We investigated similarities and differences in preferences for rural job postings among nursing students and practicing nurses in Laos. This information can help the Laos MOH better understand which strategies to pursue to address HRH challenges in rural areas in the country. Nursing students and practicing nurses had similar preferences for several job posting attributes. Both groups were willing to give up more than 35% of their monthly salary in exchange for being promoted to permanent staff directly upon hiring. Similarly, both groups of respondents were willing to give up around 21 to 23% of their monthly salary in exchange for the institution of a performance-based financial reward for high performing nurses.
Despite these similarities, there were important differences in preferences for job posting attributes between nursing students and practicing nurses in Laos. Practicing nurses placed significantly lower value on housing provision as compared to nursing students. In a recent DCE that looked at practicing nurses’ preferences for job attributes in Kenya, South Africa and Thailand, Blaauw et al. found that respondents’ preference for housing attributes were consistently lower than were preference for other attributes such as training opportunities and salary increases . Further, as compared to nursing students, practicing nurses placed significantly lower value on transportation provision for work and personal use.
There are several plausible mechanisms that could explain why we observe differences in preferences for job posting attributes. First, practicing nurses in this study were on average 39 years old and the median nurse had been in the workforce 19 years, and thus likely had substantial experience in obtaining housing and arranging transportation. On the other hand, lack of housing and transportation might be much more daunting to a nursing student contemplating a rural job, resulting in higher utilities for these incentives among students. In addition to differences in job experience, younger nursing students and older practicing nurses are in different stages in their lives, such that what they consider to be most important may be very different. Indeed, very few of the nursing students had families, while a large majority of practicing nurses were married and had children. Finally, not all nursing students choose to pursue a career in the nursing profession upon completion of their studies. Similarly, some nurses leave the nursing profession early in their career. Therefore, the practicing nurses included in this study may constitute a self-selected sample with unmeasured characteristics that influence both the probability of remaining a practicing nurse and preferences for job posting attributes.
With the data we have collected for this study, we unfortunately have limited ability to differentiate the potential effects of these proposed mechanisms. We find that, among practicing nurses, age was not significantly associated with preferences for job attributes (see Additional file 3). This may validate the self-selection explanation. There is, however, evidence from the labor economics literature that work experiences do indeed influence preferences for future job opportunities as well as actual selection of jobs [27, 28]. The literature suggests that one reason preferences differ is because experienced workers have more information upon which to base decisions . However, related research on health workers in low-income settings is limited. Future investigations should aim to understand how age, experience, and states of life might influence preferences and job decisions.
The findings we present in this study suggest that it may be important to differentiate recruitment and retention policies when addressing HRH challenges in developing countries, such as Laos. There is support for this finding in the literature. Rao et al. found, in a qualitative study conducted in India, that students in training to become doctors and nurses had different preferences for rural job postings as compared to practicing doctors and nurses . Further, in an analysis comparing preferences for job postings among medical students and practicing physicians in Vietnam, Vujicic et al. found both similarities and differences in preferences for job attributes between student and professional groups . The authors concluded that governments should tailor HRH attraction and retention strategies to doctors at different stages of their careers. We do not, however, present data in this paper that may indicate whether recruitment or retention policies should be prioritized at this time by the government of Laos. In order to make a strong argument for specific policies, it would be necessary to collect and analyze information related to the health needs of the population and the health worker labor market in the country.
This analysis had important limitations. First, we did not collect the data necessary to fully delineate the explanatory power of two plausible mechanisms - work experience and self-selection - on observed differences in preferences for job attributes between nursing students and practicing nurses. Second, we did not collect information from non-respondents and thus were unable to assess whether selection bias may have resulted from differential participation. However, because surveys were administered to students during class hours and to practicing nurses during work hours, we may conclude that the primary reason for non-response was unavailability due to class and work responsibilities. Further, we would not expect such a selection mechanism to significantly bias the observed results. Third, the DCE presented to nursing students and practicing nurses in Laos was unlabeled. That is, DCE scenarios were not identified as being in urban or rural settings. As such, we can’t comment on the effect of rural job location on respondents’ job preferences. Fourth, the hypothetical nature of the DCE methods employed in this study may raise validity concerns. Respondents may not have fully understood the survey directions and may not have accurately stated their preferences. Similarly, respondents may have made choices based on what they felt interviewers wanted them to choose, biasing results. Perhaps most importantly, it is unlikely that the preference data that we present comprises the full range of factors that determine nurses’ job-related decision making in Laos. Recent research suggests that, among workers across various economic sectors, factors related to job satisfaction do not explain a substantial proportion of job turnover . Future research should focus on validating DCE results from analyses of health worker data with information on revealed preferences, that is, observations of actual health worker job choice behavior. However, it is difficult to disaggregate job attributes to permit the analysis of their separate influence in real-life scenarios.