Introduction
According to the American Animal Hospital Association, turnover in veterinary teams may be at least 23% annually.1 The economic impact of turnover in the profession is difficult to calculate, though a recent study2 suggests burnout in veterinary medicine (a factor likely contributing to high turnover) may be costing the industry between $1 billion and $2 billion annually. AVMA research showed that in 2021 44% of veterinarians had considered leaving the veterinary profession at some point in their career for reasons other than retirement. Of those that considered leaving, 36% cited mental health reasons, followed by 27% citing work-life balance.3 These estimates are supported by the third edition of the Merck Animal Health Veterinarian Wellbeing study in which between 14% and 17% of participating veterinarians under the age of 45 and 58% of all participating veterinary technicians reported an intention to leave their job or the profession entirely within the next 2 years.4 The same study found nearly 10% of veterinarians and 18% of support staff reported serious psychological distress. Furthermore, just over 30% of veterinarians and over 70% of support staff reported they are “just getting by” when well-being was measured. Among the greatest concerns expressed by the Merck study participants were overall stress and high student debt (financial stress). Of note, in the 2019 Merck study, only 50% of participants listed team member shortage as a primary concern. In the 2021 study (published in 2022),4 82% of participants listed team member shortage as a primary concern, an increase of 32%.
The Merck study suggests that clinic climate may influence workplace stress among veterinary professionals.4 Participants who reported being in clinic environments that included high-quality communication, a sense of belonging, a high degree of trust, and sufficient time to provide medical care were significantly less likely to report low well-being or a high level of distress. However, the study did not indicate the influence of leadership on the clinic climate. In fact, there is very little literature assessing the impact of leadership in veterinary workplaces. An online search conducted in November 2022 in both Frontiers in Veterinary Science and the JAVMA found only opinion and editorial pieces related to the topic of veterinary leadership.
Leadership appears to influence workplace environments in other industries. Gallup research suggests managers (key members of an organization’s leadership) may account for 70% of the variance in team member engagement.5 Leadership may also influence job satisfaction and work environment,6 well-being and performance,7 and team member stress and burnout risk.8 One may posit the influence of leadership behaviors on veterinary nurse retention based on the results of a 2022 study9 conducted in the UK. Researchers found that nurses who reported low satisfaction with employer support were 57% more likely to consider leaving the profession.9 In addition, results of a 2022 study10 looking at shift work nurses in Korea showed that the intent to leave was a strong predictor in actual turnover. Considering new graduate veterinarians have listed leadership as a professional skill most important for success,11 we believe consideration of leadership impacts in the veterinary space is apropos. In the book Lead to Thrive: The Science of Crafting a Positive Veterinary Culture, written by one of the authors of this paper, Josh Vaisman, an argument is made that there are at least 4 areas in which leaders can have a positive influence on veterinary workplace environments and team member experience. Vaisman refers to these areas of influence as The 4 Ps of Positive Leadership, and terms them as follows: psychological safety, purpose, path, and partnership.12
This study will help close the knowledge gap on how leadership may affect retention in the veterinary workplace. In this study, associate veterinarians who work in a private practice in the US with a practice owner who exhibits positive leadership traits that support psychological safety, purpose, path, and partnership were hypothesized to report lower turnover intention and be less likely to experience burnout in the workplace.
Materials and Methods
Data source
Data used in this study were from the AVMA’s 2021 and 2022 annual Census of Veterinarians Survey. The survey was distributed and data were collected by the University of Florida Agricultural Market Research Center. This survey collects confidential and voluntary information on veterinary demographics, incomes, employment, and well-being. AVMA member veterinarians who were 1, 5, 10, 15, 20, and 25 years out from graduation received the survey in 2021. In 2022, veterinarians were randomly selected to participate in the survey. Recipients of the 2021 and 2022 surveys received an email with the survey link via the online survey platform, Qualtrics. The 2021 survey was distributed on March 25, 2021, and closed on April 30, 2021, with a 22% response rate. The 2022 survey was distributed on May 17, 2022, and closed on June 16, 2022, with a 19.6% response rate. Associate veterinarians in private practice and located in the US were used in the analysis. To assess positive leadership in the practice, 4 leadership questions on psychological safety, purpose, path, and partnership were added to these surveys, and to assess veterinary burnout, the Professional Quality of Life tool (ie, the ProQOL5)13 was used. Only associate US veterinarians who answered all questions pertaining to psychological safety, purpose, path, and partnership were included in the analysis: 2,037 associate veterinarians (1,258 in 2021 and 779 in 2022).
