In total 1910 respondents from the datasets met the criteria for inclusion, of whom 1886 respondents completed the free text box with reasons for leaving (see Table 1). 24 respondents did not give any reason. 4579 reasons for leaving were analysed. Respondents could give more than one reason for leaving.
Free text responses were assigned into 13 categories (see Fig. 1). Respondents often gave a primary reason for leaving “I’m retiring but…” and then gave additional reasons to qualify the decision with a mean of 2.2 reasons for leaving per person (range 1–6). At first, the relationships between each of the sets of reasons are not clear. Following a critical realist ontology [14], the authors sought to explore the underlying relationships that are not explicitly visible from the responses by mapping them onto two models of work satisfaction that have been used widely in healthcare [15, 16]. Herzberg et al. two factor model asserts the satisfaction is determined by two separate sets of conditions: intrinsic motivation and extrinsic work hygiene conditions [12]. Intrinsic satisfaction is enhanced by feeling valued and a feeling of achievement and productivity. Extrinsic satisfaction is exacerbated by working conditions, pay, job security, organisational policies, and status. Neither intrinsic nor extrinsic factors have primacy, and both contribute to what Hoffart and Woods [13] call the professional practice environment, which they describe as having five key components: professional values, professional relationships, professional patient care delivery system, management approach and compensation and rewards structure.
The frequency of response categories
The nature of the professional practice environments in healthcare services has been shown to be associated with better retention of staff [17]. Karaferis et al. found a correlation between recognition of healthcare workers in Greece and work motivation [18]. Similarly, Wilson (2015) surveyed allied healthcare professionals (AHP) in Australia and found a significant correlation between feeling competent to do the job, recognition for doing the job, advancement opportunities, autonomy, feelings of worthwhile accomplishment, communication and support from the manager and intention to leave [19]. Veld and Van de Voorde found that positive work environments enhanced commitment as well as retention. In particular they found that those who felt a ‘social’ relationship with their workplace were more committed than those who perceived it as an economic relationship [20].
Intrinsic motivation
The data is this study shows that threats to intrinsic motivation is the driving force in decisions to leave. Intrinsic motivation is linked to sense of self actualisation [21], or a feeling of having done a good job. Most of the leavers expressed reasons that reflect a working environment that challenged their sense of self actualisation.
“I go home knowing I have done a bad job as we don’t have enough staff” (Band 6 RN)
In some cases, the cognitive dissonance of providing care that resulted in the opposite of their intrinsic motivations made staff feel ill:
“The ward is really unsafe, and I feel sick at the thought of coming to work” (Band 4 Support Worker)
This experience can lead to moral distress [22,23,24]. In an attempt to resolve this, staff work harder and longer, compromising their work life balance and this eventually results in burnout.
“Just really, really tired and have decided to retire. I won’t be coming back” (Physician, Primary Care)
“Every Sunday afternoon I spend catching up on admin and emails when I’d rather spend it with my grandchildren, so I am retiring” (Band 7 AHP)
“We are just given more to do, the better you are, the more you are given to do and managers don’t care how tired we are” (Band 7 RN)
The subcategories of reasons for leaving identified in the data suggest that these threats come both from the organisational values and from the working conditions. The relationship between the two can be complex and we suggest that in the context of poor work hygiene conditions, it is the mechanism of the professional practice environment that influences the outcome, reflecting Rafferty et al. finding that the way work is organised is as important as the number of staff or educational level of nurses on both patient outcomes and staff satisfaction [25]. Thus, the professional practice environment is critical to maintaining intrinsic motivation and thereby job satisfaction.
Elements of professional practice environment
Professional values
Professions establish their work boundaries based on values that are reflected in their professional jurisdiction [26]. These recognise the theoretical basis for their work and thus their skill and contribution. Intrinsic motivation is challenged in practice environment where these values are disregarded. The data in this study showed that there were multiple ways in which staff experience this.
Staff reported that organisations do not recognise the unique contribution of different occupational groups:
“We have to fill in for everyone, ward clerk is off, nurse will do it, housekeeper off, nurse will do it, we are not valued” (Band 5 RN)
This reflected the taskification of care, where care is divided into a series of tasks rather than a holistic approach. Managerial focus is on the completion of tasks (regardless of who completed them) and value that distinct groups of staff bring to the overall outcome was disregarded.
