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Abstract
Background: Globally, the health workforce has long suffered from labour shortages. This has been exacerbated by
the workload increase caused by the COVID-19 pandemic. Major collapses in healthcare systems across the world
during the peak of the pandemic led to calls for strategies to alleviate the increasing job attrition problem within the
healthcare sector. This turnover may worsen given the overwhelming pressures experienced by the health workforce
during the pandemic, and proactive measures should be taken to retain healthcare workers. This review aims to
examine the factors affecting turnover intention among healthcare workers during the COVID-19 pandemic.
Methods: A mixed studies systematic review was conducted. The PubMed, Embase, Scopus, CINAHL, Web of Sci‑
ence and PsycINFO databases were searched from January 2020 to March 2022. The Joanna Briggs Institute’s Critical
Appraisal Tools and the Mixed Methods Appraisal Tool version 2018 were applied by two independent researchers to
critically appraise the methodological quality. Findings were synthesised using a convergent integrated approach and
categorised thematically.
Results: Forty-three studies, including 39 quantitative, two qualitative and two mixed methods studies were
included in this review. Eighteen were conducted in the Middle East, ten in the Americas, nine in the Asia–Pacific
region and six in Europe. Nurses (n = 35) were included in the majority of the studies, while physicians (n = 13), allied
health workers (n = 11) and healthcare administrative or management staff (n = 7) were included in a smaller pro‑
portion. Five themes emerged from the data synthesis: (1) fear of COVID-19 exposure, (2) psychological responses to
stress, (3) socio-demographic characteristics, (4) adverse working conditions, and (5) organisational support.
Conclusions: A wide range of factors influence healthcare workers’ turnover intention in times of pandemic. Future
research should be more focused on specific factors, such as working conditions or burnout, and specific vulnerable
groups, including migrant healthcare workers and healthcare profession minorities, to aid policymakers in adopting
strategies to support and incentivise them to retain them in their healthcare jobs.
Keywords: COVID-19 pandemic, Healthcare workers, Turnover intention
Background
The coronavirus disease 2019 (COVID-19) pandemic
began in late 2019, with an estimated 400 000 000 infec-
*Correspondence: nurseah@nus.edu.sg tions and 6 200 000 deaths caused by the disease as of
1
Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, April 2022 [1]. Several coronavirus variants surfaced
National University of Singapore, Singapore, Singapore throughout the pandemic, resulting in repeated waves
Full list of author information is available at the end of the article
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Poon et al. Human Resources for Health (2022) 20:70 Page 2 of 18
of widespread infections in countries worldwide. The during the pandemic might differ. Considering the press-
severity of COVID-19 infections, coupled with the large ing healthcare turnover issue and the lack of reviews
number of cases, placed immense pressure on health- addressing turnover intention among HCWs during the
care systems as high volumes of patients in need of acute COVID-19 pandemic, this mixed studies review aimed to
treatment required hospitalisation; some regions suffered examine factors affecting turnover intention in the con-
from high COVID-19 mortality rates due to shortages of text of the highly turbulent pandemic-focused healthcare
medical workers and equipment [2]. environment.
A major contributing factor to the shortages seen in the
health workforce is employee turnover [3]. In the context
Methods
of the healthcare sector, turnover intention refers to the
This review was conducted in accordance with the
willingness of healthcare workers (HCWs) to leave their
Joanna Briggs Institute (JBI) methodology for mixed
positions of employment for other positions in either the
methods systematic reviews using a convergent inte-
same or different professions [4]. The COVID-19 pan-
grated approach [21].
demic has caused an unprecedented wave of resigna-
tions. In the United States, the healthcare sector suffered
a net loss of 460 000 workers between February 2020 and Search strategy
November 2021 [5]. A survey of 1000 American HCWs An initial search of PubMed was performed with free-text
revealed that 18% of them left their jobs over the course words addressing the review aims to identify relevant arti-
of the pandemic, citing it as one of the driving factors cles. Titles, abstracts, and keywords of these articles were
behind their resignation [6]. Resignation rates of HCWs analysed, which informed the development of an extensive
in Singapore spiked in 2021, and this was driven by both search strategy, details of which are provided in Additional
foreign workers looking to migrate, as well as local work- file 1. Key search terms included ‘healthcare worker’, ‘turn-
ers experiencing severe levels of burnout [7]. over’ and ‘COVID-19’. Reference lists of all studies selected
High turnover rates cause difficulty in staffing health- for critical appraisal were also screened for additional
care facilities adequately, which has several implications studies. The PubMed, Embase, Scopus, CINAHL, Web of
on the quality of care delivered to patients. Low nurse Science and PsycINFO databases were searched for studies
staffing is associated with increased patient mortality published from January 2020 up to March 2022.
