is whether the structural change to pensions will push the average age of an NHS employee notably higher, or whether the current trend of large numbers ‘voluntarily’ exiting NHS employment in their early to mid-fifties will persist (Weyman, Meadows and Buckingham Reference Weyman, Meadows and Buckingham2013). Should the current trend continue, it is foreseeable that the British NHS will experience significant staff shortages within a decade (Weyman, Meadows and Buckingham Reference Weyman, Meadows and Buckingham2013). Moreover, the associated loss of skill and return on training investment is in tension with public policy objectives surrounding economies within the health sector, and British government policy objectives aimed at extending working life (EWL) (Department for Work and Pensions 2014).
While it is generally recognised that as we age there may be a slowing down in some areas of cognitive performance such as the speed at which new information is processed and storage retrieval (memory), the application of the significant amount of acquired knowledge and wisdom through years of practice and complex problem solving remains unaffected (Bohle, Pitts and Quinlan Reference Bohle, Pitts and Quinlan2010; Ilmarinen Reference Ilmarinen2001; Redfern and Gallagher 2013). The evidence is that for the majority of individuals under 70 years (and many aged over 70 years), cognitive deficits are negligible. Research has also shown that a number of protective factors exist which can in fact promote cognitive vitality as we age; lifelong learning being one of them (Fillit et al. Reference Fillit, Butler, O'Connell, Albert, Birren, Cotman, Greenough, Gold, Kramer, Kuller, Perls, Sahagan and Tully2002). Cognitive decline is therefore by no means an inevitability. Beyond musculoskeletal injury, background activity rates, lifestyle choice effects and general health status, empirical findings show limited impact on peak strength up to the age of 70 years (Bohle, Pitts and Quinlan Reference Bohle, Pitts and Quinlan2010; Ilmarinen Reference Ilmarinen2001).
However, this evidence does little to diminish the outlook amongst employers influenced by societal beliefs that mental and physiological decline, growing inflexibility and a reduced interest in learning new things are defining characteristics of ageing (Vasconcelos Reference Vasconcelos2013). What is needed is an informed and unprejudiced understanding of any challenges and constraints that come with ageing and a deeper insight into health-care professionals’ beliefs about their own ageing.
Beliefs are important because one's beliefs and attitudes around personal physical decline are relevant to the construction of an ageing self (Westerhof, Whitbourne and Freeman Reference Westerhof, Whitbourne and Freeman2012) and known to influence retirement decisions (Kooij et al. Reference Kooij, de Lange, Jansen and Dikkers2007). The literature when reviewed, however, only yields a few studies that address the perceptions of personal ageing in health-care professionals. Those which exist, such as the study by Draper et al. (Reference Draper, Gething, Fethney and Winfield1999), found that psychiatrists who reported good health also held more positive attitudes about self-ageing. Other research that investigated the attitudes of health-care staff towards older patients found that self-ageing beliefs influenced such attitudes. Liu, Norman and While (Reference Liu, Norman and While2015), for example, surveyed attitudes of British nurses towards elderly patients and found that when the nurses felt less anxiety about their personal ageing, they tended to hold more positive attitudes towards their older patients. Similar findings have been reported elsewhere (e.g. Gething et al. Reference Gething, Fethney, McKee, Goff, Churchward and Matthews2002).
Little is known about physiotherapist professionals’ perceptions of their own health as they age and how this impacts on decisions around work. Because of this, the emphasis of this paper is on the portrayal of physiotherapists’ beliefs about the physical and psychological challenges they may face with ageing, and importantly the interplay of psycho-social variables and organisational factors as they relate to working in the British NHS. The current literature lacks motivation theories to address specific issues around ageing and work motivation (Stajkovic Reference Stajkovic2006). Therefore, if we are to further understand and characterise health-care employee beliefs surrounding capacity in later working life, physiotherapists are a particularly interesting group to study as they are professionals who maintain mobility and are knowledgeable experts in body mechanics, injury prevention and management (Adams, Peters and Chipchase Reference Adams, Peters and Chipchase2013). Given their central orientations around maintaining physical capacity, thoughts around personal vulnerability to the effects of ageing could be intensified due to physiotherapists’ high exposure to evidence of the consequences of injury and incapacity (in others). Conversely, they are also perhaps one professional group in which stereotypical beliefs about older workers (inevitable physical decline) might be expected to be least prevalent. Some supporting evidence that this may be the case has emerged from a study of clinical health-care educators (which included physiotherapists) which found that it was the physiotherapists in the sample who had the most positive attitudes towards older patients (Mandy, Lucas and Hodgson Reference Mandy, Lucas and Hodgson2007). Also, when assessing the attitudes of allied health professionals with each other, Giles et al. (Reference Giles, Paterson, Butler and Stewart2002) discovered that compared to podiatrists and occupational therapists, physiotherapists held more positive attitudes towards ageing.