ProQOL5
The ProQOL5 tool consists of 30 statements that measure compassion satisfaction and compassion fatigue (burnout and secondary traumatic stress).13 Each measure consists of 10 statements to capture a caregiver’s positive or negative experiences in the work environment. Each individual caregiver (in this case, veterinarians who care for animals) ranks each statement on a 5-point Likert scale with their experience over the last 30 days (1 = never, 2 = rarely, 3 = sometimes, 4 = often, and 5 = very often). No language substitutions were made in the statements to reflect a veterinarian and their clients and patients to protect copyright of the ProQOL5 tool. In the survey, respondents were asked to replace “person” with “patient and/or client” and to replace “people” with “patients and/or clients” where necessary when reading the statements. Each of the 10 statements were summed up and a score given as suggested by Stamm.13 The minimum possible score was 10, and the maximum score was 50. For this specific paper, the score for the burnout statements was used in all analyses.
Four areas of positive leadership
There were 4 statement questions asked to associate veterinarians about their experience with their immediate hospital/practice leader when it came to 4 different areas of leadership.12 Each associate veterinarian ranked each statement on a 5-point Likert scale in which they considered their experience with their immediate hospital/practice leader over the past year (1 = never, 2 = rarely, 3 = sometimes, 4 = a moderate amount, and 5 = a great deal), with a prompt to help think about how they would approach answering each statement: “How would I respond to these questions if a good friend was considering working for this leader?” The 4 areas assessed were as follows:
Psychological safety, which can be thought of as a team members’ belief that the work environment is safe for the interpersonal risk-taking necessary for learning, growth, and achievement. For example, a psychologically safe team member may be willing to challenge the status quo in a team meeting because they believe their contrarian view will not be met with punishment or retribution. Rather, their perspective will be heard and considered. Research suggests psychologically safe team members report higher job satisfaction, less turnover intention, and lower burnout.14
Purpose, which speaks to a team member’s experience of mattering and meaningfulness at work. This can be thought of as a team member’s belief that they are seen, valued, and needed (mattering) and that the work they do feels positive, purposeful, and significant (meaningfulness). Research suggests these experiences may correlate to an elevated sense of job satisfaction, reduced risk for burnout, and an improved sense of workplace well-being.15 Furthermore, team members who experience purpose at work may be significantly more productive, resulting in increased revenue for the organization.16
Path, which refers to a team member’s experience of meaningful achievement, moderated by their sense of empowerment. When a team member enjoys role clarity, feels a meaningful sense of control over how to achieve what is expected of them, and is supported by the resources needed for success, they have the experience of path. Path may contribute to elevated work engagement and team performance17 as well as job satisfaction and professional vitality.18
Finally, partnership, which refers to the quality of the relationship between a team member and leadership (in most cases, their direct supervisor or manager). When a team member believes their leader cares about them personally and cares about their professional success, they are experiencing partnership. In a study19 conducted by McKinsey and Co, they found that the largest predictor of job satisfaction, accounting for 39% of the variance in job satisfaction scores, is how team members rate the quality of their relationships at work. Of note, 86% of the variance in job relationships ratings were explained by how team members rated the quality of the relationship with their direct supervisor or manager. The same study found strong correlations between team member job satisfaction and overall business performance.
Statistical analysis
Survey data use in this study consisted of years of work experience (calculated as the survey year minus graduation date); gender (male [referent group] and female); income from veterinary activities; mean centered hours worked per week to control for part-time and full-time associate veterinarians; private practice structure (independently owned single practice [referent group], independently owned group practice, and group corporate practice [defined as a group that is consolidated or owned by any major corporate company]); type of private practice employment (companion animal [referent group], food animal, mixed animal, equine, and exotic animal); private practice function (general medicine and surgery including alternative therapies for companion animals [not in shelters], equids, backyard livestock, exotics, and relief and mobile/ambulatory services [referent group]; emergency care/urgent medicine [provides exclusively emergency and intensive care of critically ill and injured animals]; referral/specialty medicine [specialized services in 1 or more specific areas of veterinary medicine recognized by the American Board of Veterinary Specialties]; and other); community where a veterinarian lives (rural [referent group], suburban, and urban); a time trend to control for 2021 and 2022 survey years; ProQOL5 burnout scores that were mean centered; whether one is likely to choose to remain employed at the organization over the next 5 years (or self-employed; no [referent group], or yes); 4 variables that measure psychological safety, purpose, path, and partnership (never [referent group], rarely, sometimes, a moderate amount, and a great deal); and a leadership index that averaged the Likert scale scores from each of the 4 leadership variables and assigned a number from 1 to 5, with 1 denoting lacking positive leadership traits and a 5 denoting all-encompassing leadership traits. Statements used in the analyses associated with the following 4 leadership variables are below:
Psychological safety: In my hospital/practice, my immediate leader holds my shortcomings against me.