rates, as low nurse-to-patient ratios result in fewer nurs-
ing care hours available for each patient[8]. Other out- Study selection
comes such as patient safety and quality of care are also This review included studies that contained HCWs, fol-
adversely affected by healthcare understaffing, as higher lowing the definition by the World Health Organization
quantities of care are left undone at the end of shifts[9]. as an occupation group consisting of doctors, nurses,
Healthcare staff may suffer from stress and burnout when and other professionals or supporting personnel, such
being overworked to compensate for low manpower as pharmacists, physiotherapists, and occupational
which compromises their ability to deliver care, resulting therapists, that provide health services [22]. Studies that
in a higher risk of medical errors [10]. contained non-healthcare workers were also included if
While some factors are known, turnover is caused by HCWs made up the majority of study participants. The
multiple factors, and a fuller understanding of these fac- review also included studies examining factors that affect
tors must be pursued if employers seek to reduce turno- turnover intention, as defined in the background [4], as
ver. A search for systematic reviews published in the last an outcome. Quantitative, qualitative, and mixed meth-
10 years examining turnover intention among HCWs ods studies of any design in the English language were
on PubMed, PROSPERO and Google Scholar produced included. Only peer-reviewed articles were considered to
nine relevant systematic reviews [11–19]; none of which ensure high quality of included studies.
included studies that took place during the COVID-19 Following the search, all identified citations were col-
pandemic. One integrative review examined the COVID- lated and uploaded into EndNote 20 (Clavariate Ana-
19 pandemic’s impact on predictors of nurses’ turnover lytics). Two reviewers (RP & PL) first independently
intention, but it included mainly pre-COVID-19 stud- screened the titles and abstracts for assessment against
ies, which diminished the focus of the results regarding the inclusion criteria, followed by full-text articles. Full-
the current situation [20]. As evidenced by the increased text studies that did not meet the inclusion criteria were
turnover among HCWs, the COVID-19 pandemic has excluded. Any disagreements that arose between the two
likely exacerbated many previously existing factors reviewers were resolved through discussion, with the
that affected turnover intention. The challenges facing assistance of a third reviewer (SL) where necessary.
human resource management in healthcare before and
Poon et al. Human Resources for Health (2022) 20:70 Page 3 of 18
Abd-Ellatif et al. (2021), To determine the effect of Cross-sectional Physicians (411) Fear of COVID-19 Scale Fear of COVID-19 is Fear of COVID-19 may con‑
Egypt fear relating to COVID-19 (FCV-19S), Job satisfaction positively correlated with tribute to turnover intention
on job satisfaction and scale/satisfaction with turnover intention Job satisfaction may miti‑
turnover intention work scale (SWWS), Turno‑ Job satisfaction is gate turnover intention
ver intention scale (TIS-6) negatively correlated with
Poon et al. Human Resources for Health
turnover intention
Alameddine et al. (2021a), To investigate the Cross-sectional Nurses (265) Connor-Davidson Resil‑ Resilience is negatively Resilience may mitigate
Lebanon resilience levels, job ience Scale (CD-RISC) correlated with turnover turnover intention
satisfaction, and turnover intention
intention of nurses
(2022) 20:70
Alameddine et al. (2021b), To determine the level of Cross-sectional Nurses (511) Connor-Davidson Resil‑ Resilience is negatively Resilience may mitigate
Lebanon resilience in the nursing ience Scale (CD-RISC), correlated with turnover turnover intention
workforce and its relation‑ Copenhagen Burnout intention
ship to burnout, intention Inventory (CBI)
to quit, and perceived
COVID-19 risk
Alameddine et al. (2022), To determine the level of Cross-sectional Pharmacists (459) Connor-Davidson Resil‑ Resilience is negatively Resilience may mitigate
Lebanon resilience and its relation‑ ience Scale (CD-RISC) correlated with turnover turnover intention
ship to burnout, job satis‑ intention
faction, intention to quit,
and changes in practice
Alenazy et al. (2021), Aus‑ To examine the relation‑ Cross-sectional Critical care nurses (152) Practice Environment Scale A positive NPE is negatively Positive working condi‑
tralia/Saudi Arabia ship between percep‑ of the Nursing Work Index correlated with turnover tions may mitigate turnover
tion of nursing practice (PES-NWI), Nursing intention intention
