SEEMEDJ 2019, VOL 3, NO. 2 Turnover intention among nurses 33 Southeastern European Medical Journal, 2019; 3(2) Original article Influence of Work Motivation, Work Environment and Job Satisfaction on Turnover Intention of Croatian Nurses: A Qualitative Study 1 Eva Smokrović 1, 2, Ivana Gusar 1, 3, Dijana Hnatešen 1, 4, Kristina Bačkov 1, 5, Antun Bajan 1, 6, Zvjezdana Grozdanović 1, 7, Harolt Placento 1, 7, Boštjan Žvanut 8 1 Faculty of Medicine, Josip Juraj Strossmayer University of Osijek, Osijek, Croatia 2 Institution for home healthcare and rehabilitation Helena Smokrović, Rijeka, Croatia 3 Department of Health Studies, University of Zadar, Zadar, Croatia 4 Clinical Hospital Center Osijek, Osijek, Croatia 5 General Hospital Zadar, Zadar, Croatia 6 Department of Emergency Medicine Osijek, Osijek, Croatia 7 General Hospital Našice, Našice, Croatia 8 University of Primorska, Faculty of Health Sciences, Koper, Slovenia Corresponding author: Ivana Gusar, igusar@unizd.hr Received: Sep 3, 2019; revised version accepted: Dec 5, 2019; published: Dec 16, 2019 KEYWORDS: job satisfaction, motivation, turnover, qualitative research, nurses Abstract Aim: The purpose of this study was to examine, identify and describe the factors that influence the turnover intention of nurses in Croatia. Methods: A qualitative descriptive phenomenological study was conducted in June 2018. The participants were 20 registered nurses working full time who were employed in different cities in the Republic of Croatia, working in different healthcare institutions and in different medical fields. The data were obtained from interviews and were analysed and interpreted using the content analysis method. Results: During data analysis, four main ideas emerged as follows: job satisfaction, work motivation, psychological factors (individual) and structural factors – work environment. Job satisfaction has been identified as a key factor with direct impact in nurses' turnover intention. Work motivation, psychological factors (individual) and structural factors – work environment does not have a direct influence on the nurses' intention to leave their job, but they have a significant indirect impact through job satisfaction. Conclusion: Recognizing nursing challenges in the healthcare system and the factors which influence the intention of nurses to leave their workplace can help with the development of a clear strategy and retention measures based on the factors that influence the nurses’ turnover intention. (Smokrović E, Gusar I, Hnatešen D, Bačkov K, Bajan A, Grozdanović Z, Placento H, Žvanut B. Influence of Work Motivation, Work Environment and Job Satisfaction on Turnover Intention of Croatian Nurses: A Qualitative Study. SEEMEDJ 2019; 3(2); 33-44) SEEMEDJ 2019, VOL 3, NO. 2 Turnover intention among nurses 34 Southeastern European Medical Journal, 2019; 3(2) Introduction The last decade has been marked by a steady increase in the proportion of the elderly, which has in turn increased the need for healthcare (1). The increasing need for healthcare is accompanied by globalization, which, in addition to increased information mobility, also enables greater mobility of people (2). The effects of employees leaving their workplace have caught the attention of many professionals who consider it to be one of the most expensive and difficult challenges faced by modern organizations (3). International migration of nurses in recent years has become a major issue in international political circles (4). Croatia’s accession to the European Union in 2013 opened a way to other European countries for many Croatian professionals, including healthcare professionals. Like other European countries, the Republic of Croatia is currently facing a shortage of nurses and nurse technicians, which has attracted the attention of the Croatian media for several years (5-7). Another phenomenon that is covertly present, in addition to the lack of professionals with qualifications, is that a great number of nurses do not want to work in the current working conditions. The studies conducted so far indicate a lack of empirical knowledge about the predictors of the intention to leave the workplace. This paper focuses on the influence of certain factors on the intention of nurses to leave their workplace, institution, or country. The phenomenon of abandonment of the nursing profession, resulting in a decline in the number of educated nurses, poses a significant problem for the functioning of healthcare systems in many countries (2, 8), and especially in the less developed countries of the European Union (EU) (9, 10). The financial crisis, limitations of the national budget, reforms of the healthcare system, the workload of healthcare professionals, the decrease (or stagnation) of personal incomes and unpaid overtime represent just some of the factors that have affected the nursing profession both all over the world and in Croatia (2). The results of numerous studies conducted on the topic indicate that a growing number of nurses are leaving their workplace (11, 12), going to a different institution, or even leaving the nursing profession altogether. Employee’s intention to leave the primary workplace is defined as the deliberate, voluntary and self- initiated change of job or institution. The intention to leave actually reflects an employee’s attitude toward their current workplace or organization (13). From the employee’s perspective, the intention to leave can be seen as a positive phenomenon. Reasons for