Purpose: In my hospital/practice, my immediate leader routinely shows me how my work and I matter here.
Path: In my hospital/practice, my immediate leader takes deliberate action to provide me with clear expectations and meaningful control over how to meet those expectations.
Partnership: In my hospital/practice, my immediate leader takes deliberate action to show me that my personal and professional success is important to them.
Two multivariable models were used in this study. The first one was a Logit model to measure the odds of an associate veterinarian choosing to remain employed at their organization over the next 5 years. After the Logit model was estimated, odds ratios were computed to illustrate the effect of a 1-unit increase in the independent variable on likelihood to remain employed at the organization over the next 5 years, controlling for other factors. The second model was a Tobit model, also referred to as a censored regression model, looking at the leadership index as the dependent variable and testing the effect of the independent variables on leadership qualities (Figure 1).
Distribution of leadership index scores (rectangular bars) and the associated normal density plot (curved line) for surveyed associate veterinarians. Almost half (42.6%) of associate veterinarian leadership index scores were 3.75 or higher, meaning associates believed their leaders practiced positive leadership a moderate amount to a great deal of the time, but 23.7% of associate veterinarians still reported that their leader never or rarely practiced positive leadership (1 to 2.5) and 33.7% reported their leaders practiced positive leadership sometimes (2.75 to 3.5).
Citation: Journal of the American Veterinary Medical Association 261, 10; 10.2460/javma.23.03.0158
To test for multicollinearity of the variables in this study, an ordinary least regression was performed to run the variance inflation factor (VIF) test on the Logit and Tobit models. The highest VIF was just under 10 for the category “a great deal” for the leadership variable that measured partnership in the Logit model, and there was no VIF > 2 in the Tobit model, indicating no major concern for multicollinearity indicating no major concern for multi-collinearity in the 2 models. The Tobit model was tested for heteroskedasticity and omitted variable bias. The Breusch-Pagan/Cook-Weisberg test for heteroskedasticity yielded a χ2 (1) value of 0.46 and a probability < χ2 = 0.4991; because the probability was greater than 0.05, we could not reject the null hypothesis of constant variance and therefore no heteroskedasticity was present in the model. The Ramsey RESET test for omitted variables was used to identify omitted variable bias. This test yielded a probability > F = 0.3375; because the probability was greater than 0.05, we could not reject the null hypothesis of no omitted variables, and therefore relevant variables were accounted for in this model.
Results
Overall, 2,037 associates were used to represent 2021 and 2022 after an initial sample of 2,691 associates (we excluded 425 observations that did not answer all of the 4 leadership questions, 223 observations that worked outside of the US or did not provide an answer to work location, and 1 observation in telehealth and 5 observations in consulting, both due to low response). In 2022, a production medicine category was added to function type; therefore, no respondents selected this category for 2021. Because of this, the decision was made to move the 9 production medicine respondents to the other category in private practice function—they did not alter the variable averages in the other category.
In the combined sample, 64.0% (1,303) of US associate veterinarians said that they were likely to remain at their organization over the next 5 years and 36.0% (734) were not likely to remain at their organization over the next 5 years; 83.2% (1,692) were female and 16.8% were male (341); and 59.8% (1,217) lived in a suburban area, 22.3% (454) in a rural area, and 17.9% (365) in an urban area. In the practice organization, 47.7% (972) were in an independently owned single practice, 16.4% (334) in an independently owned group practice, and 35.9% (730) in a group corporate practice. The majority of respondents were in companion animal practice (88.1% [1,795]), followed by 6.0% (123) in mixed animal practice, 4.1% (84) in equine practice, 1.3% (26) in food animal practice, and 0.4% (9) in exotic animal practice. Most respondents worked in a general medicine and surgery setting (78.9% [1,608]); 7.2% (147) of respondents were in emergency care/urgent medicine, 10.6% (216) in referral/specialty medicine, and 3.2% (66) in other (Supplementary Table S1).
