Retention of people working in health care is a serious concern as turnover is enormously costly and detrimental to the organizational performance and the health system in general [1–3]. As indicated by the European Union’s 2012 Commission Action Plan for the EU Health Workforce, the health sector faces major challenges, owing to labour shortages, attrition and relatively low pay in some health occupations. While turnover rates differ across health cadres—for instance, nurses are less likely to leave the workforce than medical doctors and other specialized health professionals —the replacement is costly because of the subsequent hiring and required training of new employees [3, 5]. Moreover, high turnover rates have great implications not only for the quality, consistency and stability of services provided to people in need, but also for the working conditions of the remaining staff, e.g. increased workloads, disrupted team cohesion and decreased morale [6, 7].
A variety of individual and organizational factors have been found to impact turnover. The main focus of this article, however, is on the question in how far aspects of working time and remuneration influence retention, or the intention to stay. The theoretical approach of this article is informed by the longstanding criticism of formal and bureaucratic organizations over the objectification, commodification and standardization of labour. In past decades, health care experts have theorized that these concepts have brought about a loss of humanism in medicine, depersonalization of care, and the replacement of holistic care with bureaucratic control . Central to the theory is the notion that when a free worker sells his or her labour for an indeterminate time, he or she receives a money-wage or salary and forms a continuing relationship with an employer, which is formalized through institutional processes and structures. Marxist theorists have long argued that alienation occurs when in this process the labourer loses control over his or her labour and therefore becomes a commodity. In recent decades, the associated objectification has increasingly been equated with dehumanization because it involves a professional neutralization of agency of both patients and health workers. Timmermans and Almeling speak of “an erasure of authenticity, an alienation of identities, and a silencing or even displacement of the self and the social world” .
An application of wage-labour analysis to human resources for health needs to take into account that in the field of human services, labour value is based not only on a notion of abstract (clock) time indifferent to the type of activity and used as an exchange value . Within the social services required, work is conducted much more from a processual (or concrete) time associated more with the use values of work, anchored in the duration of social practices, tasks and processes, rather than exchange values [9, 10]. Paid work in health care is illustrative of this type of labour because, ideally, processes take as long as they take, and cannot easily be hurried, as care needs are unpredictable. In recent decades, however, the conditions of neoliberal globalization have tended to privilege labour as exchange value over labour as use value.
Previous studies focusing on turnover have neglected the impact of work-related aspects of working time and remuneration. Moreover, those studies examining the relation between wages and intention to quit are rather inconclusive, pointing towards a more complex relationship between wages and additional personal and organizational characteristics. However, as working time and wages are closely related to job satisfaction, as well as attrition (or migration) of employees within and across countries [11–14], there is a need to explore their interrelation in more detail to employ retention strategies effectively. In addition, while current studies on retention have been focused on individual health care occupations or single countries, less attention has been paid to whether the observed factors also apply for a greater variety of health occupations. To optimize retention strategies, it is important for organizations to understand whether the reasons for quitting or staying are the same for the different occupations or not. A similar reasoning can be applied in exploring cross-national differences of health care systems to better understand why some countries might be more attractive for health care workers than others. However, owing to a lack of comparative data , such cross-national comparisons are lacking.
Factors influencing intention to quit or stay
In the framework of this article, we focus on ‘intention to stay’ rather than on actual attrition or turnover. This framing differs from the typical negatively framed questions asked in studies, which typically affirm leaving (e.g., “I am actively seeking other employment.”) rather than staying in one’s current position [16–20]. However, as this article focuses more on retention, it seems more logical to use an outcome that offers a long-term perspective on remaining with the same employer or not. Following the argument of Mor Barak et al., focusing on ‘intention’ rather than actual behaviour seems reasonable for two reasons. First, before actually leaving the job, workers typically make a deliberate and conscious decision to do so . In previous studies, intent to leave has been found to be a good proxy indicator for actual turnover [23–27]. Second, in a cross-sectional study, it is more practical to ask employees of their ‘intention to quit or stay’ than to actually track them down in a longitudinal study to see whether they have left or to conduct a retrospective study and risk hindsight biases .
As indicated above, the reasons that employees quit their jobs are manifold and have been examined since the 1950s. Subsequent studies have developed models based on theoretical approaches of different disciplines. As results are often rather inconclusive, depending on the theoretical approach, only a combination of different disciplinary perspectives (economic, sociological and psychological) can contribute to the understanding of the complex process leading to intention to quit [29, 30]. In the context of this article, results based on groups of factors are briefly summarized, focusing on the health care sector.
