Professional Satisfaction and Desire to Emigrate among Nigerian Physiotherapists

ABSTRACT

Purpose: Physiotherapists from developing countries are attracted to developed countries, where health personnel are in high demand. We investigated Nigerian physiotherapists' desire to emigrate, explored the possible relationship between job satisfaction and emigration, and elucidated common reasons why physiotherapists emigrate to other countries. Methods: Nigerian physiotherapists (n=181) were surveyed using a three-part questionnaire. Part 1 elicited socio-demographic information; part 2 assessed satisfaction with work; and part 3 assessed the importance of some possible reasons that physiotherapists choose to emigrate. Results: Close to half of the physiotherapists surveyed have plans to emigrate, but no relationship exists between job satisfaction level and desire to emigrate. An overwhelming majority felt that better or more realistic remuneration was the most important reason for them to leave their country, whereas age and practice experience were inversely related to physiotherapists' desire to emigrate. Conclusion: Policies aimed at mediating “brain drain” should take age and experience into consideration and should be geared toward creating opportunities for career advancement and continuing education.

The leadership role of physiotherapists in preventing and remediating impairments, restoring function, and promoting health-related quality of life is widely acknowledged. A general belief among physiotherapists in Nigeria is that there is a low level of awareness of who physiotherapists are and what they do and that the profession has yet to earn its due respect from other health professions.^1,2

According to Duncan,³ the status of a profession is a reflection of its capacity to address challenges within a national boundary. The status enjoyed by the physiotherapy profession in Nigeria may be attributed, at least in part, to the “brain drain” among physiotherapists over the past 25 years,⁴ but it is not clear whether recent improvements in remuneration and conditions of service for physiotherapists have tempered Nigerian physiotherapists' desire to emigrate.

Existing studies on job satisfaction show that physiotherapists working in the United States are satisfied with their jobs.^4–6 Studies have also shown that intrinsic context factors—including a sense of autonomy, peer recognition, and challenges to develop skills—are more important determinants of job satisfaction than extrinsic factors, such as pay and remuneration, among medical and allied health professionals.^7–8 Brain drain—characterized by highly trained scientific personnel emigrating from less developed countries to take advantage of better living standards, higher quality of life, and higher salaries and because of an unstable political situation and a lack of good education in their home countries—is not a new phenomenon.⁹ Reasons for emigrating to more developed countries have been identified as including working in a better health care system, continuing education opportunities, conducive work environment, and improved remuneration,^10,11 and low job status and low motivation have been identified as factors influencing the decision to leave Africa.¹¹

Emigration of health personnel from developing countries has been a source of concern for some time;^12–14 for example, more than 20% of working physicians in Australia, Canada, and the United States have been estimated to have come from other countries.¹⁵ Oversupply in India and the Philippines^16,17 and demand in developed economies^18,19 have been cited as reasons for this phenomenon.

Although the emigration of scientists and highly skilled professionals could be regarded as draining the home country's economy and capacity building, expatriates who send money to their home countries also contribute to the economy and the scholarly advances of those countries. Brain drain is detrimental to Nigeria because it affects service provision and reduces the country's capacity to provide quality training and to conduct high-quality research.²⁰ Empirical data on how sociodemographic factors and professional satisfaction affect the desire to emigrate are important in formulating policies to address brain drain, especially in countries believed to be underserved in the area of medical rehabilitation, such as Nigeria.

Most previous studies of migration of health professionals have focused on physicians, dentists, nurses, and pharmacists.^9,10,21 This study focuses on physiotherapists because they have not previously been studied. In search of a better life, physiotherapists from Nigeria continue to take advantage of Canadian, U.S., and U.K. immigration programs that attract highly skilled personnel from developing countries.^4,22–24 This study investigates the professional satisfaction of Nigerian physiotherapists and their desire to emigrate; it also sheds light on the level of importance that physiotherapists attach to some common reasons for emigration.