positive perception of the above relate to better job offers that include higher income and/or intangible benefits, such as greater autonomy and new challenges (14). Moyce, Lash and de Leon Siantz (2016) cite the so called “push and pull” factors as reasons why nurses leave their workplace. “Push” factors are the factors that encourage nurses to leave and “Pull” factors are the factors that attract them to new opportunities and challenges (2). Among the most common factors that drive nurses to leave are dissatisfaction with the working conditions, stress and emotional exhaustion, while the factors that attract them are higher income, greater autonomy, recognition and respect within a team of healthcare professionals (2). In a study conducted in Singapore on a sample of 814 nurses, Goh and Lopez (2016) describe leadership skills and work environment as the most important predictors of the nurses’ intention to leave (15). An individual’s statement of the intention to leave has, in previous research, been proved to be a significant predictor of their leaving the workplace (16). Simply put, an individual who verbally expresses their intention to leave a job is significantly more likely to leave the job than others. The validity of the above predictor has been highlighted in several studies of nurses’ intention to leave (17– 19). Brewer and Kovner (2014) propose and describe the concept of nurse turnover based on SEEMEDJ 2019, VOL 3, NO. 2 Turnover intention among nurses 35 Southeastern European Medical Journal, 2019; 3(2) a model that includes job satisfaction, organizational commitment, intention to leave and intention to seek a new position. Official data on Croatian nurses who have left the workplace or migrated are not available; however, according to Kovačević Barišić and Lepan Stefančić (2015), around 400-500 nurses left Croatia shortly after Croatia joined the EU, in 2014 and 2015. Identifying and understanding the factors that significantly affect job satisfaction and the level of nurses’ work motivation is useful for preventing dissatisfaction and decreasing the intention of nurses to leave their current workplace or profession (20). Barać et al. (2015) performed a study to that effect on Croatian nurses, but it focused on job satisfaction, which is a predictor of nurses leaving the workplace (21). Smokrović et al. (2019) conducted a quantitative study, where the impacts of work motivation, organisation, and absenteeism on job satisfaction and intention to leave were considered (22). However, the aforementioned studies assessed the impact of predefined factors identified in a review of the literature on job satisfaction and turnover intention. The participants did not have the option of adding extra factors. Hence, the goal of this study was to identify, through the use of the qualitative research method, potential factors that have an impact on job satisfaction and turnover by considering the opinions of Croatian nurses. We posed the following research question: Which factors influence the turnover intention of Croatian nurses? Methods A descriptive qualitative study was conducted in accordance with the guidelines on qualitative research (23). Study Design A qualitative approach was applied in order for us to gain a profound understanding of the nurses’ opinions and attitudes in the context of work motivation, work environment, job satisfaction and intention to leave. After a thorough review of the available literature and clearly defined ideas, certain claims/situations were established based on the existing theories and insights gained into each particular construct. The central phenomenon which was examined was the experience of nurses related to work motivation, job satisfaction and work environment, and the importance and impact of these concepts on turnover intention were examined as well. Participants In order to obtain a heterogeneous sample of participants, the study was conducted in different Croatian cities: Rijeka (five participants), Osijek (five participants), Zadar (five participants), and Našice (five participants); in different healthcare institutions (primary – five participants, secondary – 10 participants, and tertiary – five participants); 15 participants were employed in public, and five in private healthcare institutions); and in different nursing fields: 15 were working in healthcare centres, four were employed in departments of internal medicine, four were surgical nurses, two were employed in gynaecology departments, two were from paediatrics, one was employed in the department of neurology, one was employed in the department of oncology and one was working in the department of urology. Nurses were randomly selected from the list of nurses employed in each of the participating healthcare institutions. The list of nurses was formed in accordance with the following predefined inclusion criteria: 1) a registered nurse with a valid license, 2) a minimum of five years of work experience in the profession in the institution of current employment, 4) full-time employment, 5) open-ended employment contract, 6) voluntary participation in the study. A total of 20 nurses were selected who met the above criteria and who expressed their consent to participate in the study. Data collection SEEMEDJ 2019, VOL 3, NO. 2 Turnover intention among nurses 36 Southeastern European Medical Journal, 2019; 3(2) Data were collected using a semi-structured face-to-face interview conducted between 4 June 2018 and 22 June 2019. Interviews