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Impact of the COVID-19 Pandemic Crisis on Turnover Intention Among Nurses in Emergency Departments in Thailand: A Cross Sectional Study
Songwut Sungbun, Siripan Naknoi, Panjasilpa Somboon
This is a preprint; it has not been peer reviewed by a journal.
https://doi.org/ 10.21203/rs.3.rs-2597747/v1
This work is licensed under a CC BY 4.0 License
You are reading this latest preprint version
Background : During the COVID-19 pandemic in Thailand, a large volume of COVID-19 patients was referred to hospital emergency departments (EDs). This increased job demand and job strain among ED nurses, resulting in a high risk for intention to leave their organization. This study had two aims: 1) to investigate turnover intention during the COVID-19 pandemic among ED nurses; and 2) examine the effect of organization resources, maladaptive regulation, and job burnout on nurses’ turnover intention.
Method : This cross sectional study investigated 322 ED nurses. We divided participants into two groups: dark-red zone areas (pandemic crisis areas) and non-red zone areas (non-pandemic crisis areas). Descriptive statistics, Pearson’s correlation analysis, and multiple linear regression (stepwise method) were used to analyze factors that predicted turnover intention.
Results : Most participants were female and the mean age was 34.54 years. Overall, the mean score for the Turnover Intention Scale was 18.27±4.69 and 72.8% of ED nurses in dark-red zone areas desired to leave their organization. During the pandemic, motivation, exhaustion, and cognitive impairment positively influenced turnover intention among ED nurses in dark-red zone areas. Low availability of organization resources was associated with an increase in the turnover intention rate. Maladaptive regulation, exhaustion, and cognitive impairment positively influenced turnover intention among ED nurses in non-red zone areas.
Conclusion : Exhaustion and cognitive impairment are important dimensions of burnout that are associated with turnover intention among ED nurses. We suggest that promoting safe workplace environments and implementing interventions to reduce job demand and job strain for ED nurses may reduce turnover intention.
COVID-19 rapidly became widespread globally in 2021. In Thailand, the number of patients infected with COVID-19 quickly increased in the fourth wave and peaked in the middle of August 2021. To respond to the crisis situation, the Thai Government established the Center for COVID-19 Situation Administration and identified 29 “dark-red zone” provinces that were COVID-19 pandemic crisis areas [ 1 ]. However, the number of patients in hospitals was overwhelming, which directly impacted the healthcare system. As of September 2020, there were 126,313 patients admitted to hospital with COVID-19, of which 4,691 patients were in intensive care units. Moreover, vaccine supply limitations posed serious problems for distributing the vaccine to the general Thai population. At that time, 20.33% of Thai people had received the first dose of the COVID-19 vaccine and 5.59% had received the second dose [ 2 ].
The emergency department (ED) acts as the frontline response to any public health emergency. Nurses are the largest cadre of healthcare providers in the ED and must perform their day-to-day roles as well as managing situations of overcrowding [ 3 ]. This high job demand coupled with low organization resources, such as the lack of personal protective equipment (PPE) and unsustainable healthcare policies has been associated with exhaustion [ 4 – 5 ]. Healthcare providers who experience exhaustion are still required to maintain physical, emotional, and cognitive effort while at work. Exhaustion among healthcare providers has been related to an increased prevalence of mental health disorders and negative outcomes related to job performance. The job demands-resources (JD-R) theory and self-regulation model seek to explain the role of self-regulation in influencing employees’ strategies to prevent or reduce job strain and burnout. Employees with high job demand and strain levels may be affected by maladaptive regulation of cognition and behaviors, including inflexible coping and self-undermining [ 6 ].