METHODS

Sample

We surveyed a systematic sample of Nigerian physiotherapists practising in private, secondary, and tertiary health institutions in the six geopolitical zones and the federal capital territory of Nigeria. The geopolitical zones in Nigeria have similar administrative and health care organizations as the federal capital territory. Participants in the 2007 annual conference of the Nigeria Society of Physiotherapy and six contact people each from the six zones were identified, and all agreed to assist in compiling lists of physiotherapists from their zones for the survey. Within 6 weeks of the conference, a list of physiotherapists ordered by rank (job seniority) was obtained for each zone.

Procedure

From the rank-ordered list of physiotherapists, every third physiotherapist in each zone was surveyed. A total of 212 survey questionnaires were mailed out to the zonal contacts, who then provided the questionnaires to participants either by mail or during periodic professional meetings within their zones. Each package forwarded to a participant contained a questionnaire, a cover letter, and a postage-paid return envelope. Participation in the study was voluntary; the cover letter stated that completion of the questionnaire implied respondents' consent to participate, that the questionnaire would take an average of 17 minutes to complete, and that respondents' anonymity was ensured. Two reminders were sent to participants within 8 weeks of administration of the survey. A response rate of 85.4% (n=181) was obtained within 3 months after mailing each packet to the zonal contact. The study was approved by the appropriate ethics review board at our institution.

Instruments

The survey instrument was a three-part, 31-item questionnaire. Part 1 elicited sociodemographic information: age, gender, marital status, rank, religion, practice setting, and years of practice experience. Respondents were asked whether and how often they participated in continuing education. They were also asked whether they planned to emigrate in the future and where they would prefer to practise if professional prestige and remuneration were comparable between Nigeria and other African countries, Europe and North America, or other parts of the world.

In part 2, respondents were asked about their level of satisfaction in professional practice, using a 10-item scale addressing intrinsic context factors developed by Speakman et al.⁶ This scale has been used in previous studies^6,7 and is valid and reliable.⁶ Participants were asked to indicate their level of agreement with five negatively worded and five positively worded statements, using a seven-point Likert scale (1=strongly disagree, 7=strongly agree). Negatively worded statements relate to professional autonomy, job stress, and physical demands of the job; examples are “There is too much paperwork” and “I am overworked.” Positively worded statements relate to positive challenge, job fulfilment, independence in decision making, and job interest; examples are “My work is challenging in a positive sense” and “I am learning and improving on my work.”

To obtain a composite total satisfaction score, we reverse-coded the negatively worded statements: For example, responses to the statement “My job is demanding” were recoded as 1=strongly agree and 7=strongly disagree. The maximum and minimum possible composite scores were thus 70 and 10, respectively.

In part 3, respondents rated on a seven-point Likert scale (1=extremely unimportant, 7=extremely important) the level of importance they attach to seven possible reasons why Nigerian physiotherapists might emigrate to work in another country. The seven items in part 3 were adapted from a previous study that identified major reasons why highly skilled personnel from developing countries are attracted to developed countries.¹⁰ The items in the scale include “Want to work in a better managed health system,” “Want a better or more realistic remuneration,” and “Want to work where physiotherapists enjoy better professional prestige.” Other statements relate to continuing education or training, a more conducive work environment, better security of life and property, and living in a more democratic society.

The questionnaire was pretested with 10 selected physiotherapists for 2-week test–retest reliability. This time frame was chosen to forestall the carryover effect that may be associated with a shorter time frame and possible exaggeration of the resulting reliability coefficients. Spearman correlation coefficients indicated moderate reproducibility for the satisfaction (ρ=0.87; p<0.01) and importance (ρ=0.79; p<0.01) scales.

Statistical Analysis

Participants' responses were entered in the computer and coded appropriately, and data analysis was performed using Analyze-It Statistical Software (Analyze-It Ltd., London, UK). Descriptive statistics were computed for all items. Independent t-tests and one-way analysis of variance were used to explore differences in composite satisfaction scores by demographic variables and desire to emigrate. Pearson product–moment correlation coefficients were used to explore relationships among practice satisfaction, desire to emigrate, and age and practice experience. Multiple stepwise regression analysis with practice satisfaction as the dependent variable was used to determine the sociodemographic predictors of job satisfaction. To reduce the potential for multicollinearity, only sociodemographic variables that seemed essential to the model were force-entered as independent variables in the first block of the regression model and removed stepwise in the second block. Alpha level was set at 0.05; Bonferroni correction was used to explain the differences between items on practice satisfaction.

