To our knowledge, this study was the first to investigate the turnover intentions of RHWs in western China and to determine the mediating effect of job satisfaction on the relationship between work stress and turnover intention. A large sample of 5046 RHWs from 11 western provinces participated in the study. It provided relevant evidence from rural western China and added to the growing body of international literature on health workers’ turnover intentions.
The results indicated that 29.1% (1468/5046) of the RHWs developed turnover intentions. China is one of the most traditional Asian countries, and the Chinese are instilled with a sense of obligation to remain in their profession . RHWs who felt obliged to remain in their current profession keep themselves involved and this activity may be essential in performing their selected profession.
The percentage of RHWs with turnover intentions was lower than that in previous studies in China. Zhang et al.  and Fang et al.  reported that 52.7 and 36.8% of the rural village doctors had turnover intentions, respectively. In addition, the results varied between different countries. Dale et al. reported that 41.9% of 1192 GPs intended to leave general practice in England ; Bonenberger et al. found that 69% of 256 health workers in Ghana reported to have turnover intentions ; Ali Jadoo et al. reported that 55.2% of 576 Iraqi doctors had turnover intentions ; and Heinen et al. conducted a large-scale survey among 23,159 nurses from 10 European countries which showed that 9% of all these nurses intended to leave their profession and it varied from 5 to 17% between countries .
Our study indicated that RHWs were slightly satisfied with their jobs. The area that they were least satisfied with was reward, especially among those who had turnover intentions. RHWs could only receive a median income of $359.4 per month, which was very low and was possibly because of the poor economic situation in western rural areas. The result was consistent with prior studies among basic-level health workers (i.e., village doctors and community health workers) from China [40, 43]. Similar results were also observed in other countries. Simoens et al. found that GPs in Scotland expressed the least satisfaction with their remuneration , and Bonenberger et al. reported that the score of job satisfaction with remuneration among health workers in Ghana was the lowest .
Meanwhile, under control of the sociodemographic variables, the organizational management satisfaction, reward satisfaction, and occupation satisfaction were significantly associated with RHWs’ turnover intentions. High job satisfaction with organizational management, reward, and occupation equated to low turnover intentions of RHWs, which was consistent with previous studies conducted in China and other countries. A study conducted by Lu et al. in China reported that job satisfaction with promotion, remuneration, current job, and superiors had a significant impact on turnover intentions of physicians . Zhang et al. found that job reward and organizational management satisfaction were direct predictors of turnover intentions of physicians in China . Bonenberger et al. , Dale et al. , and Ali Jadoo et al.  found that low job satisfaction was significantly associated with high turnover intentions of health workers in Ghana, GPs in England, and Iraqi doctors, respectively. In our study, reward satisfaction was the strongest predictor of the turnover intentions of RHWs. Steinmetz et al. reported that health care employees from Belgium, Germany, and the Netherlands with low wage satisfaction were less likely to express an intention to stay . However, our study found that social recognition satisfaction was not a significant factor, which was inconsistent with previous studies. Chen et al.  and Yeh et al.  revealed that social support from patients, family/friends, and superiors was significantly associated with low turnover intentions of health workers.
In terms of work stress, RHWs felt moderately stressed with their work. It commonly existed among health workers, especially in China where it has the largest number of potential patients in the world . In fact, patients, particularly the in-patients in China, preferred to seek health care services in high-level hospitals in cities instead of in basic-level hospitals in rural areas, causing higher workload for health workers in high-level hospitals. However, the hierarchical medical system was proposed and established with the implementation of the new health care reform in China since 2009. Patients were suggested to visit basic-level hospitals first and then proceed to high-level hospitals as referrals, if necessary. Only then could they reimburse their medical costs from the social medical insurance. Therefore, the work stress of health workers working in basic-level hospitals (including the rural hospitals) might gradually increase.
