Fatores relacionados à rotatividade externa voluntária de profissionais de enfermagem * Factors related to voluntary external turnover of nursing professionals

* Extraído da dissertação “Rotatividade dos profissionais de enfermagem de um hospital universitário público”, Faculdade de Enfermagem, Universidade Estadual de Campinas, 2014. 1 Universidade Estadual de Campinas, Faculdade de Enfermagem, Programa de PósGraduação, Campinas, SP, Brasil. 2 Universidade Estadual de Campinas, Faculdade de Enfermagem, Campinas, SP, Brasil. ABSTRACT Objective: To analyze the factors related to the turnover of nursing professionals of a public teaching hospital. Method: Descriptive, exploratory, retrospective study with quantitative analysis conducted with workers from a public teaching hospital. The analysis used a data collection instrument from the service, applied at the time of the voluntary resignation of the professional. Results: 223 nursing professionals participated in the study. The factors that led to voluntary turnover were the employment bond, age and the association of both. The majority of professionals were young adults, in a high productivity phase, which increases willingness to seek challenges in the labor market and professional improvements. Conclusion: Turnover is multifactorial and influenced by economic, social and political aspects. Reducing inequalities in working conditions, which generate dissatisfaction, such as different employment bonds for professionals who have the same function and perform the same activities, is fundamental to reduce turnover.


INTRODUCTION
Professional turnover is defined as the movement of employees in and out an organization and the labor market.It is quantified by the number of people entering and leaving an organization or the ratio between the number of admissions and resignations of professionals (1) .The turnover can be external, referring to the professionals who leave the organization for various reasons, or internal, which is the transfer to positions of other areas or units within the same institution (2) .In addition, resignation may be voluntary, as a consequence of a personal decision of the professional, or involuntary, when the resignation is a decision of the organization (3) .The present study considered volunteer external turnover, that is, cases in which professionals voluntarily asked for resignation.
The high turnover of nursing professionals is an important factor for the institutions due to the high costs involved in the resignation and admission processes, since it requires planning, selection tests, continuing education and dedication from the supervision team to the specific orientations of each area, using human, physical and material resources (4)(5) .
Beyond the financial aspect, turnover generates indirect impacts such as the reduction in the efficiency of the institution, decrease of the productivity of the team and loss of competent and skilled professionals.In addition, this event leads to overload of the professionals of the work unit, demands time to restructure the team, requires overtime hours, and reflects on the motivation of the professionals and on the organizational climate (6) .
The turnover of nursing professionals is a matter of international concern.The factors that are frequently mentioned as determinants in the literature are those related to professional satisfaction and management aspects.In addition, financial consequences are highlighted.Despite the existence of studies that analyze determinants and consequences of turnover, there is a necessity for more research to analyze the intention to leave the employment and the effective institutional turnover (7)(8) .
Once managers recognize, value and praise the skills of nursing professionals in the delivery of quality clinical practice, they help employees feel that their work is appreciated and valued.Consequently, the result is greater job satisfaction (9) .The characteristics of institutions can affect even the quality of life of employees (10) .
Thus, the objective of this study was to analyze the factors related to the turnover of nursing professionals in a public teaching hospital.This study provides reflections on the turnover of nursing professionals, aiming to find better and innovative work possibilities, providing the citizens safety and quality in health care.

Type of sTudy
Descriptive, exploratory, retrospective study with quantitative approach (11) , conducted in the Nursing Department of a high complexity public teaching hospital with approximately 400 beds, located in the state of São Paulo, in the Southeast region of the country.The hospital holds teaching, research and care activities.

populaTion
The study population consisted of nurses, nursing technicians and nursing assistants, who belonged to the Nursing Department and who voluntarily asked for resignation from the institution, in the period from January 1 st , 2010 to December 31 st , 2013.Those who were in the process of transferring a work contract, that is, the professionals with a work contract by the University's Development Foundation who had voluntarily resigned to be admitted with a work contract tied to the university, were excluded.Professionals whose reason for turnover was retirement or death were also excluded.For a greater accuracy of the research, the population was considered, not the sampling.
The analysis of voluntary external turnover of nursing professionals from the Nursing Department of the university hospital studied is relevant because it is a large team.There are approximately 1,550 nursing professionals, out of the total of 3,100 professionals of the institution.In addition, it is a high-complexity, high-demand hospital that uses specialized therapies and health technologies.
The nursing professionals are employed in the hospital through a public contest of the university or through a selection process of the foundation.The employment bond with the university provides employment stability, a career plan and social benefits.The employment by the foundation does not provide stability, the salary and benefits are lower, some benefits do not exist and there is no career plan established.The foundation is a legal entity of private law and its activities include, among others, purchasing goods and hiring personnel.For both employment bonds, the resignation process from the Nursing Department is similar.

