The term “turnover” is generally defined as a change or movement of people, as tenants or customers in, out, or through a place. The frequency of turnover is closely related to the level of job satisfaction experienced by the healthcare professional. A landmark study conducted by Herzberg states the concept of employee job satisfaction should be analyzed from 2 separate categories, which Herzberg called “satisfiers” or motivational factors and “dissatisfiers” or hygiene factors.¹ Satisfiers are considered intrinsic motivators and dissatisfiers are coupled with extrinsic motivators. Some examples of extrinsic motivators are salary, working conditions with peers and management, and adhering to company policy. Some examples of satisfiers are recognition, responsibility, advancement, and achievement.¹

Research conducted by Hegney et al on the impact of intrinsic and extrinsic work values affecting job satisfaction concurs with the original findings conducted by Herzberg.2 Job dissatisfaction consistently related with high levels of occupational stress and burnout, along with physical and mental exhaustion. Holtom and O’Neill contend job satisfaction is not necessarily the most predictive of healthcare professional burnout resulting into turnover.³ The researchers suggest other variables contributing to burnout, such as organizational commitment, job embeddedness, and perceived job alternatives.³ Holtom and O’Neill found job embeddedness, in particular, to be more predictive than job satisfaction reflecting burnout behaviors.

Positive job satisfaction is twice as predictive of turnover intentions as employee tenure and 4 times as predictive as the perception of alternative employment opportunities, educational level, gender, and age.⁴ Another precursor to healthcare professionals’ turnover behavior is health complications often disregarded by either the employee or the employer.

A literature search was performed using bibliographic databases as well as retrieving full text interlibrary loan articles. The following databases were searched: Academic Search Premier, CINAHL, Medline, and Pubmed. Initial search terms were: employee turnover, absenteeism, turnover intentions, job satisfaction, professional burnout, role conflict, Maslach Burnout Inventory (MBI), stressors, and employee retention rates. Search years were limited to 2002–2008 and 67 articles were retrieved. A significant amount of the original search articles were excluded because of the large volume of articles focused on retention rate statistics. The scope of this article focuses on job satisfaction issues, stressors experienced by the healthcare professional, burnout as a predecessor to turnover, and strategies employees can implement in the time preceding turnover.

The most frequently used instrument to measure occupational burnout is the Maslach Burnout Inventory (MBI).⁵ This measurement tool is a 22 item self-assessment tool that measures the respondents burnout levels with 3 categories. Occupational burnout is a “syndrome of emotional exhaustion, depersonalization, and reduced personal accomplishment that can occur among individuals who do people work of some kind.”⁵ The first stage of burnout, emotional exhaustion, measures how frequently the respondent feels overwhelmed emotionally by his or her work environment. Secondly, the depersonalization stage of burnout measures how a respondent interacts with peers in an impersonal manner. The last stage of burnout, personal accomplishment, is assessed by how frequently the individual experiences intrinsic values at work.⁵

There is a significant amount of empirical research performed on the relationship between burnout and turnover intentions. There is little research conducted on the perceived relationship between organizational politics and turnover. Healthcare professionals perceiving higher levels of organizational politics are more inclined to leave the institution. This area of burnout too often results in turnover, which is often overlooked by healthcare management.⁶

Many researchers agree there is a direct correlation between job satisfaction and health.^7,8 Researchers divided the health complications that developed from burnout into 3 areas: physical, emotional, and psychological exhaustion. These 3 areas are burnout behaviors which are precursors to healthcare professional turnover. Some areas of physical exhaustion experienced by healthcare professionals were fatigue, weight fluctuations, and insomnia.^7,8

Ekstedt and Fagerberg divide the emotional exhaustion stage into 8 levels: inner incentive, feeling responsible, bodily and psychological manifestations, fatigue, a threatened self-image, cutting off, and reaching the bottom line.9 The majority of respondents in this study described being “trapped” in their emotional exhaustive state.

This area of emotional exhaustion is particularly evident in healthcare professionals caring for HIV positive patients.¹⁰ Healthcare professionals who provide care to HIV positive patients repeatedly are more prone to suffering burnout behaviors than providers who work with patients with cancer.¹⁰ This is evidenced by HIV positive patients having a social stigma related to the disease, whereas cancer patients are supported by family members more often. Hence, the healthcare provider frequently is the sole caretaker of these HIV positive patients, escalating the emotional exhaustion scale of the Maslach Burnout Inventory.

