Intention to leave Nursing during the COVID-19 pandemic

Abstract Objective: to investigate the percentage of professionals with an intention to leave Nursing during the COVID-10 pandemic, as well as the factors associated with this outcome. Method: a cross-sectional study conducted by applying questionnaires to 890 Nursing professionals from the municipality of Pelotas (RS). The outcome was identified by means of self-reports obtained from the question itself. Relative Risks, as well as their Confidence Intervals (95%), were calculated for the independent variables by means of unadjusted and adjusted Poisson regression. Results: the percentage of professionals who stated their intention to leave Nursing was 24.6% (n=219). There was a positive association between the outcome and higher schooling levels, negative evaluation of institutional support, moderate or intense overload, and skin lesions. A negative association was also observed between the outcome and individuals aged 51 years old or more. Conclusion: except for skin lesions, aspects such as lack of support and overload, although they may have been intensified during the pandemic, do not represent a new fact in the health services. In this sense, the associations found in the study reflect the need for cross-sectional actions to promote retention of professionals.


Introduction
Nursing represents more than half of the workforce in the Brazilian health system and, in June 2021, assistants, technicians and nurses accounted for 2,521,155 professionals (1) . Factors such as lack of support from the employer, lack of autonomy, low remuneration, increased workload and demotivation, in addition to physical and mental illness, have marked the work context of the Nursing team (2)(3)(4)(5)(6) .
On January 30 th , 2020, the World Health to risks of contamination in the work of the Nursing team, accentuated the already existing difficulties (7)(8) .
The scarcity of Nursing professionals noticed in many countries and dissatisfaction with the working conditions were aggravated during the COVID-19 pandemic. The current context, marked by deaths, illnesses and an increase in workload, has influenced these workers' intention to leave the profession and, in turn, exerted an impact on the service provided to the population (8,11) .
A cross-sectional, observational and multicenter study conducted before the COVID-19 pandemic with 23,159 professionals from the Nursing team of surgical and medical units of 385 hospitals in ten European countries (Belgium, Finland, Germany, Ireland, Netherlands, Norway, Poland, Spain, Switzerland and the United Kingdom), found that, in general, 9% intended to leave the profession (varying from 5% to 17% across all ten countries). A more negative perception about their participation in hospital affairs, older age, female gender, full-time work and Burnout syndrome were associated with the intention to leave Nursing (12) . More recently, in the pandemic context, a cross-sectional study conducted with 385 professionals from the Nursing team in community services in the Philippines showed that those who expressed fears of working in the face of the challenges inherent to the COVID-19 pandemic in the multivariate analysis were more likely to suffer from stress at work and to have an intention to leave the profession (13) .
It is noted that there are gaps in the literature about the factors that contribute for Nursing workers reporting their intention to leave the profession (3)(4)13) .
Studying these factors can contribute to planning the workforce, improving the working conditions and facing the difficulties, in addition to developing management strategies and practices so that these workers do not leave the profession.
It is believed that the intention to leave the Nursing profession is associated with factors related to the working conditions and that it has been potentiated in the COVID-19 pandemic context. Consequently, the objective of this study was to investigate the percentage of professionals with an intention to leave Nursing during the COVID-19 pandemic, as well as the factors associated with this outcome.

Method Study type and design
This is a cross-sectional study conducted during June and July 2020 in the municipality of Pelotas (RS). The study population comprised Nursing workers (nurses, nursing technicians and nursing assistants) allocated in the municipal services aimed at coping with the COVID-19 pandemic, namely: 51 basic health units; two outpatient services; two hospital services; an emergency service; a mobile emergency service and a teleconsultation service, in addition to the municipal epidemiological surveillance service and the vacancy regulation center. According to a previous survey, the total number of Nursing professionals linked to these services was 1,297.

