Work stress, workplace violence, job satisfaction and their effects on turnover intention among midwife and public health supervisor II in Myanmar

INTRODUCTION

The movement toward universal health coverage (UHC) is now one of the most prominent global health policies. As more countries guarantee UHC, they face challenges in implementing primary health care, including significant health workforce shortages globally not only in low-income countries but also in middle and high-income countries with variations in degrees of shortage. Therefore, retention of primary health care providers is necessary for overall health system to achieve UHC.

Turnover intention is a crucial factor in studying employee attitudes and behaviours. It reflects how likely employees are to quit their jobs due to dissatisfaction or poor working conditions. Turnover intention is categorized into groups such as unavoidable, desirable, and undesirable, or voluntary and involuntary turnover.

Stress is characterized as a response to internal or external pressures that exceed one’s physical and psychological limit.¹ In Myanmar, healthcare workers face additional stressors due to workforce shortages and increased responsibilities during the COVID-19 pandemic, affecting their ability to manage both routine and pandemic-related healthcare duties.

There is increasing in global prevalence of workplace violence, particularly in the healthcare sector, and highlights the varied definitions of violence across countries. Despite differences in definition, violence generally involves purposeful threats or physical force that can cause physical or psychological harm.² Workplace violence specifically refers to incidents where employees face abuse, threats, assaults, or offensive behaviour related to their work.³

Job satisfaction studies have roots dating back to the 1900s with Taylor.⁴ Gruneberg’s 1982 study emphasized that selecting suitable individuals for a job and offering incentives lead to positive outcomes and increased productivity.⁴ Mayo’s research similarly demonstrated that workers can achieve high productivity despite challenging work environments. Early perspectives on job satisfaction primarily focused on performance concepts. Hoppock’s 1935 contribution introduced the idea that satisfaction arises when employees’ psychological, physiological, and environmental needs are met.⁴

In summary, turnover intention, work stress, job satisfaction, and workplace violence are intertwined in complex ways within the workplace. Addressing these factors requires understanding their interrelationships and implementing strategies to improve working conditions, enhance job satisfaction, mitigate work stress, and prevent workplace violence to ultimately reduce turnover intention and retain valuable employees.

In Myanmar, the frontline health service providers: basic health staffs (BHSs) include health assistant (HA), lady health visitor (LHV), midwife (MW), public health supervisor I (PHS I), and public health supervisor II (PHS II). In 2011, during the assessment of townships in the vaccine alliance (Gavi) health systems strengthening (HSS) program, it was found that midwife and PHS II ratio was 10:1. Since then, the public health department has significantly increased the recruitment of PHS II so that by the year 2018, it had nearly fulfilled the target ratio.⁵ The report of Ministry of Health and Sports, Myanmar stated that the turnover rate of basic health staff is high compared to medical doctors and it is also higher in rural areas than urban areas.⁶ Furthermore, according to the data from Ministry of Health and Sports, the attrition rate of health staff is increased yearly.⁷

In addition, medical personnel from all institutions have been suffering from increased work stress and workload because of the COVID-19 pandemic and civil unrest. These rapid changes in deployment may have a serious impact over the existing civil service health care providers and consequently lead to increased intention to quit the current job. Although Ministry of Health is trying to recruit health care providers, due to the limitation of production during a defined period, a good retention policy is a practical solution to retain primary health care providers.

According to the policy mapping and analysis on rural retention policies in Myanmar (2013), a study conducted by a group of researchers from Ministry of Health and Sports found that there were some challenges for health care providers in rural and remote areas. These challenges were insufficient salary, lack of support for transportation, accommodation for staff, difficulties in communication with family back home, difficulty in getting leave from work, lack of specific rules or criteria relating to posting in hard-to-reach areas, and lack of specificity about exactly how long rural posting would last once posted and security problems, especially in insurgency areas.⁸ In addition, non-local staff has to face language barriers and found it difficult to address local cultural beliefs and taboos.⁸

In 2019, the department of public health operated a quick assessment on the performance of BHS and it was found that there were some problems between midwife and PHS II. The discrepancies between the defined workload and real-life duty, inequalities of training opportunities, questionable promotion policy, and unequal financial and non-financial incentives. These problems are needed to solve for creating favourable working environment. This assessment recommended more research to fill the gap.