There is also some pertinent recent research relevant to physiotherapists which comes from a study of Swedish health-care professionals (N = 1,756) aged 55–64, of whom 120 were physiotherapists. The researchers found that subjective self-rated health had more leverage than diagnosed disease when it came to decisions about retiring from the health-care profession (Nilsson, Hydbom and Rylander Reference Nilsson, Hydbom and Rylander2016). Feeling tired with little time for recovery, not feeling valued as an older member of staff and a lack of job satisfaction were important contributing factors to these subjective health ratings.
This current study adds to research which is starting to address the gaps in knowledge around self-ageing in health-care professionals and is also seen as an opportunity to explore how NHS organisations are currently placed to support an ageing workforce. The functions performed by a line manager are of particular interest, as this role has increased in terms of devolved human resources responsibilities, and yet the degree of backing and support offered by senior management to interpret and implement policy is often found lacking (Hutchinson and Purcell Reference Hutchinson and Purcell2010).
Overview of the study
The aim is to explore the narratives on ageing and capability to work from four focus groups with a sample (N = 43) of practising physiotherapists employed by the British NHS. Principally, to provide an opportunity to explore their beliefs about working in later life; the profile of older workers within physiotherapy; how EWL is understood and being thought about by this NHS professional group, and to identify management action that may be needed to support an ageing workforce.
Method
Data collection and participants
A qualitative focus group design was used, which is defined as interviews that aim to collect data ‘through group interaction on a topic determined by the researcher’ (Morgan Reference Morgan1996: 130). Group discussions were considered particularly suitable to meet our research aims as they reflect the norms, values and culture in groups (Dahlgren, Emmelin and Winkvist Reference Dahlgren, Emmelin and Winkvist2004). Focus groups are also well suited to exploring shared expertise, and can provide a rich and detailed insight into the complexities of health-care workers’ understandings and perceptions of the topic of interest. Group discussion data were also preferred to quantitative measures, because surveys may fail to capture the full complexity of the subject; whereas a probing qualitative approach would allow us to access proper contextual insights at the necessary level of detail, given the approach was exploratory. The sample was comprised of groups of Chartered Physiotherapists (N = 26) and physiotherapy managers in London (N = 17). There were two females and one male under the age of 30, seven men and nine women between 31 and 40, 11 females and two males between 41 and 50, and ten females and two males aged 50 + . The majority of participants were therefore women and aged between 31 and 50. NVivo was used to code and structure the data. Full ethical approval was obtained for the study.
Analysis
The researchers used a qualitative method of enquiry (Crouch and McKenzie Reference Crouch and McKenzie2006) and a thematic analysis was used to code the transcripts, a method suitable because it does not dictate a particular theoretical outlook. The analysis was undertaken by DR and AW, a process described as follows. One of the researchers (DR) listened to the tapes and read the transcripts; described as the process of emersion (Braun and Clarke Reference Braun and Clarke2006). The transcripts were then analysed line by line. The next phase was to identify chunks of data containing phrases set in context, and reach agreement on an initial set of pre-codes and independent ideas on how these pre-codes clustered. The codes and themes were amended, by all the researchers, in an iterative manner as new/anomalous material was encountered.
Findings
The researchers considered themselves to be educated outsiders in that they are not physiotherapists or health-care professionals, but social psychologists and social scientists. The approach taken was interpretative, as views expressed were from an experientially informed perspective. The findings uncovered some important beliefs about what it may be like to work in current job roles as an older person, and also influential organisational factors in the context of the British NHS. Central themes identified include: worry – over physical capability, and ability to cope; the need to maintain a professional image; work, retirement and exit norms; beliefs about ageing; extrinsic job demands; organisational support – line management; and organisational support – career progression. When asked about the prospect of working longer, discourses were dominated by pessimist beliefs around personal vulnerability to injury and incapacity.
Theme 1: Worry – over physical capability, and ability to cope
Respondents often portrayed themselves today as just managing to meet their job demands, and one female respondent in her forties feared further diminished physical capability in her later working life:
This is the contract that I came into in the NHS, working until I am 60, doing this job. Absolutely no way I would have chosen to work with children because I just can't foresee myself being able to do it. I can go dizzy now, as I have got a bit of postural hypertension. I get that now, let alone as I'm getting older.