When it came to the 4 leadership variables, the mean ± SD (range) leadership index score for the combined sample was 3.4 ± 1.0 on a 1- to 5-point scale index. The average burnout score for the entire sample was 30.6 ± 6.1, the average work experience was 10.9 ± 9.9 years, the average number of hours worked was 43.8 ± 11.2, and the overall average income was $117,653 ± $79,151. No outliers were removed from income in the analysis because there was no significant difference in the average when a minimum of $25,000 and a maximum of $500,000 were applied to the income, yielding an average of $116,353, a difference of $1,300 when including the outliers, and did not affect the overall outcome of the Logit and Tobit models (Supplementary Table S2).
Logit model results
In the multivariable Logit model (Supplementary Table S3), different variables were assessed for their effect on the likelihood that an associate would remain at the organization over the next 5 years, controlling for other factors. Burnout was a significant predictor in whether an associate would stay at the organization over the next 5 years in that for a 1-unit increase in burnout score it was expected that there was about an 8% decrease in the odds of staying at the organization in the next 5 years (P < .001). Being female revealed a 76% increase in the odds of staying at the organization in the next 5 years compared to being male (P < .001). An associate’s income was significant (P < .001), although its effect on the OR (1.0) was not appreciable due to this variable having been modeled in 1-dollar units. The odds for associates staying at the organization in the next 5 years that lived in an urban community were 44.8% lower than the odds for associates living in a rural community (P = .001), and the odds for associates that work in a group corporate practice setting were 39.2% lower than associates that worked in an independently owned single practice (P < .001).
When it came to the leadership variables in the Logit model there were no significant differences around whether a leader showed associates that their success was important to them (rarely, P = .439; sometimes, P = .548; a moderate amount, P = .968; a great deal, P = .375), controlling for other factors. However, significant differences were found in associates who worked in a practice where their leader let them know their work mattered (purpose), laid out clear expectations (path), and held their shortcomings against them (psychological safety). Associates who worked in a practice where their leader routinely showed the associate that their work mattered revealed that there was 86% higher odds of remaining employed for associates who reported “sometimes” (P = .039), 165% higher odds for those who reported “a moderate amount” (P = 0.004), and 176% higher odds for those who reported “a great deal” (P = .008). With regard to an associate whose leader(s) hold their shortcomings against them, there was 48% lower odds of associates who reported “a moderate amount” (P = .006) and 58% lower odds of associates who reported “a great deal” (P = .012), in that they would remain employed at their organization over the next 5 years. Associates in a practice in which a leader communicated their expectations and how to meet those expectations that selected “a moderate amount” and “a great deal” had 148% higher odds in the likelihood of remaining employed at their organization over the next 5 years (P < .001 and P = .003).
Tobit model results
The multivariable Tobit model revealed significant results (Supplementary Table S4). Controlling for other factors, associates that were likely to remain employed at their organization over the next 5 years were associated with a 0.656 increase in the leadership index at their place of employment for their leader compared to associates who were not likely to remain employed at their organization over the next 5 years (P < .001). For a 1-unit increase in an associate’s burnout score, there was a 0.030 decrease in the practice leadership index score (P < .001). In other words, the higher the burnout score, the lower the leadership index for their practice leader, or an associate with a burnout score of 35 would decrease the leadership index by about 1 point. A 1-unit increase in an associate’s experience level was associated with a 0.009 decrease in the leadership index of their practice’s leader (P < .001), and while significant, the coefficient is small and not of major importance. Hours worked by an associate veterinarian showed that for a 1-unit increase in the number of hours worked during the work week, there was a 0.005 decrease in leadership score (P = .001). The leadership index for associates in a referral/specialty practice decreased by 0.213 (P = .003), compared to associates in general medicine and surgery practice. The models time trend variable is also significant, showing a 0.214 increase in the leadership index for a 1-unit increase in survey year (P < .001). While not significant at the 5%, but close (0.060) and worth mentioning, the leadership index for associate veterinarians in equine practice decreased by 0.193 compared to companion animal associate veterinarians.
Discussion
The results of this study supported evidence that important leadership skills such as cultivating psychological safety in the workplace, purpose, path, and partnership may impact associate workplace experience. In turn, these leadership skills may predict associate motivation to remain employed (turnover intention) at their organization in the next 5 years and their overall mental well-being. A significant relationship exists between well-being and job satisfaction.20 Job satisfaction can predict turnover intention, which in turn is a strong predictor of actual turnover.21 Practice retention, burnout, and a toxic work-life balance tend to be main reasons veterinarians want to leave their job4 and the veterinary profession.3 This study is important because it suggests these issues could be alleviated under the presence of positive leadership behaviors in veterinary organizations.