environment (NPE), job Workplace Satisfaction Job satisfaction was not
satisfaction and intention Questionnaire significantly related to
to leave (NWSQ), Turnover Intention turnover intention
Scale (TIS-6)
Al-Mansour (2021), Saudi To investigate the associa‑ Cross-sectional Physicians (84) Perceived Stress Scale-10 Stress is positively cor‑ Stress and anxiety may con‑
Arabia tion between stress, social Nurses (134) (PSS-10), Multidimensional related with turnover tribute to turnover intention
support and turnover Paramedical workers (84) Scale of Perceived Social intention, with social sup‑ Social support may mitigate
intention among health‑ Administrative staff (209) Support (MSPSS) port acting as a mediating turnover intention
care workers factor
Blake et al. (2020), United To determine the effective‑ Cross-sectional Hospital employees (819) Warwick Edinburgh There is no significant asso‑ The relationship between
Kingdom ness of well-being centres Mental Well-being Scale ciation between turnover organisational support
on employee well-being (WEMWBS), Utrecht intention and well-being and turnover intention is
Work Engagement Scale centre access inconclusive
(UWES-9)
Page 5 of 18
Table 1 (continued)
Author, country Aim Study design Participants (n) Data collection and Results Themes derived
instruments
Cimarolli et al. (2021), To investigate the mediat‑ Cross-sectional Nursing home staff (1,683) Questionnaires Higher levels of COVID- Fear of COVID-19 may con‑
United States of America ing role of employer 19-related challenges are tribute to turnover intention
communication and staff positively correlated with Organisational support may
preparedness on turnover turnover intention mitigate turnover intention
intention Quality employer commu‑
nication is indirectly and
negatively associated with
Poon et al. Human Resources for Health
Fronda and Labrague To examine the relation‑ Cross-sectional Nurses (687) Coronavirus Anxiety Scale Coronaphobia is positively Fear of COVID-19 may con‑
(2022), Oman/Philippines ship between coro‑ (CAS), Brief Coping related to turnover inten‑ tribute to turnover intention
naphobia and frontline Skills Scale (BCS), Perceived tion, with social support Social support may mitigate
nurses’ organisational Social Support Question‑ and coping skills acting as turnover intention
and professional turnover naire (PSSQ) mediating factors
intention, and to assess
whether social support
Poon et al. Human Resources for Health
Labrague and de Los To examine whether Cross-sectional Nurses (261) Fear of COVID-19 Scale Fear of COVID-19 is Fear of COVID-19 may con‑
Santos (2021a), Oman/ frontline nurses’ fear of (FCV-19S), positively correlated with tribute to turnover intention
Philippines COVID-19 contributes to Job Satisfaction Index (JSI), turnover intention
psychological distress, Job Stress Scale (JSS)
work satisfaction and
intent to leave their organi‑
sation and the profession
Poon et al. Human Resources for Health
Labrague and de Los To examine the mediating Cross-sectional Nurses (270) Compassion Fatigue Scale Compassion fatigue is Compassion fatigue may
Santos (2021b), Oman/ role of resilience in the rela‑ (CFS), positively correlated with contribute to turnover
Philippines tionship between compas‑ Brief Resilient Coping Skills turnover intention, with intention
sion fatigue and frontline (BRCS) scale resilience acting as a medi‑ Resilience may mitigate
nurses’ job outcomes ating factor turnover intention
Labrague et al. (2021), To assess the influence Cross-sectional Nurses (259) COVID-19-Associated COVID-19-associated COVID-19-associated dis‑
(2022) 20:70
Oman/Philippines of COVID-19-associated Discrimination (CAD) scale, discrimination is positively crimination may contribute
discrimination on frontline Brief Resilient correlated with turnover to turnover intention
nurses’ mental health and Coping Skills (BRCS) scale, intention, with resilience Resilience may mitigate
their intention to quit Mental Health Inventory acting as a mediating turnover intention
the nursing profession (MHI) factor
with resilience acting as a
mediator
Lavoie-Tremblay et al. To examine the influence Cross-sectional Nurses (1705) Transformational Leader‑ High job demands and Difficult working conditions
(2021), Canada of caring for COVID-19 ship scale, Occupational poor job resources are may contribute to turnover
patients on nurse’s percep‑ Fatigue Exhaustion positively correlated with intention
tions of chronic fatigue, Recovery Scale (OFER) turnover intention Fear of COVID-19 may con‑
quality of care, satisfaction Nurses who were infected tribute to turnover intention
at work and intention to or had team members
leave their organisation who were infected with