Therefore, this study was conducted to determine the current status of turnover intention, to assess the effects of work stress, workplace violence and job satisfaction on turnover intention and to assess the mediation role of job satisfaction in the relationship between work stress, workplace violence and turnover intention. It is hoped that this information will be used to health care system policy makers and contribute to improving working practices and ongoing retention mechanism.

METHODS

Participants and sampling

This study was a cross-sectional analytical study and conducted among MW and PHS II between July 2022 and July 2024. Participants of both male and female at least one year duration of working in the civil service were involved. Sample size was calculated using G Power software (version 3.0.10) with F tests, considering 3 predictors, the design effect of 1.5 and 10% non-response rate. A multistage sampling method was used. Firstly, a total of three among seventeen states and regions were selected. The chosen states and regions were Yangon, Nay Pyi Taw, and Shan (north). Subsequently, three townships from each state and region were randomly selected. For Yangon region, the chosen townships were Hmaebe, Taikegyi, and Htantapin; for Nay Pyi Taw, the selected townships were Pyinmana, Lawe, and Tatkon; and for Shan (north), they were Lashio, Kyaukme, and Nawnghkio. Subsequently, 21 MW and 21 PHS II were randomly selected from each township. These MW and PHS II were employed in sub-rural health centers, rural health centers, urban health centers, and maternal and child health centers under the jurisdiction of the township public health department, as well as within the township public health department itself. In addition, more 16 PHS II were responded with a request from one region. An anonymous self-administered questionnaires were used to conduct by using kobo collect apparatus. The questionnaires were pretested on 20 MW and 20 PHS II from another region, Mandalay. Two data collectors were trained on electronic data collection, compilation, monitoring of data entry for data validity.

Questionnaires

Demographic characteristics

The demographic information including sex, age, marital status, education, monthly family income, balance between income and expenditure. professional title, duration in the civil service, reason for joining civil service and current health facility were collected. Back-to-back translation of the questionnaires for work stress, workplace violence, job satisfaction and turnover intention variables (from English to Myanmar and Myanmar to English) was checked by the research team and language experts from Yangon University.

Work stress scale

The questionnaires of work stress by Holmgren were applied to assess work stress.⁹ It consists of 21 items under four constructs. The constructs for indistinct organization and conflicts, individual demands and commitment has three (yes, partly, no) or two responses (yes, no) followed by appended question showing level of stress using 4 points Likert scale ranging from 1 = not stressful, 2 = less stressful, 3 = stressful and 4 = very stressful. In respect of the influence at work and work interference with leisure time, there are 4 responses using a four-point ordinal scale 1 = yes: always, 2 = yes: rather often, 3 = no: seldom and 4 = no: never.⁹ Total score was counted by adding the scores of all items and it ranges from 21 to 84 with a higher score reflecting the higher in work stress. According to the studies conducted by Holmgren, the questionnaire had good face validity and high reliability.⁴ In this study, the Cronbach’s α for the work stress scale was 0.72.

Workplace violence scale

The questionnaire for workplace violence dividing into physical violence, physiological violence, bullying/ mobbing and sexual harassment. It was measured by using the questionnaires from the workplace violence in the health sector developed by the International Labor Organization, the World Health Organization (ILO), the International Council of Nurses (ICN), and Public Services International (PSI).¹⁰ In this study, the Cronbach’s α for the workplace violence scale was 0.72.

Job satisfaction scale

Job satisfaction in this study was assessed by the psychometric instrument job satisfaction survey (JSS) of spector.¹¹ It consisted of nine constructs and divided into 36 items. The perception questionnaires contained two categories: positive statement items and negative statement items. Each item of positive statement was scored on a 6- point Likert scale reflecting 1 = disagree very much, 2 = disagree moderately, 3 = disagree slightly, 4 = agree slightly, 5 = agree moderately and 6 = agree very much and negative statement items were inversely calculated. The total possible score ranges from 36 to 216 with a higher total score indicating a higher job satisfaction. The mean score was resulted by dividing the total score by all 36 items. In this study, the Cronbach’s α for the job satisfaction scale was 0.72.

Turnover intention scale

The turnover intention scale was developed by Du Plooy and Roodt.¹² It included 15 questions and the response scale was scored on a five-item Likert scale, varying between 1=never, 2=seldom, 3= often, 4=frequently and 5=always. The total possible score is adding the scores of all items and ranges from 5 to 75 points with higher score indicates higher turnover intention. In this study, Cronbach’s α for the turnover intention scale was 0.865.