Certain specialties were identified as being particularly physically demanding, such as working with children, in rehabilitation and in neuro-rehabilitation wards. Also middle-aged physiotherapists who had been practising for a number of years reported pain and discomfort in their hands and thumbs and expressed concern that ageing will inevitably bring further long-term conditions such as arthritis.
But I think one of the concerns as well is that, especially with long-term conditions and physios having, say, rheumatoid arthritis or one of these kind of long-term things, is that when you are actually using your hands, and I've just seen it in the MSK service myself, is that people actually find that they're not actually able, you know, the thumbs have gone and they're not able to do this … I see people in their early forties who are actually leaving, changing what they're doing because they're not able to do it at the age of 40, so what are they going to be like at 60?
There were frequent accounts of experiencing musculoskeletal disorder (MSD) symptoms, caused by not only the intrinsically physical nature of the respondents’ work, but also the broader elements of job demands – views which are consistent with what has been reported elsewhere (e.g. Glover et al. Reference Glover, McGregor, Sullivan and Hague2005). MSD injury to physiotherapists can arise from their prolonged exposure to patient treatment and handling, notably with regard to injuries to backs, hands and wrists, and MSDs and official statistics from both national and international studies support this (Bork et al. Reference Bork, Cook, Rosecrance and Engelhardt1996; Darragh, Campo and Olson Reference Darragh, Campo and Olson2009; Glover et al. Reference Glover, McGregor, Sullivan and Hague2005; McMahon, Stiller and Trott Reference McMahon, Stiller and Trott2006).
I am an out-patient physio and my thumbs are shot already, somebody who works in neuro, their back is probably shot. But pretty much every area of physio has some sort of stress, emotional, muscular, skeletal, level of erode, I can't see people being able to sustain through their sixties let alone to 68.
Also, physiological stresses such as repetitive strain are a product of exposure and hence tend to be a particular correlate of age, with the potential to aggravate old injuries. Despite this, there was also a strong commitment to patient care.
So we've had some recent examples of, I'm thinking of three members of staff in the last year, one in their sixties and two in their fifties, who have taken on a different role. So they've been able, within their specialism, to take on a different role which is less physical.
What we have noticed a lot where we work is that those members of staff now who are retiring at 55 or 60 who are supported to come back into a working pattern that fits their physical needs are more likely to be able to work longer and chose to work longer. Because as [colleague] says, the physios are very very committed to their patient group and a lot of them have dedicated their whole lives to getting to that clinical expertise of where they are and they don't want to just leave work.
Theme 2: Work, retirement and exit norms
A marked finding was that respondents were only able to identify a handful of co-workers over the age of 60.
I think once you get to 63 there aren't many physios doing clinical work, it drops to about zero at 63.
Statistically physios don't work into their sixties and certainly in certain areas of physio, the demands of the job are going to be quite, potentially very difficult to carry on doing.
This likely reflects already-established pension and retirement arrangements, and indicates how the presence of older physiotherapists within the NHS is weakly normed. Professionals’ behaviour often relies upon norms as their professional identity develops (Haslam et al. Reference Haslam, Jetten, Postmes and Haslam2009) and ageing beyond 55 is a life event which three-quarters of our focus group attendees simply had yet to experience. Older workers discussed were in poor physical health, which seemed to do little to diminish the widely expressed worry in the respondents that their older self will suffer inevitable physiological decline:
I have two members of staff in my team that are 61 and 62, one female, one male, and both have to, they are continuing working for financial reasons, one has chronic back pain problems and one has really bad arthritic knees that probably need a replacement in the next year or so. And one of them, the one with the knee problem, has to take anti-inflammatory on a daily basis or else they cannot do their job.
Any anticipated personal physical and psychological deterioration for those without injuries could possibly be reliant upon impressions formed by the only examples they could readily think of:
And I work with a member of staff who's the same banding as me who's in her mid- to late sixties, and she's got an awful back. Her posture is awful, she's scoliotic, she's kyphotic, and she jokes. She said ‘oh what must these patients think coming to see me who can't stand up properly and they're coming to see me about their backs!’ And I think, that's a true point.
Even the younger members of the focus groups who had yet to experience injury expressed concern, and discourses were dominated by beliefs that physiological challenges experienced in their existing work environment would reduce their capability in later working life for some of them:
If you look at the workforce we're predominantly all in our thirties at the minute so, if we are staying where we are, there's going to be a bunch of us who are going probably not going to be able physically to do all aspects of our job.
