Healthcare providers' intention to leave their jobs during COVID‐19 pandemic: A cross‐sectional study

Abstract Background and Aims During the coronavirus pandemic (COVID‐19), healthcare providers confronted risks of disease transmission to themselves and their family members, resulting in physical and psychological burdens. This might affect their decisions to leave their jobs temporarily or permanently, fearing infection and protecting their families. This study examined the factors related to the intention to leave a job among healthcare providers during the COVID‐19 pandemic in Jordan. Methods A cross‐sectional correlational design was used to collect data using a convenience sample of 557 healthcare providers working in different sectors across Jordan. Data were collected using a self‐administered questionnaire about the intention to leave jobs during the pandemic. Results The sample included 368 females (63.8%) and 209 males (36.6%) participants. The mean age of participants was 30.8 years (SD = 6.65). Differences found in intention to leave job during COVID‐19 in relation to age (t = 2.60, p < 0.05), gender (X 2 = 4.25, p < 0.001), and marital status (X 2 = 18.2, p < 0.001). Participants with a high risk of exposure to COVID‐19 and who experienced higher workloads had higher scores of intention to leave their job during COVID‐19, while being married had lower scores. Conclusions Policy‐makers need to pay attention to young and single healthcare providers during the COVID‐19 pandemic to prevent them leave their job. Crucial guidelines for managing workload during the COVID‐19 pandemic are needed. Policy‐makers during pandemics have to protect healthcare providers who feel they are at high risk of infection.


| BACKGROUND
The coronavirus disease (COVID- 19) pandemic became a universal health issue that alarmed the healthcare systems worldwide. [1][2][3] Along with a rapid and unexpected increase in the incidence of COVID-19, countries were forced to develop and adopt massive public health restrictions to ensure protection and minimize the impact of the COVID-19 pandemic. It had negative impacts on several domains, including but not limited to educational, financial, and entrepreneurship globally. [4][5][6] Healthcare providers (HCPs), whom are called to be at the frontline of COVID-19, are the most affected and are vulnerable to various forms of consequences of COVID-19.
Healthcare systems, therefore, were required to balance maintaining a safe and healthy work environment for HCPs while providing a high quality of healthcare to infected people. Nevertheless, although HCPs have used strictly personal protective equipment, they were concerned about being infected and being sources of disease transmission to their beloved ones. 7 This has provoked the attention of healthcare systems to psychosocial health needs and concerns of HCPs caring for individuals with COVID-19. The COVID-19 pandemic has affected the daily life activities and biopsychosocial health status of HCPs. [8][9][10][11] The literature adequately addressed the psychological and mental health consequences of caring for individuals with COVID-19. Generally, studies showed that HCPs are 10-folds at risk of COVID-19 compared to the general population 12 and suffer various forms of psychological disturbances, including depression, anxiety, psychological distress, and sleep disturbances. 13 HCPs were also suffering from burden and workload, causing them further psychical fatigue. 7,14-16 Such a situation, although it seems critical to HCPs, fearing infection, being sources of infection, and suffering social discrimination and stigma due to caring of individuals with COVID-19, it forced HCPs to socially isolate themselves caring further psychosocial disturbances. 13,17 Besides the extension of the world emergency to combat COVID-19, the short and long-term consequences have contributed to job dissatisfaction, burnout, and intention to leave the job. 18 One factor found to contribute to employee decision to leave their jobs in healthcare settings is their perception of an unsafe working environment. 19 Such feeling is well enhanced with the chaos that has been witnessed during the few months of the outbreak of COVID-19.
The panic public response and the lack of resources and workforce have a significant role in increasing fear and worries among HCPs that may force many of them to leave the job, fearing infection and to look after their families. Before COVID-19, stressful working conditions, work overload, and burden were factors associated with the intention to leave their job in spite of their feeling of although a safe working environment and sufficient resources. 20,21 This would speculate that with the outbreak of COVID-19 pandemic that associated with shortage of workforce and resources, HCPs would think more seriously to leave their jobs. As aforementioned, HCPs were suffering stress, anxiety, and depression similar to general population and further were at higher risk to get infected with COVID-19 due to nature of their work. Factors such as commitment and work conscience, fear of family infection, fear of shortage of protective equipment, and organizational factors were affecting nurses' intentions to leave or stay in their profession during the COVID-19 pandemic. A recent study revealed that clinical nurses and nurse leaders who reported higher levels of contact with and management of individuals with COVID-19 had higher intent to leave their jobs. 22 While such topic was important and significant issue for discussion, few studies attempted to address such topic in lowincome countries such as Jordan. Jordan has limited resources and the healthcare systems and infrastructure is still developing which may compromise the quality of care and the HCPs willing to stay in their jobs. This is one study that attempt to understand the impact of COVID-19 on HCPs in terms of intention to leave their jobs due to the fact that burnout and intention to leave job would affect directly quality of care provided and considered a threat to stability of healthcare systems. Therefore, the purpose of this study is to