Previous research showed that a major negative effect of long-term burnout among healthcare providers was a significant association with high turnover intention [ 7 – 13 ]. In Thailand, the shortage of nurses is an attrition crisis, as indicated by a nurse to population ratio of 1:400, and the prediction of loss rate is approximately 7,000 nurses per year. This means the number of nurses in Thailand is predicted to drop to 194,260 by 2026 [ 12 ]. Since the onset of COVID-19 in November 2019, many studies have identified factors that influenced turnover intention among frontline nurses [ 9 – 13 ], although no studies have compared the impact of the disruption in emergency care delivery due to COVID-19 between non-red zone areas (areas with low COVID-19 cases reported) and dark-red zone areas (COVID-19 pandemic crisis areas). A systematic review showed that frontline nurses were at higher risk for mental health disorders than in other healthcare providers during the COVID-19 pandemic [ 14 – 16 ]. Emergency nurses also face a high risk for emotional stress, poor working environments, and worry about being infected because they took care of patients before diagnosis. The COVID-19 pandemic influenced organization resources as well as ED nurses’ self-regulation (e.g., inflexible coping and self-undermining). However, few studies have explored turnover intention among ED nurses in Thailand, where there were rapid pandemic-related changes in government and health policy, emergency care delivery, and emergency medical services that interfered with practice in all areas. The imbalance between job demand, organization resources, and safe workplace environments associated with these changes may affect turnover intention among ED nurses [ 4 , 8 , 11 ]. Therefore, this study aimed to examine the effect of emotional intelligence, self-regulation, organization resources, high job demand, and job burnout on turnover intention among ED nurses during the COVID-19 pandemic crisis in Thailand.
2.1 Research design and participants
This study used a cross-sectional design to investigate ED nurses’ turnover intention. Data were collected with a self-report questionnaire. Registered nurses who worked in the ED during the peak of the COVID-19 pandemic in Thailand were included in this study. The required sample size for this study was calculated using G power software, which showed that 322 nurses were needed to achieve 80% power, with an α-value of .05, and an anticipated effect size of 0.05 with nine predictors [ 17 ]. Participants were divided into two groups: 1) ED nurses that worked in areas with low infection rates (non-red zone group) and 2) ED nurses that worked in COVID-19 pandemic crisis areas (dark-red zone group). A snowball sampling method was used to select eligible registered nurses who: 1) had work experience in the ED, emergency medical services, or dispatch center for ≥ 1 year; and 2) had worked in the ED during the fourth wave of the COVID-19 pandemic in Thailand.
2.2. Questionnaire design 2.2.1 Burnout Assessment Tool
To assess burnout during the COVID-19 pandemic, we used the short version of the Burnout Assessment Tool (12 items) [ 17 ], which has four dimensions: exhaustion, mental distance, cognitive impairment, and emotional impairment. Responses are on a 5-point Likert scale from 1 (strongly disagree) to 5 (strongly agree). A higher score on each dimension indicates a higher level of burnout. The content validity index (CVI) and Cronbach’s alpha were 0.98 and 0.94, respectively.
2.2.2 Turnover Intention Scale (TIS-6 version 4)
The TIS-6 was used to examine turnover intention among participating ED nurses [ 18 ]. The six questionnaire items are answered on a 5-point Likert scale from 1 (strongly disagree) to 5 (strongly agree). The minimum score is 6 and the maximum is 30. A total score below 18 indicates a desire to stay in the organization, and scores above 18 indicate a desire to leave. The CVI and Cronbach’s alpha for the TIS-6 in this study were 0.98 and 0.92, respectively.
2.2.3 Organization resources and self-regulation
The tool used to assess organization resources and self-regulation comprised three parts that explored organizational resources (four items), emotional intelligence (15 items), and maladaptive regulation (four items) [19–21]. We developed these items based on the JD-R theory and self-regulation framework and focused on the COVID-19 pandemic. ED nurses were asked to rate their agreement with each item using a 5-point Likert scale from 1 (strongly disagree) to 5 (strongly agree). For the organizational resources section, the scores range from 4–20; a higher score indicates greater organizational resources. An example item is “My hospital administrators provided enough PPE for healthcare providers.” The CVI and Cronbach’s alpha for this part of the questionnaire were 0.87 and 0.82, respectively. The items assessing emotional intelligence covered four dimensions: self-awareness, self-regulation, work motivation, and social skills. The scores range from 15 to 75; scores of 15–25 indicate low emotional intelligence, 26–50 indicate medium emotional intelligence, and 51–75 indicate high emotional intelligence. An example item is “During the COVID-19 pandemic, I can adapt myself to any situation.” The CVI and Cronbach’s alpha for these items were 0.87 and 0.82, respectively. The items evaluating maladaptive regulation covered psychological distress and self-undermining with scores ranging from 4 to 25. A higher score indicates greater maladaptive regulation. An example item is “I fear to take care of patients with COVID-19 infection.” The CVI and Cronbach’s alpha for these items were 0.87 and 0.82, respectively.