Theme 3: The need to maintain a professional image
Little is understood about the professional socialisation and development of the physiotherapist's identity. Some insights can be drawn from research conducted by Cromie, Robertson and Best (Reference Cromie, Robertson and Best2002), who reported that physiotherapy has a distinct professional culture of learned values such as working hard and maintaining high standards of morality and codes of practice, but these values are often implicit, and therefore hard to tap into (Cant and Higgs, cited in Cromie, Robertson and Best Reference Cromie, Robertson and Best2002). One of the strengths of using qualitative focus groups was that it allowed for the themes to emerge through the interactions, and the topic of image was mentioned spontaneously during the discussions, along with the pressure on the younger generation coming into the profession which was particularly salient.
In terms of identity, by nature, we are a profession that wants to do a good job as well as we can, which means working that little bit extra, that is part of the nature of the beast really.
Students coming into the physiotherapy profession – we have quite a number who have eating disorders as they are coming into the profession and are faced with an image of physiotherapy about being fit and healthy and skinny – and that is how they must be.
We probably are generally healthier than most of the population, but then equally when you are, if you're working in musculoskeletal, and you get a young person coming in with a sports injury and you're being treated by a 67-year-old lady who is telling them how to do plyometrics, it sort of doesn't really bode terribly well. So there's a whole kind of role modelling kind of issue.
Yes, there's an image isn't there, but it's also how effective are you actually going to be as a health coach if you are totally overweight, you know, you're totally different to this person that you're trying to engender with a better quality of life.
This perception of a need to maintain a certain image may be intensified by public perceptions that physiotherapists should be young and fit:
And what do you do with the parent who complained to me because the therapist was old and grey and he wanted a young one to come and see his child?
This last quote suggests that public perceptions that physiotherapists should be young is something which may only exacerbate growing pressure on the older physiotherapists to maintain the very high level of personal fitness and professional standards they expect from themselves. Support for this argument comes from the following quote which alludes to people leaving because of such beliefs:
You don't tend to see significantly older physio's practising, there is a natural drop-off, some of that is some people have protected retirement. But people in general as physios love their job and they are not usually running to the door because they have got protected retirement, there is a natural point where people just realise they can't do the job as well.
In a discussion about health-promotion initiatives it also emerged that physiotherapists did not prioritise such initiatives for themselves, and in fact set themselves apart somewhat from other health-care staff with less physical roles:
We do not have time to engage in them, it is time – physios do not take up many of the initiatives because they are in a manual role anyway, or they are naturally fit and healthy people doing other things outside, and so I think your workplace health initiatives are more for the sedentary type.
This quote indicates that a set of beliefs exist in the physiotherapy profession where they think of themselves as being more naturally fit compared to other health-care workers, but yet when asked to project themselves into the future to when they were older, they saw themselves as not keeping up the pace and lacked confidence in their ability to be able to cope with the physical demands of the job. Added to this was the lack of availability of older role models for physiotherapists, because traditionally physiotherapists have changed roles or left the profession by the time they reach 60.
Theme 4: Beliefs about ageing
There appeared to be a lack of confidence about healthy ageing generally, tinged with a sense of realism from the respondents in their forties and fifties, and belief that it is inevitable that some workers will succumb to diseases associated with old age such as diabetes and heart conditions.
Physiologically people change as they get older and there is a huge change from 50 to 60, and I would imagine it's really quite difficult for people to do full-time physical work at that point, at the same level.
There is a need for investment to allow our staff that are working longer to remain healthy as we may be more likely to get diabetes, blood pressure problems.
People live longer, but you need to live longer in good health in order to be able to be active in the workplace or actively retired. So that's the stress isn't it, whether or not you are going to grow old with good health, and there is no guarantee of that.
There was therefore a certain understanding that with ageing comes some inevitable physical decline, and one senior therapist, who was 55 years old and whose professional life had revolved around elderly patients, explained that she was using her professional know-how to try to mitigate future problems she associated with growing older and highlighted that physiotherapists are in a perfect position to contribute to guidelines that could support older workers:
I am using my career and my lifetime experience – stopping myself get elderly because my arches are dropping and things like that. I've had a lifetime of seeing people's posture change working in elderly care, I try to avoid all the things I have seen, like people walking badly and make sure I mobilise my spine. So in terms of prevention, physio will be fantastic people keeping people healthier for longer.
Theme 5: Extrinsic job demands
In addition to worries about the intrinsic risks posed by the physical nature of their work, respondents accounts also consistently contained concerns about overlapping extrinsic demands, such as time pressure in a context of demanding (patient through-put) performance targets:
The actual case load has changed as well, because if you look at, if you are hospital based or working in in-patients, then length of stay has been reduced, so you are trying to do something in a very compressed timescale.