daTa collecTion
The research was carried out based on the analysis of the information in the data collection instrument, which is a structured questionnaire from the Nursing Department applied during the resignation process to nursing professionals who resigned from their function from 2010 to 2013.Data analysis was performed in 2014.
The factors related to the dyad resignation and turnover of nursing professionals, referring to the period from 2010 to 2013, were analyzed.The analysis considered data related to voluntary resignation in the various units of the hospital, which included professional category, time working in the institution, employment bond, contract by the university or by the foundation, level of education, age, gender, place of work, work shift, presence of health problem, presence of another employment bond, year of resignation and reasons for the resignation.
The categorical variables and measures of central tendency of the data collection instrument were described by absolute value and percentage and dispersion was used for the quantitative variables.For the statistical analysis, the data were inserted in a spreadsheet in Microsoft Excel ® and analyzed by statistical tests in the program Statistical Analysis System -SAS ® 9.2.The comparisons involving categorical variables in relation to the variable age at resignation were performed using the Mann-Whitney test for the variables that had two categories and the Kruskal-Wallis test for the variables with more than two categories, followed by Dunn's post-test.The chisquare test was applied to study the associations between the variables of resignation and the categorical variables.For the cases in which at least 20% of the boxes in the table of expected values had a score lower than five, the Fisher exact test was applied.A significance level of less than 5% was considered for all analyzes, that is, the data were statistically significant when p<0.05 (12) .In the statistical analysis, the variables that did not contain the information were not considered in the percentages and recorded as 'not informed'.

eThical aspecTs
The development of the study met national and international standards of research ethics involving human beings.The project was submitted to evaluation by the Research Ethics Committee of the School of Medical Sciences of the Universidade Estadual de Campinas in 2012, according to resolution n. 466/12 of the National Health Council and approved under no.259.999 (13) .

RESULTS
The study population consisted of 223 nursing professionals, with resignation between 2010 and 2013, in the following proportion: 52 professionals (23.3%) resigned in 2010, 63 (28.3%) in 2011, 71 (31.8% %) in 2012 and 37 (16.6%) in 2013.Regarding the proportion of voluntary resignation by the total of resignation by category, 39.5% of resignation was of nurses, 34.2% of nursing technicians and 25.8% of nursing assistants.
Most professionals (63.3%) reported having two simultaneous jobs and 48.4% considered their income as the 'work force' of their family.The majority (83.6%) had a prior employment bond in Campinas or in the metropolitan region of Campinas.As for the means of commuting, 49.8% used a car, 18.8% used charter buses from the university and 12.6% used common bus lines.Part of the workers (27.8%) reported having had some type of health problem during their employment contract in the hospital.The socio-demographic and professional characteristics are presented in Table 1.
The mean age of the study population was 33.6 years (SD 7.8), and the median was 31.4 years.In the 4-year historical series, the mean ranged from 32.8 to 34.1 years (SD 7.3 to 8.7), and the median ranged from 30.3 to 32.5 years.
The mean length of stay in the institution was 3.1 years (SD 4.1).The shortest time working in the institution was a resignation on the day of hiring, considered zero work days, and the highest was 25 years.The first quartile presented 0.4 year and median of 1.5 years, and the third 4.4 years.In the 4-year historical series, the median ranged from 1.1 years in 2012 to 3.5 years in 2010, and the mean ranged from 2.3 years (SD 3.1) in 2012 to 4.6 years (SD 5.0) in 2010.The first quartile ranged from 0.3 in 2012 and 2013 to 0.8 in 2010, and the third quartile ranged from 2.7 years in 2012 to 6.6 years in 2010.Note: (n=223).
Regarding the employment bond, 21.3% of nurses were hired by the university and 78.7% by the foundation.Among the nursing technicians and assistants, 48.9% had an employment bond with the university and 51.1% with the foundation.
The variable "presence of health problem while working in the hospital" was answered affirmatively by 28.7% (62 subjects), who confirmed the existence of a health situation; five workers reported more than one health problem.The most prevalent health problem was musculoskeletal disorder (43.9%, 18 subjects), followed by infectious diseases (conjunctivitis, sinusitis, pharyngeal conditions, herpes, varicella, mumps and dengue), with 12 subjects (29.4%).
Among the reasons mentioned by the professionals as motivation for their resignation, 26% were personal reasons, 9% another job outside nursing, 8.5% the salary, 4.5% health problem, 2.7 % the working conditions, 2.2% dissatisfaction with leadership, 1.4% adaptation problems with the team, 0.9% dissatisfaction with the interpersonal relationship and 56.1% claimed other reasons.
Salaries differed significantly according to the employment bond, with a variation of 33.5% between university and foundation contracts, as shown in Table 2.
The reasons given by the subjects are presented below.In the study, we counted each time a reason was mentioned.The same subject may have claimed one or more reasons, so the number of reasons is the number of times that it was mentioned, according to Table 3.
The association between the variable age at resignation with the other variables was statistically significant for the variables "employment bond" (p-value=0.0177),"time working in the hospital" (p-value=0.0262),"reason: personal problem" (p-value=0.0009) and "work force", an expression that designated a significant financial contribution to the family (p-value=0.0140),according to Table 4.
The association of the variable "reason for resignation: salary" was statistically significant for the variables "employment bond" (p-value=0.0412) and "professional category" (p-value=0.0015).The association of the variable "reason for resignation: another job" was statistically significant for the variables "employment bond" (p-value=0.0395),"time working in the hospital" (p-value=0.0280), and "health problem" (p-value=0.0307).