The final health complication developed from burnout is psychological exhaustion. Malach describes this last stage as a psychological contract. The researcher explains there is a continuous struggle by the healthcare professional to uphold the written and unwritten agreements established prior to employment. The employee experiencing a feeling of being insignificant, insecure, and powerless is more likely to experience psychological exhaustion.¹¹

Numerous empirical research studies have demonstrated healthcare professionals experiencing emotional exhaustion and depersonalization behaviors; however, one behavior receiving only moderate attention that affects the patient care lexicon is sickness absence. Sickness absence is generally defined as absence related to illness and or injury deemed by the employer. Patterns of sickness absence are strongly indicative of employee turnover.¹² Sickness absence levels are significant financially and subsequently managers, government, and taxpayers who pay for this economic burden want to curtail them.¹² Sickness absence behavior for public sector employees is dramatically higher than private sector employees and healthcare workers have the highest rate of sickness absence compared with other industrial sectors.¹² Interestingly, absence policies at healthcare facilities geared towards reducing patterns of this behavior actually contributed to increasing it. This is a result of management undermining employee loyalty to the institution.¹²

In research focusing on the predictive factors that correlate with sickness absence patterns, healthcare professionals were grouped into 3 categories: primary, secondary, and tertiary interventions.¹³ Primary intervention targets employees who are not at immediate risk for sickness absence behavior. This employee population is typically in the early stages of employment, which researchers suggest is an ideal intervention point. This would certainly behoove management to be proactive in targeting these individuals as a preventive strategy before employees display sickness absence behaviors. Secondary intervention focuses on employees who are suspected for sickness absence, or who display frequent sick leave. It is imperative for management to perform well documented counseling sessions with these individuals and review departmental leave policies prior to admonishment. This is a two-fold return where the management protects his or herself with documented counseling sessions and the employee is reminded of the departmental leave policy. Finally, tertiary intervention targets employees who are on sick leave to prevent further descent of his or her wellbeing. These employees may well be in admonishment stages without proper documentation supporting his or her sick leave; however, one solution could be for management to adopt alternative work scheduling for these individuals. From a preventive perspective, primary prevention is regarded as an ideal point of intervention.¹³

A common weakness in the research regarding sickness absence patterns prior to turnover is the lack of a screening instrument. The development and utilization of a screening instrument would identify healthcare professionals at risk for these behavior patterns.^12,13 This would be an invaluable tool for managers to assess these counterproductive behaviors.

An indicator of job dissatisfaction by healthcare professionals is displayed by verbal abuse.¹⁴ Although verbal abuse is obviously not a reward, it has the same impact as an intrinsic reward negatively affecting the healthcare professional. Verbal abuse among healthcare professionals is closely associated with poor morale, decreased job satisfaction, increased errors, and compromised patient care.¹⁴ Verbal abuse occurs when verbal aggression is frequent and consistent. In fact, verbal abuse can be silent and other passive aggressive behaviors which may lead to employee burnout and/or resignation. Verbal aggression is the core of verbal abuse. In research identifying these behaviors demonstrated toward allied health students and new hires of institutions, healthcare professionals exhibiting hostility toward a new hire increased turnover rates. Also, a trickledown effect occurs when a new hire experiences verbal abuse, he or she is likely to reciprocate to future generations of employees.¹⁴

Following are some resolutions for curtailing verbal abuse. First, management must employ strategies to enhance employee morale by involving employees in policy and procedure construction. Second, employers should discourage verbal abuse and/or aggression and immediately confront a suspected case. Finally, mandatory counseling sessions should be implemented for offenders.¹⁴

Indications of turnover intentions correspond with role conflict and role ambiguity. ⁹ Conflicting values, high ideals, and lack of clarity about tasks contribute to increased turnover rates. Role conflict and role ambiguity are associated with emotional frustration. These circumstances promote long term stress and contribute to burnout behaviors. Some resolutions to help eliminate role conflict and role ambiguity are for healthcare management to display charismatic leadership qualities, facilitate intellectual stimulation, provide more decision latitude, provide job autonomy, and provide contingent rewards.⁹

Two factors, organizational commitment and job tension, have a strong impact on an employee’s work performance and progression of employment within healthcare institutions.¹⁵ The level of organizational commitment is reflective of the employee’s assessment of his or her futuristic value within the organization. Employees with high levels of organizational commitment will likely remain employed regardless of job tension levels. In one study, employees would occasionally miss regular work assignments, but would not generally resign with high levels of organizational commitment.¹⁵ Job tension was the second factor associated with employee work conditions. Job tension is essentially a moderator variable determining whether the effects of organizational commitment on employees displaying withdrawal (dependent variable) are continuous or non-continuous.¹⁵

There has been a significant amount of studies conducted on healthcare professionals and organizational commitment, but little empirical studies have been performed on radiographer organizational commitment. However, in one study, it was noted that organizational support significantly affects radiographers’ commitment to the institution in which they are employed.¹⁶ The areas measuring organizational commitment levels among radiographers were affective commitment, continuance commitment, and normative commitment. Affective commitment targets the employee’s emotional attachment to and identification to a job. Continuance commitment is related to awareness of the costs connected with leaving the institution. Normative commitment refers to the employee’s feeling of obligation to the institution. An individual could have differing levels of all 3 types of commitment; however, transformational leadership behaviors by supervisors was a predictor of both affective and normative commitment levels.¹⁶