I think it's time. I think if you actually went round this table and said how many people actually take half an hour or whatever we're supposed to have for lunch, you would end up with very, very few people.
Time pressure, in all its manifestations, is not only a widely recognised cause of psychological stress and MSDs (Coggon et al. Reference Coggon, Vargas Prada, Martinez, Serra, Benavides and Palmer2013), it is also related to safety considerations being sacrificed, including safe patient-handling practices (Menzel et al. Reference Menzel, Brooks, Bernard and Nelson2004):
There is very much a culture, when I see staff who come through the outpatient department you're telling them that they've got to use correct manual handling techniques, and they're always saying yes, but the culture is that you don't do that, because you haven't got time, because then you're not able to give proper care to patients because you're just not quick enough. And so I think unless that culture really changes, where staff are allowed to take care of themselves properly, then that just adds to the problem really.
An important age-related issue relevant to these reported high work rates is that, while it is accepted that peak strength decrements up to 70 years tend to be modest amongst fit and healthy individuals, older workers nevertheless tend to need longer recovery times (Costa and Di Milia Reference Costa and Di Milia2008; Costa and Sartori Reference Costa and Sartori2007; Crawford et al. Reference Crawford, Shafrir, Graveling, Dixon and Cowie2009; Griffiths Reference Griffiths2000; Saksvik et al. Reference Saksvik, Bjorvatn, Hetland, Sandal and Pallesen2011; Yeomans Reference Yeomans2011) and would benefit from lower exposure to high work rates, and assessment of risks such as significant physiological demands (Australian Public Safety Commission 2010; National Programme on Ageing Workers 2002; Walker and Taylor Reference Walker and Taylor1998). Also, shortages in resources were described as encouraging an audit-oriented approach, which restricts employee autonomy (that could allow them to adapt their job to manage any aches and pains) – a widely recognised organisational phenomenon (Power Reference Power2004; Webb Reference Webb2006):
Because there's so many things where it changes, you have to do them and you are micro-managed, so there's less and less ability to choose how you do the job.
Sentiments indicated low confidence that employers will make allowances for age-related reductions in capacity to work, suggesting instead there will be an increased emphasis on capacity to work assessment, which will be used as a mechanism for exiting those who cannot meet defined performance levels:
HR [Human Resources] are going to use capability to get rid of people who have got a massive wealth of knowledge and skills, but because they can't do 10 or 20 per cent of their job, they theoretically can argue you are no longer fulfilling the role that we employed you for.
The overall impression was therefore that of a professional group who are very worried about physiological capability when imagining themselves as an older worker, in the context of an inflexible and unchanging context of high job demands, compounded by low confidence in employer support. Discourses also indicated that coping with certain job demands (such as the increase in use of technology) was an issue potentially due to generational differences in skill base (see Bohle, Pitts and Quinlan Reference Bohle, Pitts and Quinlan2010; Ilmarinen Reference Ilmarinen2001). Widespread claims were encountered that this significant source of stress being experienced by current older physiotherapists is generalising to other older health professionals within the NHS.
We are the first NHS organisation to introduce a totally electronic patient record system. And it has had a very different impact, I was waking up at night stressing about this because I have been so apprehensive because I don't have those computer keyboard skills like [colleague] will have.
I know people who have retired to avoid going through that, they are so scared about learning a skill that they don't think they have to.
Respondents portrayed a world in which decisions by older physiotherapists to leave physiotherapy are influenced by anxieties around the technology and the threat of failure in meeting high professional standards.
Physios love their job, but they are not usually running to the door because they have got protected retirement; there is a natural point where people just realise they can't do the job as well.
Theme 6a: Organisational factors – line management
Respondents described ongoing shortages in resources which is creating a climate of increased scrutiny of staff absence and an increasingly formalised approach to human resources management. These shifts in climate are limiting the autonomy of line managers to utilise options which could support older (and other) employees. Respondents reported higher satisfaction with their line managers when they took steps to support them and help alleviate stressful aspects of their job,
My direct line manager I have to say is, you know, that works fine. They are a physio where I work and that all, you know, she's in the same situation … And actually I would have to say in my workplace she's put forward a lot of things to try and actually mitigate some of the psychological side of things, giving a bit more support.
and had the freedom to handle absences informally:
I work in the [name of organisation] and our sickness policy is probably slightly better and it allows our managers discretion. So if a physio is off sick for flu or diarrhoea and vomiting and then they have another short period of absence and it triggers the HR process, the manager can say no, we don't need to call an HR meeting … because as their manager, I have no concerns.