were conducted by seven experts in the field of clinical and medical sciences, nursing sciences in collaboration with psychology and information science experts. Participants were interviewed in a room outside of their usual work environment, without external interference and without the presence of others. Just before conducting the interview, the researchers were reminded of the importance of using comprehensible language in communication, interactivity, changing the order of questions/statements or asking additional questions to get to the essence of the topic, and of the obligation to verify that they understood their interviewees’ statements. Prior to each interview, the purpose of the study and the reasons for conducting it were explained to the participants. The participants’ anonymity was guaranteed. Participants voluntarily agreed to participate either verbally or in writing. Likewise, with prior permission given by the participants, for the purpose of clearer understanding and more detailed processing of data, the interviews were recorded and transcribed verbatim. During the interview, each researcher presented a total of nine possible (fictional) situations with fictional characters – nurses. The fictional situations were designed by considering everyday real-life/work situations. After the individual statement/situation was read and presented to the participants, they had the opportunity to reflect on their position and think of a possible solution to the situation and then verbalize their opinion. After the presentation of the situations, it was left to the participants to seek further clarification regarding the presented situation. After each participant responded to the situation, a mandatory additional question was asked: Do you think the reasons would be different for male nurses? The interviews lasted between 30 and 60 minutes and there was no need to repeat any of them. Data analysis Data saturation was achieved in the 11th interview. Four additional interviews were processed to increase the quality of the study, and in total 15 interviews were analysed. All interviews were carefully transcribed and analysed, where the researchers analysed each sentence in detail according to Van Manen’s (2002) detailed analysis approach (24). Colaizzi’s (1978) seven-step approach was also used to ensure an in depth analysis of interview data using a clear and systematic approach (25). Each interview was separately coded by at least two experts. In the first step, a naive reading of interview transcripts was performed, followed by axial coding, where codes were refined, and selective coding, where the final coding was performed. After revising each transcript, the researchers consulted one another and performed the final categorization, i.e. they repeated selective coding. The researchers extracted illustrative quotes, which were classified into separate categories. For example:“… She is primarily satisfied because she loves her job, loves helping people who need help: it makes her feel happy, satisfied, fulfilled because helping someone who needs it is of great importance for her personal satisfaction. Interpersonal relationships and the atmosphere in the department where she works are good, as are the overall working conditions …” (Participant 5, female, 7 years of service). Individual ideas were identified and a detailed description of each idea was then drawn up. To verify the accuracy of interpretation, interview transcripts were read three times. In the final step, there was no need to include any further changes based on feedback from the research participants. Data saturation was achieved in the 11th interview. Four additional interviews were processed to increase the quality of the study, and in total 15 interviews were analysed. All interviews were carefully transcribed and analysed, where the researchers analysed each sentence in detail according to Van Manen’s (2002) detailed analysis approach (24). SEEMEDJ 2019, VOL 3, NO. 2 Turnover intention among nurses 37 Southeastern European Medical Journal, 2019; 3(2) Colaizzi’s (1978) seven-step approach was also used to ensure an in depth analysis of interview data using a clear and systematic approach (25). Each interview was separately coded by at least two experts. In the first step, a naive reading of interview transcripts was performed, followed by axial coding, where codes were refined, and selective coding, where the final coding was performed. After revising each transcript, the researchers consulted one another and performed the final categorization, i.e. they repeated selective coding. The researchers extracted illustrative quotes, which were classified into separate categories. Ethical aspects All participants, after being properly informed of the purpose of the research, voluntarily agreed to participate in the research. All of them signed a consent form for participating in the survey or expressed their consent orally. The interviewee’s name was not mentioned at any time during the interview to protect the privacy of the participants. All participants were made aware of the fact that they had the right and the option to refuse to give an answer to or opinion on a particular statement/situation before the start of the interview and they were aware of the fact that they could stop the interview at any time. Results Demographic data All participants included in this study were female, employed full time and were registered nurses. The youngest participant was 27 and