DISCUSSION
This research is an original contribution due to the scarcity of studies analyzing subjects that resign an institution, since the majority of the studies is based on the professionals' intention to leave the work or the profession.Since the data collection period, the study institution did not present significant transformations; it maintains the same organizational structure, with similar financial resources, physical area, staffing and employment bonds.Therefore, the data can be considered contemporary.
The population analyzed (n=223) represented 34.7% of the total number of resignations that occurred in the institution from 2010 to 2013 and were voluntary resignation, that is, it was a choice of the employee, not of the institution.Of these, 57% were linked to the hospital by a contract signed with the foundation and 43.1% with the university.
Among the professionals who left the institution, the majority (63%) worked in another job, which gave financial support for their decision.Also, the majority were working at the hospital for a shorter period.This data indicates that, for the professionals who worked in the institution for less time, it was easier to leave it.The predominance of nursing technicians (75.3%) corroborates the fact that many technicians got their undergraduate degree in nursing and resigned to take up a position of nurse in other institutions.
Voluntary turnover or even leaving the profession can be positive, particularly for the individual, because in some situations the nursing professional does not find possibilities for career development in the profession or in the institution they work.In addition, they often perceive their intellectual potentialities and skills underappreciated in the exercise of activities.In this sense, professionals who have invested in university studies or those who start a new career benefit from the changes as they seek new challenges and professional improvements, including financial (14) .
Regarding the work shift, the majority of the participants (41.4%) worked in the afternoon, the period with the greatest number of professionals admitted due to greater availability of positions, since many professionals transfer to the morning and night shifts.The latter is commonly chosen for its financial attractiveness, since the nighttime extra pay is 20% of the employee's salary over the hours worked during the night, between 10p.m. and 5a.m.Another reason is compatibility with another night work.The opportunity to choose the shift and the place of work is important for the satisfaction of the professional, considering that the work shift can be a factor that contributes to problems in workers' health (15) .
The variable age of the professionals presented a median of 31.4 years.This means that they are young adults, who are available to seek professional improvement in the labor market.
Managers who want to reduce staff turnover analyze the composition of the team regarding the integration of different generations in a harmonic way, as an approach to minimize the impact of generations.This measure helps understanding the differences of values, behaviors and desires, favors exchanges of knowledge and experiences, and establishes retention strategies (16) .
In this context, actions related to workers' health must be constantly implemented."It is necessary to invest in prevention programs, training, health education, intervention strategies and organization of existing services" (17) .
The decision to make a professional transition is based on an analysis of risks and benefits, that is, on the one hand, there is personal and professional achievement, and on the other, employment stability and salary benefits (18) .
A study conducted with 833 nurses at a university hospital in Sweden pointed out that the main reasons for leaving the job were dissatisfaction with the work (65%), psychologically strenuous and stressful work (32%), a wish to 'try something new' (28%) a and limited opportunities to make a professional career (19%) (19) .
Decision-making processes in management policies should consider improvements for nursing professionals, such as appreciation of the team, incentives for professional development, career plans, salaries, benefits and inclusion of professionals in the decision-making process (20) .Factors that contribute to professional satisfaction are dynamic and can be altered through organizational management and policies (21)(22)(23) .
In the population of this study, the number of nurses hired by the foundation (78.7%) was considerably higher than those hired by the university (21.3%).This may be associated with the degree of dissatisfaction of the worker with the employment bond, which can lead to weak commitment to remain in the institution.Studies that correlate professional turnover with the costs of resignation and admission processes, and with the impact of this process on health users and the health team are still scarce and are important for a better understanding of the phenomenon (7,24) .
The comparison between employment bond and age was statistically significant (p-value=0.0177),as well as the ...continuation employment bond in relation to the salary as reason for resignation (p-value = 0.0412).Therefore, the employment bond proved to be an important factor for the turnover of nursing professionals.
A study carried out in Portugal found that human resource managerial decisions do not value the issue of employment bond in the Portuguese health system and that the professional, personal and social dimensions are not considered with due attention (25) .
Professionals who remain in the profession must find more challenging and interesting issues, especially the new generations, who seek constant and global connections in the profession, as they have lived through technological evolution, the digital age, the wireless connectivity and information networks, with interactions that transcend territorial boundaries.For this, continued education programs are fundamental, as well as incentives for self-improvement courses and graduate studies (26) .
The public teaching hospital of this study presents a teaching and learning culture and offers many opportunities for professionals to acquire new knowledge.It has always motivated professionals interested in seeking qualification, competence and quality of care.For many professionals, it is an advantage to be a public servant of the university, which may be a contributing factor for the retention of health professionals, especially nurses, since technicians who obtain a nursing degree commonly seek the opportunity to practice their profession in the category of nurses.
Therefore, the qualification of nursing management, awareness of the importance of job satisfaction, respect for the professional regarding working conditions, adaptations of the physical structure and support to the health of the worker are organizational lines of action.With this, professionals are moving towards improvements for users, for the institution, and for themselves.

