Background
Turnover is generally viewed as the movement of staff out of an organization. It was regarded as a two-dimensional concept, distinguishing between the act of leaving as voluntary or involuntary, and between the leaving and joining of an individual to an organization [
1]. A previous study [
2] defined turnover intention as the next withdrawal behavior when employees encounter dissatisfaction. Mobley et al. [
3] pointed out that turnover intention was the intention of a worker to leave an organization deliberately after a period of time working in a particular organization, after careful consideration, which belonged to voluntary turnover. It is considered as an outcome of affective variables (such as burnout and job satisfaction) rather than actual turnover [
4]. That is, turnover intention can predict actual turnover behavior.
An American clinical psychologist first proposed the term “job burnout [
5]”. At present, job burnout was defined as the symptoms of practitioners in the service industry who were unable to cope effectively with the continuing pressure at work, included emotional exhaustion, depersonalization and reduced personal accomplishment [
6]. Initially, job satisfaction was described as the physical and psychological satisfaction of staff in their work [
7]. In later studies, it was defined as the realization of a person’s work values in the work situation, resulting in a pleasurable emotional state [
8,
9]. The definition of “the attitude towards one’s work and related emotions, beliefs and behaviors” was used in our study, which not only depended on the nature of the work, but also the personality, attitude and expectation of medical staff [
10,
11]. Low job satisfaction is the most common cause of staffs’ turnover and low quality of health care service.
There is a plethora of researches on job satisfaction, burnout and turnover intention. A study found that higher work pressure and lower job satisfaction could easily lead to burnout, that is, job satisfaction was one of the important predictors of burnout [
12]. However, another study of American surgeons had the opposite result: burnout is the biggest predictor of job satisfaction [
13]. In fact, satisfaction and burnout are in no particular order and they need to be determined on a case-by-case basis. Yin et al. [
14] found that satisfaction with work itself, occupational risks and off-duty arrangements were the main factors affecting doctors’ job burnout through a survey on doctors in public hospitals. A study showed that job satisfaction had a direct predictive effect on burnout of middle school teacher, and it also existed as a mediating variable between job stress and job burnout [
15]. Arie R and Yoram N had nosed out that negative correlation was existed in job satisfaction and job stress, burnout [
16].
Most of researches supported that burnout had a positively strong predictive effect on turnover intention [
17‐
22]. For example, emotional exhaustion, negative stagnation and other factors related to burnout have a significant positive correlation with turnover intention [
23]. Beyond that, a study revealed that job satisfaction was negative correlated with turnover intention [
24]. In the study of Guo et al. [
25], turnover intention decreased with the increase of job satisfaction, this opinion was verified from a study of medical workers in Macao. And Wu et al. [
26] also confirmed this result from a research of clinical nurses in Changsha. Therefore, the impact of job satisfaction on turnover intention is important, direct and negative. Satisfaction has a significant predictive effect on turnover intention.
At present, the medical working environment in China is tense, more and more medical personnel have left their jobs and changed their posts. As a result, there is a shortage of medical staff, which destroys the medical environment and disrupts the medical order and affects the health of the people. A study based on the National Health Service Survey in 2013 on China [
27] found that the percentage of employees with low, medium and high turnover intentions was 44.5, 43.7 and 11.8% respectively in primary care institutions. And a foreign study [
28] has investigated the turnover intention of nurses, and also found that 54% of them have turnover intention and 35% have turnover behavior. In view of the current shortage of medical personnel in various countries [
29], job satisfaction and turnover intention may therefore be a crucial and topic concern.
Most previous research focused on the relationship between job satisfaction, turnover intention and burnout, and exploring the factors affecting the three. However, few studies focus on the mediating effect of a certain factor. Such research in China is still in its infancy. The purpose of the research is to examine the mediating role of job satisfaction in the relationship between burnout and turnover intention.
Discussion
Our results demonstrated that for medical workers in primary care institutions, a mediator variable was existed in burnout and turnover intention: job satisfaction. Job satisfaction was usually regarded as a dependent variable [
40‐
42] or an independent variable [
43,
44] in most of the current studies. And work to family conflict [
42], work engagement [
40], burnout and workload [
45] were viewed as mediator variables. However, an American study suggested that burnout was the biggest predictor of job satisfaction [
13]. There were few researches focus on job satisfaction as a mediator variable, which provides new ideas for future research. That’s why we try to study how job satisfaction as a mediating variable affects the correlation between burnout and turnover intention.
The results of the study provided further support for the importance of job satisfaction in engaging the workforce and retaining staff to settle the demands and challenges facing health care setting in primary care institutions. Turnover intention was negatively related to job satisfaction and positively related to burnout. Negative correlation was found between job satisfaction and burnout. Some studies conducted in China have also obtained similar results [
14,
15,
22‐
24,
26,
27,
46], but the correlation coefficient of their results is greater than ours. In our study, the correlation coefficient of path b (Turnover intention ← Job satisfaction) is relatively small, only − 0.18. We speculated that traditional studies which usually used methods such as multivariate linear regression, logistic regression, and ANOVA may neglect the measurement error, so its negative correlation is stronger. However, the error is taken into account in the SEM.
Our finding showed that the mediating effect was a partial mediating effect. First of all, we need to realize what the difference between partial mediation and complete mediation is. In the process of partial mediation, any variable in the causal chain, when it controls the variable before it (including the independent variable), it will affect its subsequent variables significantly. And in the process of complete mediation, after controlling the mediation variables, the influence of the independent variables on the dependent variables is not significant. Job burnout is closely related to turnover intention, and job burnout affects turnover intention directly [
17‐
22], thus causing a partial mediating effect.
Although the mediation effect test confirms that the existence of job satisfaction as a mediating variable of job burnout affects turnover intention, the mediation effect has a low impact of 7.4%. That is to say, the mediation effect accounts for 7.4% of the variation of dependent variables. Despite the low mediation effect, we still believe that the research is valuable and meaningful. We speculated that the low mediation effect was caused by the following reasons. Firstly, it is related to the choice of independent variables closely. Job burnout includes three dimensions: emotional exhaustion, depersonalization and reduced personal accomplishment [
6]. For example, family conflict and doctor-patient relationship are more intuitive than job burnout as important factors that directly affect emotions. If we take them as independent variables directly, the respondent would understand the meaning of the question more clearly, therefore, the path coefficients of path a (mediator variable ← independent variables) would be larger than those of the study (job satisfaction ← burnout), which will lead to a higher mediation effect. Secondly, turnover intention, burnout and job satisfaction are difficult to measure directly. The items and measuring methods may be somewhat various in different studies [
47]. Therefore, the difference of instrument selection is also one of the important reasons for the inconsistency of results. Thirdly, the influence of job satisfaction on turnover intention is limited. There are many factors affecting turnover intention. Turnover intention is influenced not only by job satisfaction, but also by social demographic factors such as education [
43], years in work [
43], family’s relationship [
43], monthly income, social support [
48], mentoring [
49], etc. and other unobserved factors. Therefore, these demographic factors and unobserved factors should be taken into account in the future study.
Our study also has some limitations. Firstly, Because of the diversity of the participants (including doctors, nurses, technicians.), we don’t use the international scale completely. According to the research purpose, the appropriate items have been chosen from these international scales, and the reliability and validity of the questionnaire are still guaranteed. Secondly, sample representativeness needs to be improved. This research can not be generalized to all china as our study place limited. In the future, we will continue to cooperate with other local governments in central China and to conduct similar surveys to solve the problem.
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