| Design
A cross-sectional correlational study was conducted during the COVID-19 pandemic using an online survey between October 5 and November 15, 2020.

| Sample
A convenience sampling technique was used to select HCPs caring for patients diagnosed with COVID-19. The HCPs who provided care directly to patients with COVID-19 and had internet access and skills to fill out the survey online were included in the study. No exclusion criteria were used to maximize participation.

| Settings
As the nature of the online survey, this study was conducted via a structured questionnaire sent online through a social network and email to accessible HCPs from the Jordanian healthcare sector, including various governmental and teaching hospitals.
These hospitals extended over all regions (north, middle, east) of Jordan and provided care for the majority of patients in Jordan (67%).

| Measurements
Data was collected using an online platform of an Arabic selfadministered survey. WHO guidelines for translation and tool adaptation were used to translate the instruments that are unavailable in Arabic. The instruments have been evaluated for validity using the face and content validity methods through a panel of experts. The WHO guidelines were used and followed to reach the final draft of the translated versions of the survey. The survey in the current study has three parts. The first part is related to socio-demographic data (six items), including age, gender, marital status, job description, length of experience, and previous experience with patients with serious diseases. The second part consists of two items to assess the serious of HCPs' intention to leave the job. Item 1 was "Looking for another job or considering resigning because of the risk of COVID-19," and item 2 was "Considered that should not care for patients with COVID-19." Each item has two scores; score "1" if the answer is "yes" and score "0" if the answer is "No." If participants answered both questions with "Yes," they would consider leaving the job seriously.
The third part is about perceived leaving the job during the COVID-19 pandemic, which included 32 items. The 32 items were grouped into seven subscales: organizational support (six items), perceived risk of contracting COVID-19 (seven items), workload and stress (five items), social relationships (four items), emotional support (five items), the perceived fatality of COVID-19 (three items), and personal protective equipment (two items). 23 Each item scored on a 5-point Likert scale where the score of "1" reflected strongly disagree, and "5" strongly agree. A high score means a high level of perception to leave HCPs the job. The Cronbach alphas for each subscale varied from 0.73 to 0.86, revealing accepted internal consistency.

| Ethical Issues/Statement
The Institutional Review Board at Prince Hamza Hospital has approved this study. The current study followed the Declaration of Helsinki provisions, and all participants provided informed consent.
The permission to use and translate copyrighted instruments has been received from the original author. No approval from hospitals was required according to the nature of the online study. The study was conducted following the EQUATOR research reporting checklist; (STROBE checklist) for cross-sectional research. It was uploaded to the online system.

| Data collection
After checking the instruments for reliability and validity, minor changes were performed based on expert panel recommendations.
The online pilot survey was then carried out on 25 randomly selected HCPs to assess the survey's clarity, relevance, acceptability, feasibility, and time needed. Improvements were made to facilitate better comprehension and organize the survey items before the last draft. The time needs to complete the survey is less than 15 min.
These participants were excluded from the study.