the oldest was 48 years old. The average age of the participants was 33, with 6.5 to 28 years of work experience. They all worked and lived in Croatia and were native speakers of Croatian. Thematic analysis and categorization Thematic analysis of the content by code group resulted in a division into four categories. Each category contained a number of subcategories, all of which have a significant impact on the main idea (Table 1). Participants’ opinions for each category were further expanded and compared with other studies conducted in Europe and the rest of the world that have been published and made available so far, which will be presented in the Discussion section. Table 1. Nurses’ intention to leave – Thematic content analysis by category and subcategory Category Subcategory Job satisfaction Positive attitudes * Autonomy * Acknowledgment of a job well done * Stress ** Possibility of advancement * Wrong choice of profession ** Work motivation Identification with the job * Intrinsic motivation * Extrinsic motivation (material) * Psychological factors (individual) Family factors * Younger age * Change of residence * Family migration * Structural factors – work environment Working conditions ** Availability of materials, sufficient time and employees ** Conflict in the workplace ** Managers’ ability to manage and support * *positive effect; **negative effect SEEMEDJ 2019, VOL 3, NO. 2 Turnover intention among nurses 38 Southeastern European Medical Journal, 2019; 3(2) Presentation of participants’ responses Job satisfaction was most influenced by: good interpersonal relationships, complexity of the work, team atmosphere and positive team attitudes (N = 13); doing the job you love (N = 9); good organization and working conditions, job security, regular income (N = 7); and identifying with nursing as a profession because it makes me happy, satisfied and fulfilled (N = 5). The participants cite positive internal motivation, capabilities and accessibility of their superiors as other reasons. Thirteen participants believe that there is no difference in the factors of job satisfaction between men and women; however, two participants state that by acquiring the skills, a male nurse changes jobs more quickly and easily and their opinions are more respected than the opinions of female nurse. Job dissatisfaction was most influenced by: dissatisfaction with the work environment, organization of work, night shifts, performing tasks outside the scope of the job, low salaries, non-recognition of professional qualifications, conflicts in the work environment (N = 15); personal participation in internal conflicts in the work environment (N = 12); privileged positions of superiors and inequality (N = 4); choosing the wrong profession (N = 2). Other reasons indicated were that the superior is not a good manager and that the nursing profession is not appreciated enough. The majority of participants (N = 10) feels that there is no difference in job dissatisfaction factors between males and females; however, some participants state that men would switch jobs if they were not satisfied, especially if better pay was involved. Change of workplace within an institution is most often due to: poor interpersonal relationships and communication in the department (N = 9); advancement (N = 5); health problems (N = 5); being tired of one’s job (N = 3); compromised position and protection (N = 2). The opinion of 11 participants is that there are no differences of opinion between men and women, but other participants state that men have to face new challenges in their desire for promotion and a better workplace. Nurses decide to change the institution where they work because of: better working conditions and interpersonal relationships (N = 9); proximity to work (e.g. relocation) and therefore more family time (N = 9); financial situation, as well as non-recognition of a higher education degree (N = 6). The majority of participants (N = 10) believe that there is no difference in reasoning between male and female nurses; however, some say that male nurses would be looking for new challenges and better pay. Leaving the nursing profession is most often due to: wrong choice of profession, poor working conditions, interpersonal relationships and financial situation (N = 9); stress (N = 3). Eleven participants believe that there are no differences of opinion between males and females, while other participants note financial problems as a reason for changing their profession. Nurses do not intend to leave their department, institution or profession because they are: satisfied with their job, working conditions, interpersonal relationships and superiors (N = 14); in addition to the above assertion, five participants state that they have a fear of a new environment. Two participants cite status as a reason. Fifteen participants feel that there are no differences between the opinions of male and female persons. Nurses decide to go abroad for: financial reasons (N = 12); better working conditions and healthcare system (N = 11). As for other reasons, they state that younger people are more likely to choose to leave, as are those who have already family abroad, and that the profession is more appreciated abroad. SEEMEDJ 2019, VOL 3, NO. 2 Turnover intention among nurses 39 Southeastern European Medical Journal, 2019; 3(2) Direct effect Indirect effect Thirteen participants feel that there are no differences between male and female persons; however, two participants state that it