Tensions between operational performance objectives and staff health needs, and the pressures of balancing safety and wellbeing, are felt most acutely by intermediate managerial grades (Cox and Flin Reference Cox and Flin1998; DeJoy Reference DeJoy1994); a function often seen as a pinch point for a range of decisions (Kinder Reference Kinder, Ball and Osborne2013). This seems to be where older employee health and wellbeing considerations are being frequently missed, misunderstood or simply traded off against more pressing operational objectives. The positive correlation between age and days lost (Weyman, Meadows and Buckingham Reference Weyman, Meadows and Buckingham2013) indicates that older workers are at higher risk of encountering formal sickness absence procedures (Crawford et al. Reference Crawford, Shafrir, Graveling, Dixon and Cowie2009). Fatalistic feelings which were expressed indicated that it was almost inevitable that older physiotherapists will leave before their pension age because of poor health, or they will leave of their own accord feeling no longer able to live up to the image of the hard-working, physically fit physiotherapist. These worries were compounded by limited confidence that these issues were not recognised or likely to be addressed by employers:
There doesn't seem to be a recognition that their practice as an employer will have to change to accommodate the ageing workforce. Because if we are expected to keep an older workforce engaged and motivated and committed, then you have to positively promote an environment that supports that.
This raises the question of what will happen to those who want to keep working, but may not be able to maintain the pace of work and working conditions, and what scope will exist for them to make later career transitions.
Theme 6b: Organisational factors – career progression
A ubiquitous topic, interwoven through much of the discussions, was the option of redeployment later in the NHS physiotherapist's working life. Discourses around career development opportunities for older NHS physiotherapists contained claims of opportunities to move into more senior roles diminishing, which may not bode well for the EWL agenda:
Redeployment is an option, but what do you redeploy if there are not jobs for you? When you are a very specialised clinical physio at, say, a band 8 to be redeployed – where are they going to redeploy you? I don't think it matters what profession you are, if there is not a job out there for you to go into – bye bye.
Again, there was little confidence in the availability of support at an organisational level, which reiterated the claim that line managers carry a high proportion of the burden for finding redeployment opportunities:
You talk about redeployment and it ends up being the manager's responsibility and I mean how do you know what other jobs are in this very, very large health-care organisation, and there are thousands of jobs. So there's a certain amount of pass the buck.
Perspectives on opportunities to re-train tended to be based on beliefs that they are diminishing rather than broadening because of the pressures on British NHS health-care providers to make cost savings.
Discussion
The aim of this qualitative study was to understand how a group of physiotherapists were making sense of the prospect of having longer working careers. Central issues and themes identified in this paper include: worry – over physical capability and ability to cope; the need to maintain a professional image; work, retirement and exit norms; beliefs about ageing; extrinsic job demands; organisational support – line management; and organisational support – career progression. We found that physiotherapists were pessimistic about the physical health of their older self and believed there was no prospect of a change in their current working context of high job strains, or that supportive policies would be introduced that could reduce the work rate pressures. This is worrying as previous research has demonstrated that negative attitudes around personal physical decline can nudge people towards taking early retirement (Kooij et al. Reference Kooij, de Lange, Jansen and Dikkers2007). Also, more recently, evidence from Sweden suggests that feelings of fatigue, with insufficient recovery time, and not feeling valued were some of the factors which had more influence on subjective self-rated health, which in turn predicted retirement decisions, when compared to diagnosed disease such as MSDs and arthritis (Nilsson, Hydbom and Rylander Reference Nilsson, Hydbom and Rylander2016). There is no doubt that physiotherapists are at risk of both (Glover et al. Reference Glover, McGregor, Sullivan and Hague2005), and working longer can increase exposure to work rates and extend the period over which latent or on-going injuries have to be managed. This does not explain however, why their older self was so negatively perceived, given that as a professional group, they believe they are fitter than other health-care workers, are very well placed to mitigate any normal effects of ageing as much as possible within realistic limits, often work with pre-existing MSDs, and have more positive attitudes towards ageing compared to occupational therapists or podiatrists (Giles et al. Reference Giles, Paterson, Butler and Stewart2002). The picture presented is contradictory, and it is clear that the present context of risk of injury, managing pain, high work rates, a lack of availability of positive ageing role models and lack of organisational policy in place that supports older workers were contributing to this group of physiotherapists’ feelings of pessimism about their physical condition when they imagined themselves reaching the age of 60 and above.