Selection of the participants
The following inclusion criteria were adopted for this study: being over 18 years of age; being a Nursing professional duly registered at the Regional Nursing

Data collection procedures
After applying the inclusion and exclusion criteria, a total of 1,186 eligible professionals were identified for the study. Among these, 944 successful contacts were made, with 242 cases in which, after at least ten attempts on different days and times, it was not possible to contact the professionals. Contacts with the participants were in charge of 18 undergraduate or graduate students attending the Nursing or Psychology courses, previously trained to follow the study protocol (approach means and method; clarification of the study procedures and objectives; ethical issues). They were supervised by professors or researchers with a PhD and previous experience in the conduction of research studies.
Among the successful contacts, and after clarification regarding the study objectives and the right for nonparticipation and anonymity, 54 professionals refused to participate in the study. Consequently, 890 professionals were included in the study, corresponding to a response rate of 75% of the eligible population.
Those who agreed to participate in the study received, through their email address, Short Message Service (SMS) or personal messaging app, a link that directed them to a self-applied online questionnaire, hosted on the Google Forms platform, which could only be accessed after reading and agreeing with the Free and Informed Consent Form (FICF).

Quality control
The questionnaires received were reviewed daily by the supervisors in order to identify those that were only partially answered or other issues that could invalidate them, such as if they had been answered by professionals who were not included in the lists provided by the services.
Each participant was instructed to answer the questionnaire only once, even if they worked in more than one service. In these cases, they were asked to answer the questionnaire thinking about the job they considered as their main employment contract.

The outcome and its measurement
The intention to leave Nursing was assessed through a question elaborated and validated by the study researchers in a pilot test with ten Nursing professionals, who did not comprise the study sample. The question asked the following to the professional: "Did you think about changing professions at some moment during the COVID-19 pandemic?". Presence of the intention to leave Nursing was considered when the professionals gave a positive answer to this question.

Independent variables
The questionnaire applied to the participants was self-prepared and took into account a previously

Statistical analyses
The statistical analyses were performed in the The associations between the outcome and the independent variables were tested using unadjusted and adjusted Poisson regression models with robust variance estimators. In the adjusted analysis, the stepwise forward technique was employed for selection of the potential confounding factors, adopting p-value ≤0.20 as selection criterion (14) . Statistical significance was defined as p < 0.05. www.eerp.usp.br/rlae 4 Rev. Latino-Am. Enfermagem 2022;30:e3549.
After selection, the "skin color", "Nursing category", "evaluation of the institutional support received", "overload", "skin lesions" and "reduced interaction with family members" variables were defined as potential confounders. In this sense, they were used for adjustment between each other and for each of the other variables included in the study.
It is emphasized that the regression analysis was preceded by a collinearity test and that the results were satisfactory to perform the analyses (Variance Inflation Factor -VIF < 1.36).

Ethical procedures
The study was submitted to and approved by an

Results
In total, 890 Nursing professionals answered the online questionnaire. Of these, 319 (35.8%) were nurses, 501 (56.3%) were nursing technicians and 70 (7.86%) were nursing assistants. Most of the participants were female (84.8%; n=755) and the mean age was 40.4 years old (SD=8.58). Regarding the workplace, the majority worked in hospital services (64.8%; n=577) or in Primary Care (10.3%; n=92). The participants' full characterization can be seen in Table 1. The variable with missing data was per capita income (n=80).

