The prevalence of turnover intention and influencing factors among emergency physicians: a national observation

The study protocol was approved by the Institutional Ethics Board of the Second Affiliated Hospital of Hainan Medical University, Haikou, China. All individuals provided written informed consent.

A cross-sectional study was carried out in China from July 2019 to September 2019. A multistage stratified random sampling design was used in this study. First, a total of 31 Chinese provinces were classified as developed, developing, or less-developed regions according to per capital household income in 2018. Second, we selected 10 hospitals randomly from each province. Third, based on the number and scale of the hospitals, 40% of the emergency physicians who had practiced in the emergency department for at least 6 months were randomly selected from each hospital to complete a self-administered questionnaire. The participants included only emergency physicians and not nurses and other technicians who provided emergency care. In total, 15,455 emergency physicians were asked to participate in this survey, and 182 physicians did not respond. In addition, 30 questionnaires were discarded due to missing information. Ultimately, 15,243 eligible questionnaires were used in this analysis.

The questionnaire was designed based on literature reviews, group discussions, and preliminary interviews. Furthermore, a pilot study was conducted in one Wuhan community to improve the quality of the questionnaire. This questionnaire focuses on the physical and mental health and professional attitude of emergency physicians, and the relevant parts of this study include sociodemographic information (e.g., region, age, gender, education level, marital status, and professional title), workplace violence, depression and turnover intention. The “turnover intention” section have one items, which is “Wether you have turnover intention”. The answers can be either "yes" or "no".

WVS was developed by Wang et al. [26], has a good reliability and validity for measuring the incidence of workplace violence when applied to medical staff in China. It includes 5 items measured with a four-point ordinal scale ranging from 0 (never) to 3 (more than 3 times/year). In this study, the Cronbach’s alpha for WPV was 0.81.

CES-D was used to assess depressive symptoms. The scale includes include 20 items; each item is scored on a four-point scale ranging from 0 ("little or none of the time") to 3 ("most or almost all of the time"). The total score ranges from 0 to 60 points, and the higher the score is, the more severe the depressive symptoms. On the original CES-D scale, a total score of 16 was used to detect the presence of depressive symptoms [27]. However, a large number of studies have assessed the diagnostic accuracy of CES-D in detecting depression in the general population and have proposed multiple cutoff points, such as a cutoff point of 18 for elderly people living in residential homes [28] and a cutoff score of 22 for older Chinese individuals [29]. A meta-analysis systematically reviewed 28 CES-D studies, including several Chinese studies, and obtained an optimal cutoff point of 20 points [30]. As a result, an overall score of 20 or higher was considered an indicator of depressive symptoms in this study, consistent with previous research [31]. The CES-D has good reliability and validity, and it has been widely used in the Chinese population. In this study, the Cronbach's alpha coefficient of the scale was 0.90.

A web link to the online questionnaire, which was designed using Questionnaire Star, was disseminated to the participants through WeChat (similar to WhatsApp, WeChat is the largest communication platform in China, with over one billion users). To prevent the same participants from repeatedly answering the questionnaire, each device (e.g., smartphone or computer) was eligible to complete the questionnaire only once, and logical checks were concurrently run on the WeChat platform to identify invalid questionnaires. The data were entered into a web-based database by trained investigators to ensure accuracy.

The descriptive analyses used means for the continuous variables and percentages for the categorical data. This study examines the effects of both single and multiple factors. The descriptive statistics for the categorical variables were reported as the frequency (percentage) and were compared between “yes” and “no” using Pearson’s χ² test. Weather having turnover intention as the dependent variables, were treated as categorical variables. Multivariable logistic analysis was used to calculate the odds ratios (ORs) and 95% confidence intervals (CIs) for factors that might be associated with the prevalence of turnover intention. All analyses were performed using STATA 13.0, and all tests were two sided with a significance level of 0.05.

Our study found that emergency physicians who were older, male, worked in eastern China, and had high income levels were less likely to develop turnover intention. These findings are consistent with previous studies. Eastern China is economically developed, while central China and western China are relatively backward. Lu et al. [32] found that that physicians who are younger and work in under-development region had higher turnover intention because of low salaries and lack of promotion prospect. The same phenomenon also could happen in lower level hospitals. While Sperlich et al. [33] reported that women are more likely to be influenced by family and social factors at work and have higher levels of work stress which is an important reason for their turnover intention [34]. In addition, some studies mention that attractive salary is the pivotal factor to increased job satisfaction and reduce turnover intention [35, 36]. Low salary can make it difficult to attract and retain new employees. Fang et al. [37] also found that the lower the salary level, the more likely physicians were to develop turnover intention. This suggests that more attention should be given to emergency doctors who are younger, female, work in less developed areas and lower level hospitals, and have poor salary.