CONCLUSION
In the present study, most of the professionals were young adults, in a high productivity phase, which increases willingness to seek challenges in the labor market and professional improvements.The factors that led to the decision to leave the job were having an employment bond with the foundation, age and the association of both.
The employment bond with the foundation leads to dissatisfaction due to its lower salaries and benefits and lack of employment stability.This relationship was considered a predisposing factor for the decision to resign.The decisions related to the management of hospital and university personnel should consider this factor and the analysis of the direct and indirect costs involved, along with the quality of care.
The turnover of nursing staff has direct influences on the quality and safety of the care provided to the user, since the training of the professional goes beyond the knowledge acquired in the curriculum of college courses; it also includes the knowledge of the work processes, the institutional norms and routines and the interpersonal relationships with the team, which are acquired through the institutions' commitment with continued education and with dedication and time of professional experience.
To reduce turnover, it is necessary to reduce differences in working conditions, such as different employment bonds for professionals who have the same function and perform the same activities.
The factors related to resignation are complex, and their management is a challenge for managers in their way to achieve safe and quality assistance, professional satisfaction and reduction of institutional costs.
Since the institution studied is a high complexity hospital, member of the university and a reference in the region, the working conditions provided are close to what is appropriate for the health worker, which may be different from the reality experienced in other regions.In this sense, the limitations of this study are that the results probably cannot be generalized to hospitals that do not have this profile.

Table 1 -
Distribution of resignation professionals according to socio-demographic and professional characteristics -Campinas, SP, Brazil, 2014.

Table 2 -
Salaries of nursing professionals of the Public Teaching Hospital of the São Paulo state, according to the employment bond -Campinas, SP, Brazil, 2014.

of nursing categories according to employment bond by the university and by the foundation University Foundation Salary Difference Value of in % Value of salary difference
Source: General Office of Human Resources -Salary table of professionals who support teaching, research and extension, in force from 05/01/2013 onwards and selection processes for nurses, nursing technicians and nursing assistants of the Foundation, in the 1st half of 2014.Minimum wage in Brazil on January 1st 2014: R$ 724.00.

Table 4 -
Association between the variable age at resignation with the other variables -Campinas, SP, Brazil, 2014.