and the profession COVID-19 were more likely
to experience turnover
intention
Lotfi et al. (2021), Iran To determine turnover Cross-sectional Operating room nurses Anticipated Turnover Scale Perceived safety climate is A strong safety climate may
intention among operating (190) (ATS), Safety Climate Scale negatively correlated with mitigate turnover intention
room nurses during the (SCS) turnover intention
COVID-19 outbreak and its
association with perceived
safety climate
Magnavita et al. (2021a), To measure the perception Cross-sectional Intensive care physicians Colquitt questionnaire, Physicians who put in high Difficult working conditions
Italy of organisational justice (120) Siegrist effort/reward effort and perceived low may contribute to turnover
and occupational stress imbalance model ques‑ rewards from work were intention
and how these varied in tionnaire more likely to experience A lack of organisational
relation to external factors, turnover intention support may contribute to
such as turnover intention turnover intention
Page 8 of 18
Table 1 (continued)
Author, country Aim Study design Participants (n) Data collection and Results Themes derived
instruments
Magnavita et al. (2021b), To assess the well-being Cross-sectional Physicians (105) Goldberg Anxiety and Healthcare workers who Difficult working conditions
Italy and mental health of the Nurses (47) Depression Scale (GADS), put in high effort were may contribute to turnover
workers after the first 10 Sleep Condition Indicator more likely to experience intention
months of the pandemic (SCI-02) turnover intention, with A lack of organisational
and to evaluate the extent perceived rewards from support may contribute to
to which their attitude work acting as a mediating turnover intention
toward the pandemic had factor
Poon et al. Human Resources for Health
changed
Majeed et al. (2021), To investigate the mediat‑ Cross-sectional Nurses (103) Modified Perceived Vulner‑ Perceived risk of COVID-19 Fear of COVID-19 may con‑
Pakistan ing role of perceived fear Paramedical staff (59) ability to Disease (PVD) is positively correlated with tribute to turnover intention
of COVID-19 between Doctors (16) questionnaire, Fear of turnover intention, with
perceived risk of COVID-19 COVID-19 Scale (FCV-19S) fear of COVID-19 acting as
and turnover intention a mediating factor
(2022) 20:70
Mercado et al. (2022), To examine the association Cross-sectional Medical staff (328) Mindful Self-Care Scale, Age and quality of Personal demographics may
United States of America between personal, work- Allied health staff (379) Mental Health Continuum work–life were negatively affect turnover intention
related and contextual Administrative staff (224) Short Form correlated with turnover Working conditions may
factors, and stress, burnout Others (36) (MHC-SF), Healthcare intention affect turnover intention
and turnover intention Worker Exposure Response
among healthcare workers &
in the COVID-19 pandemic Outcomes (HERO) Daily
Impact Index, Pandemic
Experiences and Percep‑
tions Survey, Perceived
Stress Scale (PSS-4)
Mirzaei et al. (2021), Iran To evaluate the relation‑ Cross-sectional Nurses (479) Impact of Event Scale- Job stressors were Difficult working conditions
ship between turnover Revised (IES-R), General positively correlated with may contribute to turnover
intention and job stressors Health Questionnaire turnover intention. Married intention
in nurses during the (GHQ), Turnover Intention nurses and male nurses Personal demographics may
COVID-19 outbreak Questionnaire, Job Content were more likely to experi‑ affect turnover intention
Questionnaire (JCQ) ence turnover intention Social support may mitigate
Social support was turnover intention
negatively correlated with
turnover intention
Naja et al. (2021), United To examine the conditions Cross-sectional Dieticians (371) Connor–Davidson Resil‑ Resilience is negatively Resilience may mitigate
Arab Emirates and changes in the work ience Scale (CD-RISC) correlated with turnover turnover intention
environment as well as intention
resilience and its correlates
among dieticians during
the COVID-19 pandemic
Page 9 of 18
Table 1 (continued)
Author, country Aim Study design Participants (n) Data collection and Results Themes derived
instruments
Nashwan et al. (2021), To compare nurses’ turno‑ Cross-sectional Nurses (512) Turnover Intention Scale Nurses were more likely to Fear of COVID-19 may con‑
Qatar ver intentions before and (TIS-6) experience turnover inten‑ tribute to turnover intention
during COVID-19 tion during the COVID-19
pandemic as compared to
beforehand
Öğütlü et al. (2021), Turkey To determine the relation‑ Cross-sectional Psychiatrists (217) Copenhagen Burnout Burnout is positively Burnout may contribute to