Data management and analysis

Two trained personnel checked the data accuracy and completeness after each day of data collection and checked data accuracy and completeness. The calculated sample size was 378 and the actual participants involved were 413. After removing 19 missing or blank data, 394 valid data sets were left finally (effective response rate =95.4%). For the continuous data, significant outliers were assessed by the visual inspection of Q-Q plots and normality was assessed by Shapiro-Wilk test. As the data were normally distributed, mean and standard deviation were used.

Descriptive statistical analysis was performed. Frequency and percentage statistics for the background characteristics of the participants were done. The item mean scores (SD) of work stress, job satisfaction and turnover intention were calculated. The scores of work stress were collapsed into three levels (low, moderate and high) to evaluate the status of work stress and also the scores of job satisfaction were collapsed into three groups (dissatisfied, ambivalent and satisfied) based on the bloom’s cut off value. The scores of turnover intention were also collapsed into three groups (low, moderate and high) to evaluate the status of turnover intention. The workplace violence score was changed into factor score by performing PCA without rotation, using 100 iteration time based on eigen value >1 using regression method. Pearson correlation coefficients were calculated to determine the correlation between work stress, workplace violence, job satisfaction and turnover intention with a significant p value of less than 0.05. The goodness of fit was analyzed using comparative fit index (CFI), root mean square error of approximation. A model that meets RMNSEA<0.08 and CFI>0.90 is accepted to have a good fit model. Boot strapping was used to test the statistical significance of the direct, indirect and total effects of the model. Next, path analysis was performed to verify the mediation role of job satisfaction between work stress, workplace violence and turnover intention. Descriptive statistics and correlation analysis were performed SPSS statistics 26.0. And path analysis was performed JASP (Jeffrey’s Amazing Statistics Program). Statistical significance was set at p<0.05.

RESULTS

Demographic characteristics of the respondents

Among the 394 participants, 53 participants (13.5%) were male and 341 (86.5%) were female. The mean age of the participants was 29.87 (7.88) years old. The majority of the participants were age group between 18-29 years (61.9%). Only 15 participants (3.8%) were divorced or widowed whereas single was (45.2%) and married was (51%). Most of the participants (51.3%) got bachelor. Just more than half of the participants (52.5%) earned 200,000 to 400,000 MMK per month and majority (86.3%) showed that there was no balance between income and expenditure per month. Nearly half of the participants (42.4%) had 5 to 10 years duration in the civil service following (32.5%) of >10 years duration. Just more than half of the participants (53.8%) joined the civil service to provide health care to the community. The majority of the participants (61.9%) served at sub rural health centre (Table 1).

Work stress

Work stress score was measured with 4 points Likert scale. The total item mean (SD) score of work stress was 1.7 (0.28). Among the four domains, the participants had high stress for indistinct organization with conflicts and interfering their leisure time with mean score of 2.1 (0.54) and 2.0 (0.61) respectively. The mean score of other domains of individual demands and commitment, influence at work was 1.4 (0.36), 1.7 (0.50) (Table 2). Twenty-nine participants (7.4%) had high level of work stress, 172 (43.7%) had moderate level of work stress and 193 (49.0%) had low level of work stress.

Workplace violence

Some of the participants 99 (25.1%) had at least one type of violence. Among the violence, verbal violence was the most common and sexual violence was the least common. Some participants experienced more than one violence.

Job satisfaction

Job satisfaction was measured with 6 points Likert scale. The total item mean (SD) score for job satisfaction was 3.36 (0.6). Among the nine domains, MW and PHS II were least satisfied with pay domain, 2.52 (0.85) and most satisfied with coworker domain 3.97 (1.01). The item mean score of other domains like supervision, nature of work, promotion, communication, supervision benefits, operating procedures, contingent rewards were 3.96 (1.04), 3.85 (1.02), 3.57 (0.99), 3.47 (1.13), 3.05 (0.93), 2.95 (0.81), 2.9 (0.95) respectively (Table 2). Most of the participants 248 (62.9%) expressed ambivalent job satisfaction, then, 94 participants (23.9%) expressed job dissatisfaction and 52 participants (13.2%) showed satisfaction.

Turnover intention

The total item average score of turnover intention was 3.18 (0.59) (Table 3). Twelve participants (3.0%) had low level of turnover intention, 145 participants (36.8%) had moderate level of turnover intention and 237 (60.2%) participants had high level of turnover intention.