Discussion
This study evidenced a high percentage of Nursing professionals with an intention to leave the profession.
This outcome was associated with schooling level, lack of institutional support and moderate and intense workload, with an emphasis on those who presented skin lesions due to PPE use.
The intention to leave the profession during the COVID-19 pandemic was also found in a study conducted with 210 Nursing professionals in hospitals from Zagazig, Egypt, where more than 95% had the intention to leave their current job in a hospital for COVID-19 screening, while around 25% intended to leave the profession altogether (15) .
In the initial stage of the pandemic in South Korea, a research study conducted with 377 professionals from the Nursing team evidenced that more than 10% of the participants reported their intention to leave the profession (16) . Likewise, the results of a survey involving where 20.3% of the 398 professionals studied had the intention to leave the profession (18) .
A research study conducted with 512 Nursing professionals in Qatar found an increase from 13.24% to 15.54% in the intention to leave the job during the COVID-19 pandemic. Although there are differences between the intention to leave the job and look for another one with less exposure and the intention to leave the profession, it is important to realize that this intention can be a fact that precedes leaving the profession (19) .
In addition to that, in a report from the United The results also pointed out that the outcome was associated with the stratum referring to people with higher schooling levels. However, in a study conducted with Nursing professionals in Qatar, the researchers concluded that education qualifications did not interfere in this intention (19) .
In opposition to what was observed in other studies, the results of this research indicate that lack of PPE was not associated with the intention to leave the profession.
In a research study carried out with Nursing professionals in the United States, it was found that stress and anxiety were present in 89% of the participants who heard news about the scarcity of PPE. In addition to that, lack of PPE was considered as with a positive relationship with the intention to leave the profession (20) . In Israel, one third of the Nursing professionals reported fearing going to work due to potential contamination and to feeling inadequately protected in the work environment, reasserting the importance of PPE. However, when asked if they regretted choosing the Nursing profession after the pandemic, the interviewees strongly disagreed with this assertion (21) .
Also in contrast to other studies, no statistically significant differences were found between the type of service in which the professionals worked and the intention to leave the profession. In the Philippines, during the COVID-19 pandemic, community service nurses, even with moderate levels of job satisfaction, indicated their intention to leave their jobs and change professions (13) .
The results of the present investigation pointed out that the Nursing professionals who presented intense and moderate workloads had deficient support in the workplace and that those who presented skin lesions were more likely to state their intention to leave Nursing.
It is noteworthy that work overload has been widely discussed in the literature even before the pandemic context. The high level of demands, especially work overload and Burnout, contributed to the intention to leave Nursing (12,22) .
Before the pandemic context, in Poland it was identified that the most important factor for the overall mental health status of the category was work overload.
In the study in question, 66.5% (n=371) of the Nursing professionals who worked in hospitals assessed work overload as a negative aspect of the service (23) .
A survey conducted with Nursing professionals in the Nursing workers who lacked support at work had 4.8 times more chances of feeling dissatisfied (25) .
However, a research conducted with 111 Nursing professionals from Alabama working on the front lines in the fight against COVID-19 pointed out that more than 54% reported that the supervisors had little concern for the professionals. However, the "supervisor support" variable was not associated with the "intention to leave the profession" outcome (20) .
In the current research, an association between presenting skin lesions and the intention to leave Nursing was observed. In contrast with the other factors that were associated with the intention to change professions, skin lesions are directly related to the COVID-19 pandemic context. As evidenced in the literature, this relationship is due to the increase in the PPE use time (26) .
A study carried out with Nursing professionals and physicians in a Chinese province found 97% prevalence of skin lesions due to PPE items used by front-line professionals in the fight against COVID-19 (27) . Likewise, in Turkey, skin problems were found in 90.2% (28) of the professionals. In turn, in a study conducted in the province of Wuhan (China), this prevalence was 91.8% (29) .
Skin lesions due to prolonged use of PPE items and to frequently hand washing or antisepsis were widely addressed in the COVID-19 pandemic context. However, up to the present day, no other studies have been identified in the literature associating skin lesions with the intention to leave the profession.
The association between skin lesions and the intention to leave the profession may have been due to subjective feelings in relation to the injuries, such as presence of pain, discomfort and infections. Lack of support in receiving products to adequately protect the skin, such as facial wipes, moisturizer and protective tape, is also pointed out. Protection of the professionals must be a priority in the health services to ensure that they can work without harms resulting from the use of equipment that, a priori, is intended to be protective (30) .
As a highly contagious and pathogenic disease, COVID-19 already took the lives of thousands of people, with many professionals among them. As evidenced, the fact that the professionals thought about leaving the profession was already a problem prior to the pandemic moment that exacerbated issues associated with overload and lack of institutional support at work (12,19) .
Although the pandemic has evidenced inadequate conditions and work overload, in addition to physical and mental risks, this research reinforces that deficient In addition to this, it is important for the panorama of the profession, as it contributes to problematizing the need for improvements in the labor rights and working conditions, evidencing the importance of assessing the Nursing professionals' needs.
It is to be pointed out that, for being a cross-sectional study, reverse causality cannot be disregarded. It is also noteworthy that the question used to track the outcome alluded to all the time elapsed since the beginning of the pandemic until the collection date, when the contagion curves were on an important rise. In this sense, it is important that future studies may strive to assess evolution of the outcome throughout the pandemic period, considering specific time clippings.

Conclusion
High prevalence of the intention to leave Nursing was observed. Among the associated factors were sociodemographic aspects such as higher schooling levels (positive association) and age 51 years or older for services and health systems for the establishment of cross-sectional actions that can contribute to retention of Nursing professionals.