RESULTS

Participants ranged from 24 to 61 years of age (mean 34 y, SD 3). Most (61%, n=111) were male; 76% and 23%, respectively, identified as Christian and Muslim. Approximately half were single (50%, n=90), half were married (50%, n=91), and more than half of those who were married reported having children (54%, n=49). Respondents' reported median monthly income was 77,000 naira (95% CI, 70,000–81,000), equivalent to about CAD$500 (US$510; range, 15,000–750,000 naira), and most respondents (83%, n=150) said they were members of Nigeria's professional physiotherapy organization.

Table 1 shows demographic characteristics, emigration plans, and country of practice preference for the participants. Almost half of respondents held the rank of intern or physiotherapist grade I (49%, n=88); the overwhelming majority (81%, n=147) practised in teaching or specialist hospitals, and one-quarter (25%, n=45) had not participated in any continuing education activities in the past 2 years. A substantial proportion (41%, n=75) had plans to emigrate to another country in the future, but most said they would prefer to practise in Nigeria if the remuneration (70%, n=126) and prestige (74%, n=133) attached to the profession were comparable between Nigeria and other countries.

Table 1.

Demographic Characteristics, Emigration Plan, and Country of Practice Preference of Nigerian Physiotherapists

Independent variable	No. (%) of physiotherapists; n=181
Rank
Chief or director	25 (13.8)
Senior or principal	68 (37.6)
Intern or physiotherapist grade I	88 (48.6)
Religious affiliation
Muslim	41 (22.7)
Christian	138 (76.2)
Other	2 (1.1)
Setting
Teaching or specialist hospital	147 (81.2)
General hospital	23 (12.7)
Private hospital	3 (1.7)
Private clinic or home care	8 (4.4)
Continuing education
None	45 (24.9)
1 time/2 y	35 (19.3)
1 time/y	68 (37.6)
2 times/y	13 (7.2)
>2 times/y	20 (11.0)
Emigration plan
Yes	75 (41.4)
No	42 (23.2)
Undecided	64 (35.4)
Country of practice preference if remuneration were comparable
Nigeria	126 (69.6)
Europe and North America	40 (22.1)
Other African countries	7 (3.9)
Other	8 (4.4)
Country of practice preference if professional prestige were comparable
Nigeria	133 (73.5)
Europe and North America	36 (19.9)
Other African countries	6 (3.3)
Other	6 (3.3)

Table 2 shows the respondents' satisfaction ratings for the clinical practice aspects of their jobs. Almost three-quarters of respondents (74%) either agreed or strongly agreed that their job is physically demanding, and 81% either agreed or strongly agreed that they were learning and improving on their work. The mean agreement score for the item “There is too much paper work” was 3.0 (SD 1.7), and the mean score for the statement “My job is fulfilling” was 5.6 (SD 1.5). This shows that, overall, respondents minimally disagreed that there is too much paperwork and that their ratings fall between minimal agreement and agreement on the item “My job is fulfilling and enables me to use my abilities.”

Table 2.

Frequency Distribution (%) of Physiotherapists' Agreement or Disagreement with Statements on Practice Satisfaction

Statement*	Strongly disagree	Disagree	Minimally disagree	Neutral	Minimally agree	Agree	Strongly agree	Mean (SD)
There is too much paperwork.	17.7	33.1	12. 2	18.8	6.6	8.3	4.4	3.0 (1.7)
I am not given enough autonomy (freedom to do my work the way I want to).	12.7	23.2	10.5	19.9	11.0	14.9	7.7	3.7 (1.9)
My job is mentally stressful.	9.9	26.5	22.1	17.1	8.3	12.2	3.9	4.6 (1.7)
My job is too physically demanding.	0	3.9	2.8	6.1	13.3	28.7	45.2	6.0 (1.3)
I am overworked.	2.2	8.3	7.2	12.7	19.9	28.2	21.5	5.1 (1.4)
My job is challenging in a positive sense.	1.7	1.1	1.7	9.9	10.5	42.0	33.1	5.9 (1.2)
My job is fulfilling (i.e., enables me to use my ability).	2.8	2.8	3.3	11.0	14.9	34.3	30.9	5.6 (1.5)
I have sufficient independence in decision making.	3.9	6.6	5.5	11.6	16.0	36.5	19.9	5.2 (1.6)
My work is interesting.	1.1	1.7	0.6	8.5	16.0	36.5	35.9	5.9 (1.2)
I am learning and improving on my work.	1.1	1.7	0.6	5.5	10.5	42.5	38.1	6.0 (1.1)

^*The first five statements are negatively worded; the remainder are positively worded.