is easier for men to leave. The most common reasons for nurses only doing their job enough to “satisfy the form” are: there are no rewards or praise, which is demotivating (N = 12); routine and saturation (N = 6). Participants also indicate selection of the wrong profession and early retirement of employees. A total of fifteen participants believe that there are no differences between the opinions of male and female persons. Nurses are pleased with their superiors because of: systematization and regulated scope of work and good organization in the department; leadership, good communication skills, understanding of team needs and teamwork, managing the department professionally and responsibly (N = 15). Thirteen participants are of the opinion that there are no differences between male and female persons; however, two participants note that more tolerance is shown for male than female nurses. Presentation of the main category relationships on nurses’ intention to leave By further analysing the results obtained regarding the defined main categories and subcategories, we detected categories that have a direct impact on nurses’ intention to leave. Additionally, we also present the categories that directly affect job satisfaction and indirectly affect the nurses’ intention of leaving. The results are shown in Figure 1.. The ability of a manager, support of superiors, interpersonal relations and working conditions Structural factors (work environment) Work motivation Job satisfaction TURNOVER INTENTION Individual psychological factors Figure 1. Main category and subcategory influences on nurses’ turnover intention Discussion The results of the study indicate that four main categories of factors are important for nurses’ intention of quitting their jobs in Croatia. The first category is job satisfaction, which has been identified as a key factor in nurses’ turnover intention, as has been confirmed in a number of previous studies conducted in Croatia and SEEMEDJ 2019, VOL 3, NO. 2 Turnover intention among nurses 40 Southeastern European Medical Journal, 2019; 3(2) worldwide (3, 16, 22, 26). The results indicate that dissatisfaction with work and the work environment is a clear indication that nurses will leave their jobs in the future. A survey conducted in Turkey in 2015 recognizes job satisfaction as an important factor and states that 61% of nurses intending to leave their job register a moderate level of satisfaction (12). Positive attitudes, autonomy, recognition of a job well done, and the ability to advance in the workplace were highlighted as subcategories of job satisfaction, which has been confirmed in previous research. In a recent Croatian survey, Barać et al. (2017) also describe nurses’ job satisfaction and cite that nurses who are more committed to their work have greater job satisfaction (27). The level of job satisfaction is closely related to work motivation (27, 28), which represents the second category in our research. Work motivation does not have a direct influence on the nurses’ intention to leave their job, but it has a significant indirect impact on job satisfaction. Similar results were previously reported in a study conducted in Croatia (22). Singh and Tiwari also found a correlation between job satisfaction and work motivation in their research. They claim that increasing job satisfaction increases work motivation and vice versa. Employee satisfaction thus increases work motivation, while dissatisfaction effects motivation decline (27). The results indicate a significant impact of work motivation through the subcategories of identification, intrinsic motivation, and extrinsic (material) goals. Gagné et al. (2015) state that an autonomous type of motivation, especially intrinsic, which is also the preferred type of motivation, is related to job satisfaction and the intention to leave (29). The same results were also found in a study conducted in the Netherlands (30), which aimed to examine the connection between work stressors and the reactions of employed nurses. In another study, Singh and Tiwari (2007) describe that lack of job satisfaction is a predictor of leaving, driven by an individual’s motivation (27). Goh and Lopez (2016) especially emphasize the impact of intrinsic and extrinsic factors on employee satisfaction, which is also highlighted in our results in the category of work motivation (15). In contrast with the results of Smokrović et al. (2019), where nurses who identified with the profession felt lower job satisfaction, our results indicate a positive relationship between identifying with the profession, intrinsic and extrinsic motivation and work motivation. Since extrinsic motivation plays a significant role in overall satisfaction, the impact of a system of support, rewards and bonuses on employee motivation should not be neglected. If the nurse is acknowledged and supported by the staff and superiors, their self-esteem and satisfaction at work will grow. This reduces the possibility that the nurse will consider leaving the workplace. In a study conducted in Jordan, Mahmoud Al- Hussami (2008) also cites a strong relationship between job satisfaction and support from superiors (31). The same results were found in a study conducted in Croatia, where the authors said that managers’ support is a valid predictor of job satisfaction (22). The majority of participants emphasize extrinsic material motivation and inadequate material income in their responses as a reason for dissatisfaction and demotivation. They