The Logit model shed light on different associate demographic and employment information and their motivations to stay or leave their organization in the next 5 years. Burnout level was a significant indicator on an associate’s intent to remain employed at their current place of employment and that their likelihood of staying decreased the higher the associate burnout levels. Similar characteristics around well-being have also been found in other studies.3,4,8 Associate veterinarians in urban areas are less likely to remain employed at their organization in the next 5 years compared to rural associate veterinarians. Veterinarians in rural areas likely have less mobility because they heavily depend on their client base and building trusting relationships to build business,22 so the opportunity cost to leave is great. Average incomes are not as high compared to urban and suburban areas, so maintaining a client base is critical for practice revenue and compensation,23 whereas in urban areas there is a larger pool of pet owners from which to pull. Associates working in a group corporate practice setting are less likely to remain employed in the next 5 years at their organization compared to associates in a private practice owned by a single veterinarian. While the reasons are unclear, the AVMA’s Veterinary Career Center shows 3 times the amount of job postings coming from group corporate practices compared to independently owned practices.24 While this increase is partly due to increased consolidation in the veterinary profession, a reduced leadership influence in a practice, or a negative view of leadership, may play a part due to the result of corporate leadership teams not always being on-site.25,26 Associate veterinarians who reported that their leader made sure to communicate that the associate’s work matters and laid out clear expectations were more likely to remain in the practice. Furthermore, associates who reported that their leader held shortcomings against them were less likely to remain in the practice. Team members whose leaders harvest a psychologically safe work environment and give employees a purpose and path in their job have higher job satisfaction,6,9,15,16,18 lower burnout, overall well-being,7,8,15,16 less intention to leave the practice,9,15 and overall better engagement and performance in the practice.5,7,15–18
The Tobit model explored the quality of practice leadership on the health of associate veterinarians in private practice, and while it measured similar variables as the Logit, it is a completely independent model with different results. Associates employed in practices where leadership did not emulate positive leadership practices reported less intention to remain in the practice for the next 5 years, similar to associate veterinarians who reported high levels of burnout.
Associate veterinarians in a referral/specialty practice reported a lower leadership index for their practice leaders compared to general medicine practice. The more hours associates reported working, the lower the leadership index they reported. Veterinarians reported working more hours than they expected, an average of 5 hours more/week.24 About a quarter of veterinarians desire to work fewer hours for less compensation,3 with the top reasons being a desire for better work-life balance and to protect their mental health.3 The findings above reflect those in the leadership literature that suggest poor leaders may negatively impact an associate’s well-being.4,8 Veterinarians in an equine practice reported their leaders lower on the leadership index than in companion animal practice. A retention issue has been identified for equine veterinarians, and leadership is 1 area of influence to examine.27,28 Lower compensation, higher levels of debt, and higher working hours have been attributed to equine veterinarians leaving equine practice for other sectors.27 Given our findings from this analysis, leadership qualities should be assessed further among equine practice owners as to whether this can offset the intent to leave equine practice.
Recruiting, hiring, and onboarding new associates is a costly and time-intensive endeavor. Retaining an engaged team is critical to practice success in turbulent economic climates. As this study revealed, positive leadership practices—contributing to an associate’s workplace experience of psychological safety, purpose, path, and partnership—correlates with an associate’s intention to stay at the job. A workplace climate conducive to burnout, low job satisfaction, and low team engagement will contribute to higher turnover in veterinary practices. Our study shows the impact that positive veterinary practice leaders can have on a team member’s workplace experience and retention. As such, practices should consider assessing the current state of leadership within their organization and provide targeted positive leadership training. In this way, practices are likely to improve their ability to retain a healthy, engaged veterinary team.
The present study had some limitations. First, the majority of associate veterinarians in this study were in companion and mixed animal practice, followed by equine practice. While results can still be interpreted for food animal and exotic practice veterinarians, it is important to note the small sample for these veterinarians. Second, while the items used to measure the 4 leadership variables in this analysis were evidence-based, they did not go through a validation study as is common practice when using psychometric-based assessments.
Supplementary Materials
Supplementary materials are posted online at the journal website: avmajournals.avma.org
Acknowledgments
Charlotte H. McKay declares no conflicts of interest. Joshua M. Vaisman authored the book referenced in this study called Lead to Thrive: The Science of Crafting a Positive Veterinary Culture.
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