Table 3 shows respondents' importance ratings for the reasons why Nigerian physiotherapists might leave to practice in another country. The overwhelming majority (93%) believed that better remuneration is either an important or an extremely important reason, and only 35% considered living in a democratic society as an important or extremely important reason. The desire to work in a better-managed health system and the desire to work in a place where physiotherapists enjoy higher professional prestige were considered comparable in importance (mean importance 6.2, SD 1.2).

Table 3.

Physiotherapists' Importance Ratings (%) of Possible Reasons Why Nigerian Physiotherapists May Leave Nigeria to Work in Another Country

Reason	Extremely unimportant	Unimportant	Minimally unimportant	Neutral	Minimally important	Important	Extremely important	Mean (SD)
Want to work in a better managed health system.	1.7	0.6	2.2	5.5	6.1	26.0	58.0	6.2* (1.2)
Want to continue education or training.	1.7	1.7	1.7	5.5	14.4	34.4	34.3	6.0† (1.3)
Want a more conducive working environment.	1.1	0.6	0.6	3.9	7.7	30.9	55.2	6.3‡ (1.2)
Want better or more realistic remuneration.	0	0.6	0.3	3.3	2.2	22.7	70.7	6.6* (0.8)
Want better security of life and property.	3.9	3.9	7.7	13.8	7.7	22.1	40.9	5.5§ (1.7)
Want to live in a more democratic society.	8.3	8.8	7.7	22.1	18.2	18.8	16.0	4.5¶ (1.8)
Want to work where physiotherapists enjoy better professional prestige.	2.2	1.1	0.6	5.0	9.9	2.5	59.7	6.2‡ (1.2)

Note: Mean importance scores that do not share a common symbol are statistically different at p<0.01.

Participants' mean satisfaction rating was 46.1 (SD 6.2). Physiotherapists who were members of their professional organization, were married, or held the rank of chief or director reported significantly higher satisfaction scores than their counterparts who were not members (p<0.01), were single (p<0.05), or worked as interns or physiotherapists grade I (p<0.01), respectively (Table 4).

Table 4.

Differences in Composite Satisfaction Scores by Sociodemographic Variables and Emigration Plan

Variables	No. of physiotherapists	Mean score (SD)	Values	p-value
Sex			0.008*	0.99
Female	70	46.1 (6.4)
Male	111	46.1 (6.2)
Marital status			2.127*	0.035†
Single	90	45.2 (6.1)
Married	91	47.1 (6.2)
Religion			1.854*	0.07
Christianity	138	46.6 (6.3)
Islam	41	44.6 (5.9)
Other / no religion	2
NSP membership			2.779*	<0.001†
Yes	150	46.7 (6.2)
No	31	43.4 (5.6)
Rank‡			5.183†	<0.001†
Intern or physio I	88	45.1 (6.2)
Senior or principal	68	46.3 (6.7)
Chief or director	25	49.5 (6.7)
Continuing education			2.286†	0.06
None	45	45.0 (6.6)
1 time/2 y	35	44.7 (5.6)
1 time/y	68	46.6 (5.8)
2 times/y	13	46.9 (5.4)
>2 times/y	20	49.3 (7.7)
Employment setting			2.039†	0.11
General or state hospital	23	48.0 (5.5)
Teaching or specialist	147	45.6 (6.4)
Private hospital	3	51.0 (3.6)
Private practice	8	48.4 (4.4)
Emigration plan			1.677†	0.19
Yes	75	45.2 (6.3)
No	42	47.1 (6.6)
Undecided	64	46.7 (5.9)

^*t-values from independent t-test

^†Denotes significant group differences in job satisfaction score. For example, although is no difference by gender, the married group had a higher score than the single group.