ship between stress, Inventory (CBI) correlated with turnover turnover intention
Poon et al. Human Resources for Health
Said and El-Shafei (2021), To assess occupational Cross-sectional Nurses (420) Expanded Nursing Stress Nurses with longer work‑ Difficult working conditions
Egypt stress, job satisfaction, and Scale (ENSS), Specific ing hours and more night may contribute to turnover
intent to leave among COVID-19-Associated duties per week were intention
nurses dealing with sus‑ Stressors (SCAS), McClo‑ more likely to experience
pected COVID-19 patients skey/Mueller Satisfaction turnover intention
Scale (MMSS)
Schug et al. (2022), To examine the correlation Cross-sectional Nurses (757) Effort-reward imbalance Perceived reward levels A lack of organisational
Poon et al. Human Resources for Health
Germany between frequency and scale were negatively correlated support may contribute to
associated factors of sick (ERI), PHQ-2 (Patient Health with turnover intention turnover intention
leave and intention to quit Questionnaire), General‑ Changing work depart‑ Difficult working conditions
among nurses ized Anxiety Disorder ments during the may contribute to turnover
2-item (GAD-2) pandemic was associated intention
with increased turnover High levels of depression
(2022) 20:70
Varasteh et al. (2021), Iran To explore the factors Qualitative descriptive Nurses (19) Semi-structured interview Professional commit‑ Professional commitment
affecting nurses’ inten‑ ment was associated with may mitigate turnover
tions to leave or stay in reduced turnover intention intention
their profession during the Fear of COVID-19 was Fear of COVID-19 may con‑
Poon et al. Human Resources for Health
turnover intention
Wibowo and Paramita To investigate the impact Cross-sectional Nurses (188) Modified Mindfulness Mindful leadership was Organisational support may
(2022), Indonesia of mindful and empathetic Attention Awareness associated with reduced mitigate turnover intention
leadership on resilience Scale (MAAS), Motivating turnover intention, with Self-regulation may mitigate
and turnover intention, Language Scale, Connor- self-regulation acting as a turnover intention
with self-regulation as a Davidson Resilience Scale mediating factor
mediating variable (CD-RISC)
Wood et al. (2021), United To understand the experi‑ Mixed-methods Nurses (124) Questionnaires (Likert PPE shortages and fear Fear of COVID-19 may con‑
Kingdom ences of advanced practice scales & open-ended of COVID-19 were both tribute to turnover intention
nurses during the COVID- questions) associated with turnover
19 pandemic in relation intention
to safety, shortages and
retention
Yáñez et al. (2020), Peru To assess the anxiety, Cross-sectional Hospital technicians (80) Generalized Anxiety Disor‑ Younger workers were Personal demographics may
distress, and turnover Nurses (63) der (GAD-7) scale, Kessler more likely to experience affect turnover intention
intention of healthcare Pharmacists (63) Psychological Distress turnover intention
workers during the COVID- Physicians (53) scale (K6)
19 pandemic Hospital volunteers (20)
Others (24)
Yang et al. (2021), China To elucidate the effects Cross-sectional Doctors, nurses and allied Perceived Social Support Workplace violence was Difficult working conditions
of workplace violence on health workers (1,063) (PSS) scale, Depression positively correlated with may contribute to turnover
turnover intention among Anxiety Stress Scales-21 turnover intention, with intention
Chinese health care work‑ (DASS-21) social support and mental Social support may mitigate
ers, and to identify the health acting as mediating turnover intention
potential mediators in this factors General stress and anxiety
relationship may contribute to turnover
intention
Page 12 of 18
Poon et al. Human Resources for Health (2022) 20:70 Page 13 of 18
turnover intention [54, 58, 61, 63]. Furthermore, two Chi- positively correlated with turnover intention. Two stud-
nese studies found that HCWs were at a greater chance ies from Turkey and China found that being subjected
of experiencing turnover intention if they were suffering to workplace violence was associated with increased
from poor mental health or a combination of psychoso- turnover intention among HCWs, as traumatic experi-
cial issues [40, 68]. A study that surveyed nurses from ences accelerated burnout and mental health deteriora-
the Philippines found that turnover intention was posi- tion [55, 68]. HCWs were also more likely to experience
tively correlated with compassion fatigue [43]. In addi- turnover intention if they faced changes at work [63]
tion, COVID-19-associated discrimination was positively or deployment to other departments [55, 60]. A study