Correlation analysis

Correlation analysis showed that there was a weak positive, and significant relationship between work stress and turnover intention (r=0.4, p value <0.001). In addition, there was a moderately strong, negative, and significant relationship between job satisfaction and turnover intention (r=-0.530, p value <0.001). However, workplace violence had no significant correlation with turnover intention (Table 4).

Test of study models

To quantify the relationship between the four dimensions, SEM was applied. The overall model fit indices of the hypothetical model were GFI=1, NFI=1, CFI=1, IFI=1, TLI=1, RMNSEA=0. All indices met the recommended values and the model was fitted well.

Direct, indirect and total effects on turnover intention

Table 5 summarizes the results of the direct and indirect effect of the model. The direct effect of a variable on another variable is equal to the path coefficient of the two variables. Work stress had a direct effect on turnover intention with estimate (γ=0.03). Job satisfaction had a direct effect on turnover intention (γ=-0.44). The indirect effect of work stress on turnover intention was equal to the product of estimates of work stress on job satisfaction and estimates of job satisfaction on turnover intention (-0.09 × -0.44). The indirect effect of work stress on turnover intention was found to be significant at 0.04 (Figure 1). The total effect of work stress, job satisfaction and workplace violence on turnover intention was 0.07, - 0.44 and 0.00 respectively. Job satisfaction had mediation role between the association of work stress and turnover intention, meanwhile, it had no mediation role between the association of workplace violence and turnover intention.

TI = Turnover intention, JS= Job satisfaction, WPV= Workplace Violence, WS= Work stress.

*Comparative fit index, 1.00 and root mean square error of approximation (RMESA) 0.00.

DISCUSSION

Sociodemographic characteristics

Our study also revealed that most of the respondents encountered imbalance between income and expenditure and so the job less attracts them. Furthermore, due to government-mandated basic public health services, MW and PHS II are tasked with providing both essential public health services and basic medical care, resulting in significantly increased workloads. It was found that heavy workload and stagnant income is the main cause of increased work stress and job dissatisfaction leading to increased turnover intention. If there was increased turnover, resulting in a significant loss of human resources which leads to the inefficient health system. A similar study has also found that the discrepancy between income and workloads significantly contributes to dissatisfaction among primary health care providers.¹³

Turnover intention

The shortage of primary health care provider is an ongoing and pressing problem worldwide that is exacerbated by turnover of them. This study investigated the status of turnover intention and relevant determinants among Midwife and PHS II in Myanmar. In general, it was found that most MW and PHS II had high turnover intention. Our finding was same to the finding in the study conducted by Han et al in which 60% of primary health care providers had high level of turnover intention.¹⁴ The study conducted in China showed that 78.35% of Chinese general practitioners had moderate and high level of turnover intention while our study revealed that 97% of the participants had moderate to high level.¹⁵ The difference might be due to the study population and the study area. And also, our finding was different from the study conducted in rural China in which only 14.06% had high turnover intention.¹⁶ The variation between these two studies might arise from differences in the study populations: our study including only 2 kinds of primary health care providers while the other study encompassed nearly all categories. Another factor might be due to the better situation of medical care in China. It can be seen in a study conducted in Finland and Madrid on physicians, the turnover intention was low as those countries are developed nations.^17,18 On seeing in a study conducted in Iraq which was poor living conditions and poor security country, 55.2% of Iraq doctors had high turnover intention.¹⁹

Work stress

This study also revealed that a considerable proportion of MW and PHS II were suffering from moderate work stress due to increased workload. Comparing with other study conducted on all categories of primary health care providers including from urban area of Myanmar, our study reported lower in moderate level of work stress (43.7% versus 70%).¹⁴ The inconsistence of the findings can be explained by differences in the study population and geographic scope. Our study selected providers from nine townships covering three states and regions in Myanmar meanwhile the previous study selected all types of primary health care providers from just two townships within a single state.

Job satisfaction

Our study showed that 13.2% of the study population had job satisfaction which is lower than a study conducted in teaching hospitals in Yangon, Myanmar in which 17.8% medical officers had job satisfaction.¹⁹ Another study conducted to the medical officers and nurses in Myanmar which showed 38.3% had job satisfaction.²⁰ The discrepancies may be due to the difference of study population and study period, as, previous study was conducted among medical officers and nurses in 2019. Our study indicated that MW and PHS II were most dissatisfied with pay, contingent rewards and operating procedures with the satisfaction rate being only less than the mean score of 2.95. The study conducted in medical officers and nurses showed that the respondents were most dissatisfied with fringe benefits, promotion, pay and contingent rewards.²⁰ It can be inferenced that pay and contingent reward was the common less satisfied factors in both studies.