^‡In this category, mean scores for the “Chief or director group” were found to be significantly different when compared with those of the “Senior or principal” or “Intern or physio I” groups (Scheffé post hoc test).

Physio I=physiotherapist Grade I; NSP=Nigeria Society of Physiotherapy.

Age, years of practice experience, and years of membership in the professional organization were significantly correlated (p<0.01) with satisfaction scores (r=0.32, 0.33, and 0.34, respectively). Age and practice experience were inversely related (r=−0.51 and −0.56, respectively, p<0.01) to the desire to emigrate, which suggests that the desire to work in a foreign country was modestly linked to young age and less practice experience. No link was found between physiotherapists' level of job satisfaction and plans to emigrate. Participation in continuing education, employment setting, membership in the professional organization, years of membership, marital status, rank, age, and years of post-qualification experience combined to account for 16.0% of the variance in job satisfaction in the preliminary model, but none of these variables were significant. In the final regression model, years of membership in the professional organization was the only significant variable, accounting for 12% of the variance in job satisfaction (β=0.34, p<0.001).

DISCUSSION

Nigeria is located in the western part of Africa and is the most populated country on the continent, with an estimated population of 152,217,341.²⁵ Professional physiotherapy training in Nigeria consists of 5 years of university education and 1 year of internship; graduates provide services mainly in government-owned general hospitals, university teaching hospitals, and medical centres scattered throughout the country, as well as in a few private hospitals and clinics concentrated in the major cities. A national health insurance scheme was recently introduced, but health and physiotherapy services are still provided on a self-pay, fee-for-service basis for most of the population. In the past, many physiotherapists from this country have emigrated in search of better life.⁴

Our findings indicate that physiotherapists in Nigeria believe that they are learning and improving in their jobs; that they consider their jobs interesting, challenging, and fulfilling; and that, to a lesser degree, they believe they have sufficient independence in decision making. The overall fair or moderate level of job satisfaction expressed by this cohort of Nigerian physiotherapists is consistent with the results of previous studies..^4–6,26 Nevertheless, many Nigerian physiotherapists plan to emigrate in the future.

No study exists that would allow a direct comparison with our finding that physiotherapists at the higher rank of chief or director express higher job satisfaction. However, the finding is consistent with a similar study of physicians in Geneva, Switzerland, in which physicians in residency training were found to be less satisfied than consultants.⁸ Higher job satisfaction among those in the higher ranks of the profession may be attributed to the higher prestige, respect, and administrative decision-making power that such professionals may enjoy.

For the Nigerian physiotherapists in our study, issues relating to the work of physiotherapy, such as better remuneration, a better-managed health care system, higher professional prestige, and continuing education, are more important in the decision to emigrate than non–work-related issues such as security of life and property and the desire to live and work in a more democratic society. A plausible explanation for this finding is that issues that directly affect these professionals play a more dominant role in their disposition to emigrate than issues that affect society in general.

The finding that better remuneration is considered an important reason for emigration affirms an earlier report that pay disparities between developing and developed countries attract immigration from the former to the latter.²⁷ Similarly, physiotherapists' expressed preference to stay and practise in their home country if remuneration were comparable to that in other countries also affirms, albeit indirectly, earlier reports that the prospect of making substantially more money is a pivotal factor in the decision to emigrate.^28,29

Our study showed that younger and less experienced Nigerian physiotherapists may be more disposed to emigrate than their older and more experienced counterparts. Order of practice preference in foreign countries, which placed developed countries in North America and Europe over countries in other parts of the world, may be attributed to the high living standards, professional development, and advancement opportunities that are perhaps not seen as available in other parts of the world. It is plausible that the immigration policies of Canada,²² the United States,²³ and the United Kingdom²⁴ are attracting young and less experienced Nigerian physiotherapists who seek a better quality of life and more access to advanced education.