The socio-cultural theory of socially situated cognition (Aydede and Robbins Reference Aydede and Robbins2009; Semin and Smith Reference Semin and Smith2013; Smith and Semin Reference Smith and Semin2004) offers an explanation for why current high work rates and high strain jobs being experienced may be making people feel negative about their physical older selves. In effect, what people constructed in terms of their own future ‘older’ identity seems to be dependent on their current demanding work situation – in other words, thoughts or cognitions were being shaped by the social and environmental contexts in which they currently operated. According to this socio-cultural perspective, the perceptions and cognitions of an older self are embodied and therefore intertwined with sensorimotor processes (Smith and Semin Reference Smith and Semin2004) and impact negatively on motivation. Those with pain and ongoing MSDs compounded by high work rates were physiotherapists who believed their condition and associated pain would only increase with age. Such beliefs were particularly salient in the discourses in this current study. For those who had yet to personally experience injury, one could argue their concerns about self-ageing were drawing on negative impressions formed by the only current external examples of physiotherapist still practising in their sixties, and in poor physical health, and therefore influenced how they saw themselves as older health-care professionals. Again, it seems the current working context seems to be shaping beliefs about self-ageing.
All of this seemed to embed widely expressed worry that their older self will suffer inevitable physiological decline. These threats may emit a particularly large shadow in a profession which sees its own professional image and responsibilities to be dependent upon remaining in physical good health (Aguilar et al. Reference Aguilar, Stupans, Scutter and King2013; American Physical Therapy Association 2009; Cromie, Robertson and Best Reference Cromie, Robertson and Best2002; Jacobson Reference Jacobson1980) We also encountered discourses which spontaneously emerged from the discussions about certain pressure, not just on older physiotherapists, but also younger physiotherapists coming into the profession, to be in very good physical shape and ‘skinny’. As Cromie, Robertson and Best (Reference Cromie, Robertson and Best2002) suggest, much of the professional identity of physiotherapists is not explicitly taught, and students have to adopt a ‘hidden curriculum’ and, given this observation, what could be of particular interest for further research is how this professional group is beginning to address ageing within their profession per se and consider also the extent to which a female-dominated profession is adjusting as more male physiotherapists join the workforce; such insights may prove to offer valuable insights into how other health professions could address such issues. Such proactive approaches by professional bodies will be particularly important for those who functionally may be feeling old already and are seriously demotivated when they consider the prospect of an extended working life, which could be pushing them towards an early exit instead of a rewarding longer career.
The narratives also portray the complexity of managing an ageing workforce, and in some NHS health-care organisations in the UK, physiotherapy line managers are effectively being left to ‘carry the can’ in this regard. In fact, line managers described working within a system that has very little room for manoeuvre. Examples of older practising physiotherapists in the NHS are few, meaning simply that managers have not had much opportunity to gain direct experience in managing an older workforce, something known to leave managers prone to holding stereotypes about older workers (Leisink and Knies Reference Leisink and Knies2011); overlooking older workers for promotion, for example, because managers perceive that they are just ‘filling in time’ before retirement (Weyman, Meadows and Buckingham Reference Weyman, Meadows and Buckingham2013). Nevertheless, knowledge of the key role line managers can play in addressing staff support needs is encouraging, and has already been recognised in other domains (Mackay et al. Reference Mackay, Cousins, Kelly, Lee and McCaig2004). Clear human resource policies around managing an older workforce could provide the necessary back-up line managers need to enable them to continue to absorb and accommodate constant change, regulate flexible working requests and manage on-going health issues (Mackay et al. Reference Mackay, Cousins, Kelly, Lee and McCaig2004; Purcell and Hutchinson Reference Purcell and Hutchinson2007), all of which will only become more onerous as the workforce continues to age. Line managers can be supported by a choice architecture that enables this.
Moreover, as already mentioned, cultural shifts needed, that are signposted in the exploratory findings of this study, include an organisational-level response to the ageing workforce issue to address gaps in human resource policy, and employers need to ensure lifetime learning and support equal opportunities for professional growth for all age groups. Redeployment and opportunities to learn new skills (e.g. Saxon, Gray and Oprescu Reference Saxon, Gray and Oprescu2014) seem intuitively the right way forward to enable older staff to remain feeling valued, stimulated and motivated, as perceiving oneself to be on a path of continued learning can promote feelings of psychological vitality, and reverse lower negative ratings of subjective self-rated health, instead of feeling old and under-valued (Kooij et al. Reference Kooij, de Lange, Jansen and Dikkers2007).