Previous research has shown that well-educated workers are more likely to leave for career development [38, 39]. This situation is further aggravated if career opportunities within the organization are limited [40]. We also found that highly educated emergency physicians were more likely to have turnover intention. In addition, the sense of achievement is also an important factor that affects work enthusiasm [41]. Emergency physicians with high professional titles and longer working tenure may experience a decreased sense of professional accomplishment and turnover intention. In addition, longer working tenure may lead to fatigue, tension and burnout, which has an indirect effect on the turnover intention [42]. This is consistent with our findings and indicated that the turnover intention of emergency physicians with high professional titles and long working experience should not be ignored. In reality, these community are often responsible for crucial medical serves.

Emergency physicians bear high physical and psychological job demands that may jeopardize their health status. Illness and health problems are the main causes of turnover intention [43]. Our study showed that emergency physicians with poor physical health were more likely to report turnover intention. In addition, the history of coronary heart disease is also significantly related to turnover intention. The discovery is the first reported and needs further exploration. The decline in sleep quality reflects that physicians may have higher work pressure, which is ultimately translated into turnover intention [34]. Heponiemi et al. showed a positive association between decreased sleep quality and physicians' intentions to change their profession [44]. The decline in sleep quality could lead to mood disorders, such as depression [45, 46], both of which lead to chronic fatigue. Moreover, depression may decrease concentration, which reduces the productivity of physicians and affects physicians’ judgment, thus increasing occupational injury and turnover intention [47, 48]. Therefore, the managers of health institutions should commence to improve the physical health of emergency physicians, and avoid their psychological problems, which could decline their turnover intention.

Some studies have found that shift work is associated with an increase in turnover intention; moreover, reducing restrictions on working hours and providing more flexible shift work will have a positive impact on reducing turnover intention [49‐51]. Our study also demonstrates that shift work increases the turnover intention among emergency physicians. On the other hand, workplace violence in emergency department has received increasing attention in recent years [52, 53]. The survey of Occupational Health Safety Network (OHSN) in America during 2012–2015 showed the incidence of emergency room violence was 19.3%, with an average annual growth rate of 23% [54]; and previous studies have shown that only 30% of cases were documented [55, 56], while nearly 80% of cases was undocumented [57]. Heponiemi et al. [58] reported workplace violence in the health care sector may lead to increased turnover and job dissatisfaction, which is consistent with our findings. Therefore, targeted measures are needed to optimize the health service system, provide more flexible working regimes for emergency physicians, and mitigate doctor–patient relationships to reduce workplace violence.

It is worth noting that among the factors identified, some are "push" factors (e.g., violence, poor health and shift work) and others are "pull" factors (e.g., ambition and career development). Comprehensive measures could reduce turnover intention more effectively. In the process of developing targeted measures, the government and medical institutions should pay more attention to eliminating the negative impact of "push" factors and improving the retention rate. Moreover, for the "pull" factor, it is important to provide sufficient development opportunities for physicians. Proper turnover is acceptable.

The shortage of physicians is the focus of the current medical service field, but there is no effective solution to this problem. It might be a potential direction to commence by reducing turnover intention. This study is based in China, the largest developing country. Currently, many countries have the similar incomplete medical service system, and are also faced with excessive medical demand. This contradiction is particularly evident in the global COVID-19 pandemic and also creates a higher workload for physicians, especially emergency physicians. Therefore, researching the prevalence and influencing factors of turnover intention of emergency physicians in China will provide a valuable reference for researchers and policy makers of the global emergency health service system.

Our study used a large-sample cross-sectional survey to explore the influencing factors of turnover intention among emergency physicians. First, the large sample size significantly increased the statistical power. We surveyed nearly a quarter of the nation's emergency physicians, so the participants was representative. Second, this study included more than twenty potential contributors and produced many valuable findings, which reflects their working status and presented a broad view of the challenges faced by emergency physicians. Third, the survey was anonymous and self-administered, which likely made the respondents provide more valid responses and eliminated interviewer bias.

This study had several limitations. First, the study used a cross-sectional study design, which precluded the evaluation of the temporality of the observed relationships. Second, the data were collected from the participants’ self-reports; thus, recall bias was unavoidable. Finally, the study was performed before the COVID-19 pandemic, which may have led to changes in the turnover intention of emergency physicians after the pandemic.

Based on our findings, we suggest that, first, prospective studies are needed to investigate the association between the identified factors and turnover intention. Further research should also conducted into the post-turnover whereabouts of emergency physicians. Second, this study highlights the need for the investigation or implementation of interventions to improve emergency physicians’ well-being or promote strategies to reduce work pressure on healthcare settings. Finally, investigating the potential impact of turnover intention on emergency physicians’ work performance, the quality of patient care delivery, and family life would provide important insights.