correlated with turnover intention, as it contributed to from Iran found that the perceived safety climate was
aggravating factors, such as poor mental health and burn- negatively correlated with turnover intention [46]. In
out [44]. On the other hand, resilience within HCWs was addition, nurses who perceived greater issues with
found to be negatively correlated with turnover intention patient safety and quality, as well as work environment,
[27–29, 52], with two studies concluding that it acted as were at a greater risk of experiencing turnover inten-
a protective mechanism against factors that contributed tion, as they were more substantially affected by moral
to turnover intention [43, 44]. Professional commitment distress [62]. Two Italian studies found that HCWs who
and job satisfaction were other psychological factors that put in higher levels of effort in their work also had a
were associated with reduced turnover intention within higher chance of experiencing turnover intention [47,
nurses and physicians, respectively [26, 64]. 48]. Other factors that were associated with turnover
intention among HCWs include poor job resources
Socio‑demographic characteristics [45], low staff morale [45] and perceived high pandemic
Three studies noted that certain socio-demographic impact on practice [57]. Conversely, a study from Saudi
characteristics significantly influenced the likelihood of Arabia found that a positive nursing practice environ-
HCWs experiencing turnover intention [34, 51, 67]. Two ment was negatively correlated with turnover intention
studies reported that married nurses were more likely to [30].
experience turnover intention [34, 51]. Mirzaei et al. [51]
also noted that male nurses experienced turnover inten-
tion at a higher rate. While two American studies found Organisational support
that seniority in nurses was associated with greater turn- Several domains of organisational support were exam-
over intention [34, 50], this was in contrast to findings ined by studies and were found to impact turnover
in a study from Peru [67], which reported that younger intention among HCWs in various ways. Organisational
HCWs were more prone to experiencing turnover inten- trust and perceived organisational support were core
tion. Social affiliation was also identified by some studies factors that protected nurses from increased turnover
to impact turnover intention, as nurses with strong ties intention [63]. Other factors, such as quality employer
to friends and family perceived greater social support. communication and job preparedness, were also asso-
Three studies determined that social support was able to ciated with decreased turnover intention among nurs-
act as a mediating factor in reducing turnover intention ing home staff [33]. Moreover, leadership support was
among nurses [31, 39, 68]. A direct correlation between linked to decreased turnover intention among nurses
social support and reduced turnover intention was also [41, 65]. A qualitative study from Iran discovered that
established by an Iranian study [51]. Conversely, an Aus- both a positive organisational atmosphere and organisa-
tralian study found that nurses who did not feel con- tional motivation were associated with reduced turno-
nected to their colleagues or team were at greater risk of ver intention among nurses [64]. In contrast, Australian
experiencing turnover intention [35]. nurses who did not feel connected to their organisation
were more likely to experience turnover intention [35].
Adverse working conditions HCWs who perceived low rewards from work were also
The COVID-19 pandemic placed heavy pressure on more prone to experiencing turnover intention [47, 48,
healthcare systems, resulting in excessive job demands 60]. A study from the United Kingdom did not find any
and tumultuous work environments. Increases in work- significant association between turnover intention and
load were widely found to be positively correlated with access to well-being centres [32].
turnover intention among HCWs [38, 45, 55, 56]. In
addition, HCWs who worked long hours, or faced an Discussion
increase in working hours due to the pandemic, were Findings of this study identified multiple factors influenc-
more prone to experiencing turnover intention [40, 50, ing turnover intention among HCWs during the COVID-
55, 59]. Mirzaei et al. [51] found that job stressors were 19 pandemic. The five emerged themes encompassed
Poon et al. Human Resources for Health (2022) 20:70 Page 14 of 18
factors ranging from individual, interpersonal, job- considerations of the consequences and the initiation of
related, and organisational determinants, and many of mitigating health policy measures.