| Data analysis
The IBM-SPSS (V. 25.0) software was used to analyze the data.
Descriptive statistics using the central tendency and dispersion measures were used to describe the study's variables. Frequencies and percentages were used to describe the categorical variables. The chi-square test and independent t-test were utilized to assess the difference between respondent characteristics and serious consideration of leaving the job.
Multivariate logistic regression was conducted to determine the predictive factors associated with HCPs considering leaving the job.
The relationship between the perception of HCPs to leave the job and participants' characteristics was assessed using analysis of variance (ANOVA) or t-test for independent categorical variables and Pearson correlation coefficient for the continuous variables. were females (63.8%), and 209 were males (36.6%). The mean age of participants was 30.8 years (SD = 6.65). More than half of the participants were married (n = 326, 56.5%). Most of the participants (n = 502, 87%) were nurses who were directly involved in providing direct care for patients with COVID-19. Despite 30.5% of participants having less than 5 years of experience, 64.1% have previously cared for patients with infectious diseases (Table 1).

| HCPs' serious consideration of leaving the job
The item analysis showed that 26.2% of the respondents agree with the statement "I feel that I should not be looking after patients with COVID-19," and 36.7% agree with the statement "I am looking for another job or considering resigning because of the risk," see Table 2.
Also, those who agreed with both statements accounted for 61 participants and considered seriously leaving the job (10.6%). In addition, the chi-square results revealed that gender was significantly related to intent to avoid caring for patients with COVID-19 (χ 2 = 2.94, p < 0.05) and seriously considering leaving the job (χ 2 = 4.25, p < 0.05). Similarly, marital status was significantly associated with intent to avoid caring for patients with COVID-19 (χ 2 = 16.4, p < 0.001) and seriously considering leaving the job (χ 2 = 18.2, p < 0.001). Moreover, participants' age was related to looking for another job and seriously considering leaving the job (t = 3.7, p < 0.001). In contrast, the length of experience was related to looking for another job (χ 2 = 24.2, p < 0.001).

| Factors affecting HCP's consideration of leaving the job
Factors contributing to leaving the job were assessed using multivariate logistic regression ( Table 3

| Perception of HCPs leaving the job
The relationship between the perception of HCPs of leaving the job and socio-demographic variables is described in Table 4. Younger  leave their jobs during the pandemic of COVID-19. 22 We also found that HCPs with fewer years of experience or those without past experience caring for individuals with infectious diseases were more likely to consider leaving the job during COVID-19. Such findings sustain previously reported findings and positively connect years of experience to intention to stay in the job. 25 In other words, HCPs with fewer years of experience might be unable to adapt to the intense job requirement and feel incompetent due to a lack of experience in managing such cases and intense death scenarios.
However burnout. A recent study found that nurses who directly interact with COVID-19 patients were more worried about being infected and have higher job stress and burnout levels than nurses who are not. 30 Similar findings were also found among HCPs in China and United States. [31][32][33] The current findings indicated that HCPs who intended to stay at the job were more than those who had a perception to leave the job seriously. This could be related to several factors, including organizational commitment and a sense of selfachievement. 34,35 Moreover, the younger and single HCPs more intent to leave the job seriously during the COVID-19 pandemic than others. Similar findings of recent studies supported these findings. 36,37 Also, this study confirms that male HCPs intent to leave their profession than females; these findings are congruent with a previous conclusion. 38 On the other hand, some studies found no relationship between the intent HCPs to leave the job and their socio-demographic variables. 39 give the HCPs a sense of safety and maximize teamwork that minimizes stress. Promoting psychosocial support for HCPs from their organizations and the public will enhance their satisfaction and minimize their fear, resulting in low intention to leave the job.
Considering that participants were enrolled from various public hospitals in the region, this could reflect the strength of the study and thus could support the generalizability of the findings to Jordan. Similarly, the study considered a clustering effect because the data were collected from different regions. However, this study had some limitations related to the use of an online cross-sectional survey that might affect the attrition rate of the participants. In this regard, many surveys were excluded due to missing data that could introduce potential bias and affect the study's findings. In addition, missing some confounding factors such as the specialty of the physicians, professional level, and daily working hours could all affect the participants' intention to leave job.

| CONCLUSIONS
This study highlighted that HCPs with a high risk of exposure to writing-original draft; writing-review and editing.