feel that material motivation has a significant impact on the intention to leave the country and the workplace. In previous research, material welfare was also recognized as a significant factor (8). Job satisfaction is also closely related to employees’ personal characteristics (29, 32) and the work environment (28, 29, 33, 34). Our results show that individual psychological factors of employees, work environment and work motivation are important for achieving the level of ultimate satisfaction. In their literature review, Lu, While and Louise Barriball (2005) highlight working conditions, working relationships, salary, promotion opportunities, job security, accountability, recognition by superiors and overtime as the most common factors that have a direct impact on satisfaction. Additionally, Toode, Routasalo and Suominen (2011) state that personal characteristics and priorities, in addition to the internal SEEMEDJ 2019, VOL 3, NO. 2 Turnover intention among nurses 41 Southeastern European Medical Journal, 2019; 3(2) psychological state, influence work motivation. The results of this study reveal that personal characteristics of employees are extremely important predictors of their intention to leave. The study implies that the intention to leave is not necessarily related to the institution of employment, work organization, collective or motivation, and we believe that personal characteristics need to be singled out and emphasized as a separate factor in the intention to leave. In this study, we categorized individual psychological factors that have a significant indirect impact on the intention to leave, such as family, age, change of residence, and family migration; this was also partially confirmed in a previous study (22). Employees report that the choice to leave is easier for younger people, as well as for those whose family members have previously migrated. Different results specific for some EU countries have also been published in a study conducted in 10 EU countries that aimed to discover the factors that influence leaving the workplace (1). As the last category which, in addition to indirect influence through job satisfaction, also has a direct impact on nurses’ intention to leave, the work environment was also found to be a factor in our study, and it was also highlighted in studies mentioned above (1, 22, 28, 31, 34). Masum et al. (2016) conducted their research in private healthcare facilities in Turkey and, in addition to the factors mentioned above, specifically emphasized the importance of the work environment and the relationship with colleagues and superiors. Our results also confirm that a strong correlation exists between the characteristics and quality of the work environment and the decision to leave the workplace. The participants stressed material and human resources, e.g. availability of materials, working conditions, sufficient time and number of employees, as important determinants of the work environment. As in previous studies, the possibility of further advancement and qualities of the manager were classified under the category of work environment (1, 34). A Chinese study conducted by Wang et al. (2015) examined the impact of nurses’ work environment on job satisfaction and considered the work environment to be a key factor in an organization. They found that it has a stronger impact on job satisfaction than any other organizational or personal factor. The same results were obtained in a study conducted in the United States of America (33). As stated by Latham, Hogan and Ringl (2008), work environment is highlighted as a crucial factor in the intention to leave or remain in the workplace, along with job satisfaction (35). Employees will find it much more difficult to leave the workplace if they work in a good, positive environment where they do not encounter daily conflict situations. The ability to advance, the superiors’ ability to lead and manage, and support by the superiors are the factors that are most commonly mentioned as factors that influence the decision to leave in this category. In conclusion, the departure of nurses from Croatia or the workplace poses a major challenge to the healthcare system. The results of this study are thus aimed at managers who, in the present-day migration of all healthcare professionals, including nurses, should prioritize the development of a clear strategy and measures for retention of nurses based on the factors that influence their intention to leave. Decision makers in healthcare must take all steps that are necessary for creating a positive work environment and stimulating employee motivation and satisfaction. This research was conducted on a relatively small sample of nurses, and we believe that in the near future a detailed and extensive combined examination of the reasons for the turnover intention of nurses in the Republic of Croatia, covering all territorial regions, will be required. The proposed research would certainly provide detailed insight into the above factors, which would lead to a deeper understanding of this phenomenon. SEEMEDJ 2019, VOL 3, NO. 2 Turnover intention among nurses 42 Southeastern European Medical Journal, 2019; 3(2) Acknowledgement. We would like to thank all the participants in this research who contributed to the development of knowledge in the field of nursing with their answers. We would also like to thank Maja Frencl Žvanut for her support in developing this study. 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