Starting with sociodemographic characteristics of employees, only a few characteristics seem to meaningfully predict the intention to quit. In particular, age and education are significant predictors. Studies have shown that younger and better educated employees are more likely to leave their jobs to seek career advancement [6, 31, 32]. This particularly happens if there are limited career opportunities within the organization . For the health workforce, the findings are inconclusive when differentiating by profession. While well-educated younger nurses are more in favour of developing their careers and older nurses are likely to be a more stable workforce [6, 16, 33, 34], quitting behaviour was independent of educational level for other health occupations . Moreover, it seems unclear whether the observed relation between age and intention to quit simply reflects age, rather than work experience and tenure . A further consistent significant predictor for turnover in health care facilities is ethnicity, showing that white people have, possibly due to increased job mobility or opportunity, a higher turnover than persons who are members of minority groups . With respect to gender or marital status, there is little evidence that these characteristics are linked to turnover [16, 33, 36–38], though having children at home correlates with turnover, especially for women [36, 39]. This is confirmed for nurses, showing that kinship responsibilities involving home obligations, children, spouses and ageing parents affect the work and turnover habits of nurses, possibly requiring a change in work environment [6, 40–42]. McKee et al. find marital status to be indirectly related to intention to quit in that employees who are married are more satisfied with their jobs and feel more supported and less stressed than their unmarried colleagues.
Besides sociodemographic factors, many studies show that professional perception, in particular job satisfaction—defined as the extent to which one feels positively or negatively about one’s job —is a rather consistent predictor of turnover behaviour [6, 21, 44–49]. Employees who are satisfied with their jobs are less likely to quit [18, 50–54]. However, it has been questioned whether job satisfaction is a valid predictor of turnover [37, 55–58], in particular, since it remains unclear whether the relationship is direct or indirect via the impact on professional and organizational commitment [46, 59–61]. For example, several authors view turnover as a product of job satisfaction and commitment, which in turn are influenced by organizational factors, demographics and environmental factors, such as alternative job opportunities outside the organization [18, 40, 62–64]. Overall, it seems that the number of influencing variables that are dependent of the underlying theoretical models appear too complex to provide clarity.
Finally, intention to quit is also associated with work-related characteristics, such as organizational climate, including the quality of relationship among staff members [65, 66] and perceptions of job insecurity, as they are closely linked to job satisfaction and performance [23, 24, 67, 68]. In addition, research among nurses has shown that promotional opportunities, career development and lifelong learning activities promote job satisfaction and increased retention [6, 69]. A similar positive effect has been found for organizational responsibilities and empowerment on intention to quit, as employees feel more valued by being given responsibilities [70, 71].
While such factors seem to be associated with retention, research has shown that, by contrast, a consistently heavy workload increases job tension and decreases job satisfaction, which in turn increases the likelihood of turnover [6, 32]. In this context, it has been demonstrated that, for the health workforce in particular, working time is a crucial variable. Studies have found that temporal burdens, such as overtime (e.g. long shifts) and irregular working times (weekends, nights and holidays) are related to anticipated turnover [39, 72], while limitations on working hours and the provision of rest periods (more off-time, flexibility in shifts, more choice of shifts) have a direct positive impact, not only on the quality of services but also on the intention to quit [19, 34, 40].
While time plays a central role in the constitution of the employment relationship, wages are closely related, as they constitute a key exchange value within abstract, commodified labour time. Moreover, wages have long been assumed to be central to health service delivery, as they presumably affect job and life satisfaction, employment and working conditions, as well as attrition of employees. However, studies on the impact of wages on turnover in the health services context are inconclusive. A Taiwanese hospital study from Yin and Yang  finds that pay (salary, fringe benefits and night-shift benefits) is the strongest factor related to nurse turnover. In contrast, Hayes et al. show in their literature review that the impact of wages appears to be mixed, and also depends on whether other types of financial benefit, such as bonuses, pensions, insurance, allowances, fellowships, loans and tuition reimbursement, are considered. Tai et al. also report evidence that more affluent individuals might have less need or motivation to change jobs in order to improve their income status. While these studies focus on absolute wage levels, no studies were found that explore the impact of perceived satisfaction with wage and wage-related collective bargaining coverage on intentions to quit, whereas in most European Union Member States, wages are primarily moderated by collective bargaining.
Research question and hypotheses
Against this background, the main objective of this article is to understand the relationship between working time and remuneration on intention to stay using cross-sectional survey data. In particular, the following research questions will be addressed:
What is the influence of working-time-related factors on intention to stay?
What is the influence of wages and wage-related factors on intention to stay?
First, it is assumed that full-time work will increase the chance of staying with an employer (H1) as the commitment of full-time workers to a job is assumed to be higher, possibly because labour is less explicitly measured by the hour. Furthermore, it is hypothesized that long and additional working hours (H2) as well as non-standard working hours (such as shifts and evening hours, H3) will decrease the intention to stay with an employer. In addition, it is assumed that long commuting times will decrease the intention to stay with an employer (H4).
With respect to wages, it is assumed that an increase in wages also increases the chances of staying with the employer (H5). In addition, as collective bargaining coverage is mostly perceived as a stable, thus attractive, working condition, it should also increase the likelihood of employees to stay with the employer (H6). Finally, it can also be expected that employees who are satisfied with their wage will have a higher chance of remaining with the employer, as the rewards offset the disadvantages of commodified labour time (H7).