Developed countries in which demand is high will continue to attract physiotherapists from developing countries. Although a viable approach to stemming the brain drain and influencing health professionals' decisions about emigrating must necessarily address remuneration and working conditions,^27,30 this may be difficult for developing countries with scarce economic resources; factors such as conducive work environments, opportunities for advancement, and graduate education and training may therefore be more practical options.

In our study, years of professional membership accounted for a higher proportion of the variance in job satisfaction among physiotherapists. This finding underscores the importance of professional organization to job satisfaction among Nigerian physiotherapists. It is plausible that longer membership in a professional organization yields greater benefits from the networking and socialization activities available to members, which may have an impact on members' job satisfaction and desire to emigrate.¹³

Professional networking support has been identified as one important strategy that can be used to address the problem of brain drain.³⁰ However, decisions about balancing individual success or freedom with national loss are not so easy to make. Global awareness of brain drain as it affects physiotherapists could be described as low compared with how it affects physicians and nurses, because reports on brain drain among health professionals have excluded physiotherapists.^13,30 As a result, appropriate debate and discussion are needed at the global level to increase awareness of brain drain and migration as they affect physiotherapists in developing countries.

Our findings indicate that international migration of physiotherapists needs to be on the agenda and should be the subject of a comprehensive strategic approach and policy statement from the World Confederation of Physical Therapy. Such discussion, which could lead to a coherent consensus on the brain drain among physiotherapists, is needed to facilitate input into any comprehensive international policy on health professional migration in multinational forums such as the United Nations.

One limitation of our study is that the physiotherapists surveyed were selected from listings of physiotherapists connected through employment or membership in the national professional association and compiled by volunteers. Because government remains almost the sole employer of physiotherapists in Nigeria, those in private hospitals or offices may not be suitably represented in the sampled population. Nevertheless, the sample was as representative as possible given the unreliable address listing of registered physiotherapists in Nigeria. Furthermore, as in any self-report survey, participants may have provided the responses they felt were acceptable to the researchers. The non-uniformity of the procedure, in which most survey participants received the questionnaire in person and others received it by mail, may have introduced bias and is therefore another limitation of the study.

Those in the higher ranks of any profession are likely to be older and more experienced than those in the lower ranks. In our study, although the former subgroup expressed more job satisfaction than the latter, and associations between composite satisfaction score and both age and practice experience were observed, higher-ranked physiotherapists as a group did not plan to emigrate. Yet, a declared plan to emigrate is a projection, not a guarantee, of future action. Although many physiotherapists indicated that they plan to emigrate in the future, only a few may eventually succeed in leaving the country. It is also plausible that those who indicated they do not have such a plan may nevertheless eventually emigrate. Therefore, our study's findings on desire to emigrate should be interpreted with caution.

CONCLUSION

Nigerian physiotherapists are satisfied with their jobs, agree that their work is interesting and challenging in a positive sense, and believe that they are learning and improving on their work. They also feel they have sufficient independence in decision making, but they may be overworked and may find their work physically demanding. These physiotherapists would prefer to practise in their own country if remuneration and prestige were comparable to what is available in other countries but would choose countries in North America and Europe over countries in other parts of the world as their preferred destination for emigration.

For the Nigerian physiotherapists in our study, a desire to live in a foreign society believed to be more democratic is of least importance in the decision to leave their country. However, obtaining better or more realistic remuneration is the most important reason that Nigerian physiotherapists may leave their country. Because our study shows that the risk of loss due to brain drain may be associated with less experience or lower age, any policy aimed at mitigating brain drain should take these factors into consideration and should be geared toward creating opportunities for career advancement and continuing education.

KEY MESSAGES

What Is Already Known on This Topic

Intrinsic factors such as a sense of autonomy, peer recognition, and challenge to develop skills are important determinants of job satisfaction, and physiotherapists are generally satisfied with their jobs. Emigration of health personnel from developing to developed countries in search of better quality of life and advanced education is not new.

What This Study Adds

This study affirms that physiotherapists in Nigeria are satisfied with their jobs and that their desire to emigrate may be associated with less experience and younger age. In addition to these factors, any policy aimed at mitigating brain drain among Nigerian physiotherapists should address needs including career advancement and continuing education.

Physiotherapy Canada 2012; 64(3);225–232; doi:10.3138/ptc.2010-45