Workplace violence

In our study, 25.1% of respondents experienced some form of violence, a lower percentage compared to another study where 40% of various specialties encountered violence.²¹ These discrepancies could arise from variations in both the study population and the geographical area under investigation. The previous study conducted on civil assistant surgeons (AS), staff nurses and trained nurses from a tertiary hospital of Myanmar. That hospital was very congested, over workload and the participants handled patient including critically ill. The respondents from our study take leading role in providing health care among their community and there was rare occasion to meet with their supervisor than assistant surgeons and nurses. However, it was found that the psychological violence was more than physical violence in both studies. A study conducted against physicians and nurses in the Palestinian public hospitals showed that 80.4% of the participants had both physical and psychological violence which was more than the findings of our study.²² The difference might be due to the cultural disparities for perception about workplace violence between Palestinian and Myanmar although the public hospitals of both countries face challenges such as understaffing, overcrowding, and inadequate working conditions and medical supplies. A study conducted on medical professionals in 12 hospitals of two provinces of China revealed that about 50% of study subjects reported at least one type of workplace violence, which is higher than our study and possibly due to the types of health care providers.²³

Correlation between work stress, work place violence, job satisfaction and turnover intention

Our study showed that work stress was weekly positively correlated with turnover intention (r=0.4) which is similar to the study conducted in Myanmar on all categories of primary health care providers in 2021(r=0.22).¹⁴ A study also revealed that work stress had correlation with turnover intention in China.²⁵ It was quite similar to a study conducted on health care workers in rural Taiwan work stress had a positive effect on turnover intention.²⁶

The results of our study indicated that the nine job satisfaction domains had a significant impact on turnover intention. The results were consistent with previous studies in Myanmar in which there was positive relationship between job satisfaction and turnover intention.^19,20 The results were consistent with the studies in other countries.^27-29 The findings of our study revealed that workplace violence was not correlated with turnover intention. This finding was inconsistent with another studies in China which indicated that workplace violence was positively weekly correlated with turnover intention.²⁹

Mediation role of job satisfaction

Our study showed that job satisfaction played a mediation role between work stress and turnover intention and no mediation role between workplace violence and turnover intention (Table 5).

There were some limitations in the study. First, the reliance on self-reported data may introduce recall bias, as participants may not accurately recall details of their violence experiences. Second, since the sample came from nine townships across three states and regions, applying the conclusions to the national level could be challenged. Third, while the study included a significant number of participants, the findings may not be fully generalizable to other basic health staff due to the specific context of MW and PHS II in the selected states and regions.

CONCLUSION

The mean score of the overall perception of turnover intention of MW and PHS II was 3.176 (0.59) on a five-point scale. A total of 60.2% had high turnover intention, 36.8 had moderate turnover intention and 3% had low turnover intention. It is concluded that turnover intention of MW and PHS II was significantly correlated with job satisfaction, work stress but not with workplace violence. The results may be useful for policy makers and health administrators wishing to stop primary health care providers leaving their professions at civil service especially in rural areas. To fulfil the aim of reducing turnover intention, the appropriate policies should be developed on focusing on work stress and job satisfaction, especially job satisfaction. Administrative departments should pay more attention to the primary health care providers who work in rural areas. Measures should be taken to reducing workload, allowing more leisure time, raising salary, providing more opportunities for career development and promotion, supporting by the senior colleagues and creating reward mechanism could contribute to the reducing of turnover intention of MW and PHS II.

ACKNOWLEDGEMENTS

First and foremost, the author would like to express sincere gratitude to the co-authors, supervisors and the rector of the University of Public Health, Ministry of Health, for their critical direction and significant input. The author also acknowledges all participants for their active and voluntary participation. Lastly, profound appreciation is extended to the department of medical research for facilitating the implementation research grant.

Funding: The research was financially supported by implementation research grant, Ministry of Health, Myanmar

Conflict of interest: None declared

Ethical approval: The study was approved by Institutional Technical and Ethical Review Board, the University of Public Health

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