which were known factors prior to the pandemic [11– Resilience within HCWs was observed to be a vital pro-
19]. However, the theme ‘fear of COVID-19 exposure’ tective factor against turnover intention, as it enabled
was unique and specific to this pandemic. them to better respond to the disruptions that occurred
HCWs’ fear of COVID-19 infection emerged as the during the pandemic. Staff who exhibit resilience are able
most prevalent theme, especially during the initial stage to effectively use coping skills that reduce the psychologi-
of uncertainty and limited understanding of the viru- cal burden of treating COVID-19 patients [81]. However,
lence, transmission, and health management of COVID- when confronted with extended turmoil, HCWs found
19. Prior to the widespread deployment of vaccines, it increasingly difficult to remain unaffected while car-
COVID-19 was potentially a life-threatening infection. rying out their everyday duties. High levels of psycho-
Some HCWs were at high risk of exposure while tending logical and moral distress were experienced by HCWs as
infected patients in the face of shortages of fundamental they witnessed patient death and suffering on a massively
resource, such as PPE [70]. The possibility of spreading increased scale during the pandemic [82]. To make mat-
COVID-19 to family members also created a concern- ters worse, frontline HCWs around the world endured
ing overlap between nurses’ professional and personal episodes of harassment and violence at the hands of
lives [71]. Several countries, such as Singapore and Hong members of the public who held irrational beliefs about
Kong, which experienced the 2002–2004 severe acute the transmissibility of COVID-19 [83]. HCWs of Chi-
respiratory syndrome (SARS) outbreak, reported higher nese and other Asian ethnicities were subjected to harsh
pandemic preparedness and response resources, e.g., COVID-19-related racial discrimination, adding to the
PPE and negative pressure rooms in intensive care units difficulties experienced during the pandemic [68, 84].
(ICU), and this could have better mitigated HCWs’ fears Future studies could look into the impact of racism on
regarding COVID-19 [72]. Other strategies for address- turnover intention among HCWs. It is important to pro-
ing fear include clear, trustworthy, and timely COVID- vide HCWs with opportunities to ‘let off steam’, obtain
19-related interpersonal, institutional and systemwide peer support, allow access to keep in contact with fam-
communication, to avoid disparities in understanding ily and friends, and perform daily quick check-ins and
and reduce work-related stress among HCWs [73, 74]. check-outs to monitor their health status, support them
The adverse working conditions as a result of pandemic emotionally and bolster their resilience [85]. At the
emergency responses contribute to HCWs’ turnover organisational level, ensuring the provision of accessible
intention. With the increase in patients requiring ICU and optimal professional psychosocial support, such as
care and mass testing services, HCWs faced increased by having a multi-disciplinary psychosocial team, 24/7
workloads, higher nurse-to-patient ratios and deploy- hotline and efficient referral system could also be facili-
ment to areas requiring more staffing [75]. In particular, tated [85]. Measures to provide psychosocial support and
mass staff deployment means that members of a health- mitigate secondary stressors related to the basic needs of
care team are not familiar with each other, which can life (e.g., childcare, grocery shopping) for HCWs in isola-
impact interprofessional collaboration [76]. This results tion or quarantine should also not be neglected [86].
in continuous tensions between healthcare profession- Several studies in this review investigated different
als attempting to maintain patient safety under trying domains of organisational support. In essence, any form
conditions [77]. In addition, the limitations posed by of organisational support that can be perceived by HCWs
public health measures forced HCWs to quickly adapt will empower them to adapt to the demands of their
new and frequently changing protocols and establish work and motivate them to perform their duties to the
new workstreams, such as delivering care through tel- best of their ability [87]. During a health crisis leader-
ehealth [78]. Expectations of maintaining high standards ship is challenging, but it is in times of crisis that the vis-
of quality care remained, despite HCWs having to adapt ibility and roles of leaders become apparent and provide
to fluid and demanding working environments, facing opportunities for healthcare teams to grow and develop
new challenges and learning new skills [79]. Inevitably, stronger relationships. Apart from communication and
HCWs experienced immense pressure and eventually empowerment, Walton and colleagues [86] recom-
burnout, which is a major contributor to turnover inten- mended the importance of understanding the humanity
tion [55]. Burnout accompanies the progression of emo- of the situation and exercising humility in demonstrat-
tional overburdening, deteriorating mental well-being, ing role responsibilities among healthcare leaders in
and job dissatisfaction, which may drive HCWs to con- supporting their teams through the pandemic. Similarly,
clude that resignation is their best option [80]. In hind- being present was especially powerful in boosting nurses’
sight, these phenomena could be alleviated by judicious morale—high visibility of nurse leadership was evident
Poon et al. Human Resources for Health (2022) 20:70 Page 15 of 18
during instances, where nurse leaders were physically reform [95]. Ultimately, it is in the interest of public
present in COVID-19 treatment units to assist in various health stakeholders to capitalise on this opportunity to
roles, building confidence and encouraging staff nurses to re-evaluate the support and compensation of HCWs,
continue working [88]. particularly in countries that face an increased demand
Interestingly, this review did not identify financial for health services due to ageing populations.