Data were collected from September 1 to October 31, 2021, which was during the peak of the COVID-19 pandemic in Thailand. During this period, Thailand declared a national lockdown. After obtaining research approval from the relevant ethics committee, we disseminated an invitation link to the online questionnaire through the ED nurse group LINE application and Facebook pages. The invitation to complete the survey set out the objectives of the study and included a self-assessment eligibility check that participants completed before proceeding with the questions. Those who were interested in participating in the survey were asked to provide online informed consent, and then proceed to complete the questionnaire via an online platform (Google Forms).
The collected data were analyzed using SPSS version 22. The demographic and major variables in this study were analyzed using descriptive statistics, including percentages, means, and standard deviations. Multiple linear regression (stepwise method) was used to identify which variables could explain turnover intention among ED nurses during the COVID-19 pandemic, after testing the linearity, normality, homoscedasticity, and multicollinearity of the data. The level of significance for this study was set at p < .05.
This study received ethical approval from the relevant ethic committee (No.:136/2564). The objectives of the study were clearly stated for all participants. All participants provided written electronic consent before responding to the survey.
In total, 332 participants completed the questionnaire. As shown in Table 1 , participants comprised two groups: the non-red zone group (n = 208) and the dark-red zone group (n = 114). Most participants in both groups were female (68% and 78.1%, respectively). The mean age in the non-red zone group was 34.20 years and that in the dark-red zone group was 35.64 years. Most participants were trained ED nurses or ED nurse practitioners (44.7% and 52.6% in the non-red zone and dark-red zone groups, respectively) and were not married (65.9% and 63.2%, respectively). The largest number of participants in both groups worked in government hospitals (88.9% and 95.6%, respectively) and 57.0% of the dark-red zone group worked > 60 hours per week. Most ED nurses (83/114, 72.8%) in the dark-red zone group desired to leave their organization, whereas 44.7% of ED nurses (93/208) in the non-red zone desired to stay (Table 1 )
Characteristics of participating emergency nurses
Training in nursing specialty program
Emergency nurse/emergency nurse practitioners
The average number of patients with COVID-19 was lower in the non-red zone group than in the dark-red zone group (3.51 ± 2.68 vs. 20.96 ± 7.62). The average score for turnover intention in the non-red zone group was 17.27 ± 5.81 and in the dark-red zone group was 18.39 ± 4.69. The mean emotional intelligence score was higher in the non-red zone group than the dark-red zone group (59.14 vs. 55.77). The dark-red zone group had a higher mean burnout score than the non-red zone group (35.16 vs. 32.26), but the two groups had similar mean maladaptive regulation scores (11.75 vs. 11.12) (Table 2 ). The Pearson’s correlation analysis showed there was a significant positive correlation between overall burnout score and turnover intention score in both groups (non-red zone group: r = 0.688, p < .001 vs. dark-red zone group: r = 0.32, p < .001). Turnover intention in the dark-red zone group was significantly negatively correlated with motivation (r = − 0.525, p < .001) and organization resources (r = − 0.157, p = .047). Turnover intention in the non-red zone group was significantly negatively correlated with age (r = − 0.279, p < .001), self-awareness (r = − 0.222, p = .001), self-regulation (r = − 0.242, p < .001), motivation (r = − 0.245, p < .001), social skills (r = − 0.258, p < .001), and organization resources (r = − 0.336, p < .001). There was also a correlation between a high maladaptive score and turnover intention (Table 2 ).
Correlations between key st
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