Further consideration should also be given to the potential for an increase in intergenerational tensions as the number of older workers inevitably increases; tensions which have already been identified as problematic in the nursing profession (Sherman Reference Sherman2006). While there was no evidence in the discourses of this study that younger physiotherapist held negative attitudes towards their older colleagues because they may be preventing promotion opportunities for the younger people (in fact it was the older staff themselves who had some concerns about job-blocking), there is potential for tensions in the future. Younger workers could, for example, see the creation of age-adjusted working arrangements as unfair privileges for older colleagues (Sherman Reference Sherman2006). Another area for potential tension is in relation to lifelong learning and professional growth, and consideration needs to be given to how trainers accommodate the needs of all age groups. The anxiety and resistance towards the use of information technology in the older physiotherapists has been highlighted in this paper, whereas the use of computer technology is second nature to many younger workers.
Limitations
It is important to also point out a number of limitations to this research. While members of the Chartered Society of Physiotherapy in the sample represented all regions in the country, the physiotherapy managers were London-based, a region not typical of the rest of the UK due to high turnover and a higher proportion of younger workers in the workforce. Further studies that investigate ways for organisations to support line managers could sample a regional cross-section to address this bias. Secondly, focus groups are a valuable research tool for gaining insights into the perspectives of groups of people, but it is recognised that the use of group discussion may provide less opportunity to explore the variations in individual perceptions of ageing that may exist in younger and older physiotherapists, and also any variations due to gender effects. We recommend that individual interviews also be employed in future research to address such issues, and offer further support to the findings reported in this paper. Finally, this analysis is interpretative and can by no means offer a definitive account of all challenges posed by the EWL agenda. However, what this analysis does is provide an insight into some of the reasons why we encountered high levels of concern about ageing and physical decline, and how this might be related to highly skilled physiotherapists choosing to exit from the NHS prematurely.
Conclusions
In providing an account of ways in which physiotherapists’ exposure to high physical demands at work and their own professional standards can result in negative perceptions of ageing, this study raises some important questions as to how we should consider the extension of working lives in the future. Firstly, in the context of an independent review commissioned by the British Department of Health which found absenteeism and staff turnover to increase as staff wellbeing declines (Boorman Reference Boorman2009); this study's findings regarding the way in which physiotherapists perceive their own health as they age provides important lessons as to how we might improve the retention of health-care staff in the future. Given that we know that subjective self-rated health has more leverage than a diagnosed disease when it comes to decisions about retiring from the health-care profession (Nilsson, Hydbom and Rylander Reference Nilsson, Hydbom and Rylander2016), taking measures to gainfully improve the wellbeing of staff across the lifecourse would seem crucially important. It would, therefore, seem prudent to recommend the reduction of prolonged staff exposure to high work rates, as well as the offering of age-adjusted roles. This would permit the improvement of wellbeing of all employees, and in turn allow them the opportunity to view their ageing selves in a more positive light.
We also hope that the findings of this research put the spotlight on the role of the line manager in terms of a being significant support to an older workforce. In saying that, we need to be mindful that line managers must be interested and motivated to provide this much-needed social support in first place, suggesting age-awareness management training should be offered which would enable employers to comply with their responsibilities in terms of supporting their line managers (Leisink and Knies Reference Leisink and Knies2011).
Furthermore, in the context of long-standing theories of work-intensification (Green and McIntosh Reference Green and McIntosh2001), and ongoing initiatives to improve the sustainability of pension systems across Europe, the findings of this research pose important questions regarding the necessary prerequisites to the extension of working life that apply well beyond the UK NHS. As an increasing number of European countries defer statutory retirement ages, this study's attempts to highlight how stressful and high-strain working environments influence people's mental representations of their older ageing self, and subsequently contribute to their exits from gainful employment, reinforces the importance of improving work sustainability. The extension of working life has been identified to have many potential benefits, including increasing individual incomes, increasing future pension entitlements, and improving the retention of cognitive skills as well as overall mental health (Baucknecht and Cebulla Reference Baucknecht and Cebulla2016). However, without ensuring fair working conditions are sustained over the lifecourse, the extent to which people are able, or indeed willing to work into later life, remains uncertain.
Acknowledgements
The authors would like to thank the UK Medical Research Council for funding the Extending Working Lives in the NHS project, and Professor Peter Nolan and Hilary Metcalf for their support in carrying out this research. Also, we would like to thank Penny Bromley from the UK Chartered Society of Physiotherapy for her invaluable support in organising the focus groups, and those who gave up their time to participate in this research. Full ethical approval was obtained for this research from the University of Bath Psychology Department Ethics Committee (reference 14/123).