“Technology has made the role as DN [District Nurse] a more task orientated role rather than a holistic autonomous role it used to be, tick boxes are now the driving force for quality outcomes, rather than patient focused, individualised care planning.” (Band 7 RN)
“I’m no longer giving good care, it’s just about targets, that’s all managers care about” (Band 6 RN)
“I don’t deal with people anymore just tasks the joy has gone out of my work” (Physician Primary Care)
Failure to recognise the ‘gestalt’ of professional practice, and the resulting division of work into discrete tasks means that important but invisible professional work is not recognised. As it is not recognised, the educational or developmental work to support and develop professional practice is replaced by specific task-based education:
“Have been a CNS for ten years but there is no funding to develop any further or undertake my masters, being left behind” (Band 6 RN)
“There is nowhere to go, no development opportunities” (Band 5 RN)
“No career prospects here, keep being turned down for courses” (Band 6 AHP)
Failure to recognise professional values is also demonstrated by the way in which staff are deployed. Mandated redeployment during the COVID-19 pandemic where staff numbers were measured but there was a lack of appreciation of the complexity and risk and its impact on staff. This was cited as a reason for leaving by registered nurses:
“The pandemic was horrendous I was redeployed but also still had my own caseload” (Band 7 RN)
However, redeployment of staff (particularly nurses) has been and remains a constant feature, independent of pandemics:
“I often have to move wards and it causes me to be anxious” (Band 5 RN)
“We often have to fill in on the wards, once I was put in charge and I have not worked on a ward for ten years, its disrespectful to us and our patients” (Band 6 RN)
Professional relationships
Many studies have shown that social support helps employees to effectively mitigate workplace stress [27] and is associated with higher job satisfaction and reduced turnover intentions [28]. Laschinger et al. (2014) proposed that this is particularly so when there is a collective (as opposed to individual) perception that the work environment has good inter professional relationships [29]. Perceptions of poor relationships and poor leadership have been linked with intention to leave in UK [30], Canada [31, 32] and other European countries [33].
Poor relationships, described as bullying, were explicitly given as reasons for leaving in the data. Consideration of the subcategories showed this included poor group dynamics that were not managed:
“Cliques at work are really nasty, I don’t like it here” (Band 5 AHP)
Sometimes managers were said to be complicit:
“Bullies are friends with managers, no point reporting it” (Band 5 RN)
“I work with bullies, they bully the staff and the patients, no one cares” (Band 3 Support Worker)
Bullying also related to the way in which managers handled performance management:
“Everything I do is wrong according to my manager, but they don’t help me to learn” (Band 3 Support Worker)
Professional patient care delivery system
Professional practice environments have (intentionally or unintentionally designed) care delivery systems that can enhance or impede professional values. In the data (lack of) staffing was by far the most common reason given for leaving. This led staff to become anxious about the safety of their practice:
“I was the only nurse on for sixty patients on two wards overnight, the staffing is unsafe, I have resigned” (Band 5 RN)
“The workload is too much, I have too many patients, I don’t feel safe at work” (Primary Care Physician)
“Can’t recruit staff they may have to close service when I have gone” (Community Pharmacist)
Where staff had additional duties, such as the supervision of unregistered staff, students, and new second-level roles, they had less time to practice directly with patients and this challenged their motivation. When compounded with a shortage of peers, staff felt that they were not doing any of the work to a satisfactory standard:
“Most shifts I have to support and supervise support workers, students, international colleagues waiting for PIN and sometimes volunteers. I don’t have time to supervise or teach” (Band 5 RN)
“Our support workers are fantastic, but I can’t supervise them all and it makes me anxious. I know we are missing things, so I have decided to leave” (Band 6 RN)
Technology is often promoted as a tool to improve practice environments. However poor implementation, or systems that do not pay attention to professional values can make things worse not better:
“Due to [scheduling platform] often poor function, things are being missed/duplicated leading to time wasting and mistakes. One of the reasons I am retiring now.” (Band 6 RN)
“The work seems pointless; the IT never works” (Band 7 clinical scientist)
Leadership is a key determinant of a practice environment, and local managers are critical in how staff perceive the organisation’s values, regardless of corporate mission statements. Individual teams may differ dependent on their line managers:
“Managers don’t value what we do for patients.” (Band 6 AHP)
“My manager doesn’t understand our work at all, they are not a nurse, they don’t understand nursing” (Band 6 RN)
Compensation and rewards structure
Whilst Herzberg et al. propose that job satisfaction is determined by intrinsic motivation, and professional practice environments may enhance or impede this, a distinct concept of dissatisfaction with terms and conditions is often given as a reason for leaving [12]. Pay and pension ranked 9th of the 13 categories in terms of frequency and its subcategories of pay and pension relate to the lack of affordability of continuing to do the job:
“I love what I do, I just can’t afford to do it anymore” (Band 6 RN)
“I have two kids and third on the way, I can’t afford to do this job now” (Band 4 Support Worker)
“I am retiring. The pension issues make it impossible for me to stay” (Consultant Physician)
Ironically, promotion (which might be expected to be perceived as a recognition of value and confirm intrinsic motivation) often comes with a reduction in take home pay, sending mixed messages on value:
“I was promoted but lost unsocial hours for more responsibility, more work for less money doesn’t make me feel valued” (Band 7 RN).
This is also apparent in employers’ responses to requests for flexible working, where the member of staff would be doing the same work, with the same skill mix but was told this would be on a lower pay grade:
“Asked to work part time but told policy is no part time for band 7. Offered a band 5 job/secondment so I have got a job at [charity] for band 7 pay”. (Band 7 RN).
There was no regard given to the role of retaining experienced staff in supporting the team:
“I’m a carer for my parents and my manager refused flexible working as it would have a negative effect on the team” (Band 3 Support Worker)
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