renumeration as a factor contributing to turnover inten-
tion in times of the COVID-19 pandemic. Similarly, in
another systematic review that identified barriers to Implications for future research
manpower retention during health emergencies, poor While it would be valuable to healthcare leaders and
leadership communication, emotional support and fam- policymakers for identifying the significant contribut-
ily worries were most commonly reported, while lacking ing factors impacting HCWs’ turnover intention in times
budget in training, salaries and compensation of person- of pandemic crisis, it was not the intent of this review to
nel were least reported [89]. While it is unclear what con- identify the strength of relationships between them, or
tributes to such a finding, financial renumeration is an the changes in weighting of these factors. Some of these
important factor that impacts the livelihood of HCWs. existing factors might have become more important or
Reimbursing HCWs to continue their professional edu- less important during the COVID-19 pandemic. Future
cation, establishing career ladders with attractive com- quantitative works could examine this. Future research
pensation progression, and maintaining salaries that are conducted in times of crises could also focus on specific
reasonably comparable with other local healthcare facili- factors, such as working conditions or burnout, to elu-
ties are recommended forms of financial expenditure that cidate the main drivers that influence them and how to
can reduce turnover intention [90]. better support or incentivise HCWs to stay in their jobs.
This review also identified that certain socio-demo- In addition, specific vulnerable population groups, e.g.,
graphic characteristics were associated with turno- migrant HCWs and healthcare profession minorities,
ver intention. Married nurses struggled to achieve a could be examined as they may face different and unique
work–life balance, especially those with children, as the challenges in their personal lives and lines of work, respec-
pandemic caused increased childcare needs as a result tively. As border controls inevitably ease over time, inter-
of the implementation of virtual learning during lock- national travel will likely return to pre-pandemic levels
downs [91]. The inconsistent finding on impact of age and researchers could also investigate global labour mar-
on turnover intention was likely attributed by the dif- ket trends, such as migration, when analysing data related
ferent pandemic-related challenges faced by young and to HCWs turnover. While the fear of COVID-19 is a pan-
senior HCWs. Older HCWs were more susceptible to demic-specific factor, the remaining factors identified in
severe COVID-19 infection and faced age-related dis- this review were already present before the pandemic and
crimination, while the less experienced younger HCWs were exacerbated by the extreme conditions of the pan-
had lesser personal resources and might be not as capa- demic; it is unclear whether these factors will diminish as
ble of protecting their well-being via self-regulation [92]. the pandemic wanes, and thus future research can also
Special attention should thus be given to young/inex- serve to investigate the persistence of these factors.
perienced and conversely, older HCWs. Social support
protects against mental health stressors, acting similar to Strengths and limitations
resilience in helping HCWs cope better during such diffi- This review captured studies conducted across a wide
cult times [93]. Other vulnerable groups not identified in range of countries with different cultural and social con-
our review included the migrant HCWs who have been texts. However, it did not include grey literature and
separated from their families since the start of pandemic studies published in non-English languages. The meth-
and were unable to visit their country of origin due to odological quality of the studies included in this review
travel or hospital administration restrictions [94]. ranged from medium to high, but some studies did not
Prior to the pandemic, many countries were fac- account for confounding factors in their analyses, which
ing healthcare workforce shortages, and the pandemic would likely influence the reliability of their results.
brought added challenges for healthcare stakeholders in While the included studies focused on turnover inten-
retaining the current workforce. Nonetheless, the pan- tion instead of actual turnover, there is evidence that
demic has also stirred sympathy and gratitude toward these are correlated [69]. Due to the lack of heterogeneity
the plight of HCWs among citizens, providing a crucial across the included studies, a meta-analysis could not be
opportunity for policymakers to justify and commit the performed.
resources required to achieve meaningful healthcare
Poon et al. Human Resources for Health (2022) 20:70 Page 16 of 18
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