The items of organizational commitment the researchers used on their instrument were organizational support, organizational type, transformative leadership behavior exhibited by supervisor, years of employment as radiographers, educational level, hours on-call per month, role conflict, and role ambiguity.¹⁶ Including a transformational leadership style among healthcare managers facilitates group cohesion and empowerment among employees.¹⁷ This leadership style inversely correlates to burnout among nursing professionals, causing a heightened awareness and commitment among subordinates, also resulting in followers to transcend his or her self interests.¹⁷

A study addressing the issue of turnover among hospital chief executive officers (CEOs) focused on CEOs at non-federal general surgical and medical community hospitals.¹⁸ Eight hundred five surveys were returned yielding an overall response rate of 38%. Respondents reported the biggest contributor that would make an impact on CEO turnover is hospital competitors luring employees and doctors away from the target hospitals¹⁸:

There is a strong correlation between hospital CEO turnover and turnover by lower levels of management in healthcare.¹⁸ Another study examined employee trust in direct supervisors versus CEOs and determined to what extent employee trust varies between different levels of management. ¹⁹ Three classes of variables were modeled: characteristics of trustee (gender, ethnicity, years under this manager), characteristics of the organization (layoffs and managerial turnover), and characteristics of the manager (technical expertise and credibility). The researchers found employees scored his or her direct supervisor more trustworthy than upper level managers or CEOs.

An ongoing daunting task for healthcare management is to devise strategies to improve employee retention rates while maintaining consistent work productivity. A healthy work environment is essential to facilitate productive healthcare professionals. Focusing strategies to improve retention rates among registered nurses should be age specific.²⁰ To improve orientation programs for newly hired registered nurses, provide career development strategies blanketing all registered nurses and tailor pension benefits and retirement options for senior registered nurses.²⁰ Altering work schedules and working conditions could possibly reduce physical and mental stress for healthcare professionals as retention initiatives. ⁴Moreover, there are multiple initiatives managers could perform to reduce turnover: teamwork efforts, providing adequate equipment, open-door policy, respect for subordinates demonstrated by management, and educational opportunities. All these areas facilitate improvement of employee morale.⁴

One often overlooked strategy to improve employee turnover issues is the ability of healthcare facilities to grow their own.²¹ Applying this strategy enables employers to avoid luring personnel away from their current employer by routes of costly sign-on bonuses and vacation incentives.²¹ This strategy enables managers to use already established employees for upward mobility. One example is to provide educational opportunities.²¹ Many researchers concede that a strong preventive measure healthcare management can exercise to reduce turnover is to provide flexible work scheduling.^22–24 When healthcare professionals are stressed because of inflexible work scheduling this compresses life outside of work, influencing family interactions and leisurely activities. The largest task confronting healthcare management is facilitating flexible work scheduling for employees while providing adequate coverage for patient care issues.^22–24 This is a simple, yet bewildering solution to this managerial quandary.

Another current strategy healthcare management exercises to reduce turnover intentions is to offer sign-on bonuses and retention bonuses.²⁵ The negative impact when management chooses to award bonuses is resentment experienced by employees who did not receive bonuses.²⁵ In one study, researchers surveyed 800 full time employed Canadian registered nurses all of which had tenure of 15 years. The sample was varied with some registered nurses receiving bonuses and some not. Nurses who did not receive retention awards and sign-on bonuses experienced greater anger and less optimism associated with an unfair distribution. They concluded that the registered nurses who had not received retention awards or a sign-on bonus began experiencing turnover intentions themselves. This study supports research regarding the relationship between extrinsic rewards and job dissatisfaction. Monetary rewards and salary are regarded as extrinsic motivational factors which are temporary in length.²

There is adequate anecdotal evidence suggesting a pessimistic attitude displayed by experienced personnel who do not receive sign-on bonuses and retention bonus awards; however, there is little empirical research evaluating the impact of this issue on job satisfaction and turnover intentions.²

Improving strategies to retain healthcare professionals should be a primary goal of every healthcare institution. More creative innovations are needed from management to improve organizational commitment for current employees and future employees on this issue. The existing body of knowledge on healthcare professional turnover demonstrates a paradox, in that the healthcare employees providing the care often report feeling neglected themselves

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Ben D. Wood, MSRS ,RT (R) is an assistant professor of radiologic science at Northwestern State University, Shreveport, LA. Ben can be reached at woodb@nsula.edu.

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The information in this home-study resource is generally accepted as factual at the time of publication. However, the AHRA, the AHRA Education Foundation and the author disclaim responsibility for any new or contradictory data that may become available after publication. Opinions expressed in this article are those of the author and do not necessarily reflect the view or policies of the AHRA, the AHRA Education Foundation or the sponsor.