Our study indicated that there was only univariate association between work stress and turnover intentions of RHWs in this study. High work stress (workload and negative emotion) led to high turnover intentions of RHWs. This result was similar to that in previous studies. Zhang et al. found that emotional exhaustion was identified as a significant director predictor of the turnover intentions of physicians in China . Another study conducted in China reported that trouble falling asleep and nerves because of work were significantly associated with physicians’ turnover intentions . Workload and burnout were significantly associated with health workers’ turnover intentions in Ghana . Steinmetz et al. found that working-time-related factors significantly affected health care employee’s intention to stay in Belgium, Germany, and the Netherlands . Dale et al. found that volume and intensity of workload were the factors that most influenced intentions to leave general practice among GPs in England . Meanwhile, Heinen et al. revealed that burnout was a very strong influencing factor associated with nurses’ intentions to leave the profession in 10 European countries .
In addition, when controlling other variables, the association between work stress and turnover intention in this study became insignificant. This was probably because the respondents in our study were RHWs rather than health workers working in urban medical institutions in other studies. And after testing mediating effect, the results indicated that work stress had an indirect effect on RHWs’ turnover intentions through the total mediating effect of job satisfaction including organizational management satisfaction, reward satisfaction, and occupation satisfaction. Reward satisfaction was identified as the strongest mediator. Similar results were reported by Kuo et al. that job satisfaction played the mediating role with a partial effect in the relationship between work stress and turnover intentions among long-term care nurses in Taiwan . However, we didn’t found related studies conducted in other countries.
In addition to job satisfaction and work stress, three sociodemographic characteristics, i.e., age, income, and medical institution, were significantly associated with RHWs’ turnover intentions.
First, younger RHWs were more likely to have turnover intentions than older RHWs, which was consistent with Lu et al.’s and Yeh et al.’s studies conducted in China [19, 33]. Yeh et al. found that older hospital pharmacists had lower turnover intentions and they might have experienced their career challenges and have found ways to accommodate their professional careers in their lives . Similar results were found in many previous studies in other countries [9, 42, 44]. Steinmetz et al. found that young health workers were more likely to leave their jobs to seek career advancements, particularly when limited career opportunities were available within the current hospitals .
Second, RHWs with a lower-level income were more likely to have turnover intentions than those with a high-level income. These RHWs with a low-level income might desire to pursue a high-level income through landing a job in urban hospitals or changing professions. Income is assumed to be essential to health service delivery . The results corresponded well with previous findings. Steinmetz et al. demonstrated that health care employees with a low wage were less likely to express an intention to stay in Belgium, Germany, and the Netherlands . A Taiwanese study indicated that compensation (salary and bonus) was the strongest factor associated with turnovers of nurses . Hinson et al. found that salary was the most important factor affecting retention of nurses in the United States . Our study and Steinmetz et al.’s study  confirmed that both a high-level income and reward satisfaction were essential to retain health workers.
Third, the medical institution was another influencing factor. RHWs in THs were 1.38 times more likely to had turnover intentions than those working in CGHs. The working conditions of THs were worse than county- or above-level hospitals , thereby retaining and attracting health workers there had become slightly difficult. A similar finding from Lu et al.’s study was that physicians in low-level medical institutions (i.e., community health service center and health clinics) were more likely to have turnover intentions than those working in high-level hospitals where there were better welfare treatment, work environment, etc. . However, working in CDCs, which were one of the county-level hospitals, reduced the likelihood for RHWs to have turnover intentions compared with those working in CGHs. This result might be due to a significantly higher job satisfaction and lower work stress of RHWs employed in CDCs (3.23 ± 0.52, 3.11 ± 0.58) than those working in CGHs (3.19 ± 0.57, 3.35 ± 0.66) in our study.
In addition, contrary to prior studies [9, 13, 23], our study found that gender, marital status, and education were insignificantly associated with RHWs’ turnover intentions.
The study has several implications. As a large percentage in total health workers in China, RHW’s turnover intentions are major problems facing the rural health care system, especially in western remote region, which should attract more attention from related health service managers and policy makers. Our study highlighted the important effects of job satisfaction and work stress on turnover intentions of RHWs, especially the job satisfaction which had direct effects and played a mediating role. Thus, we recommend providing effective regulations to protect RHWs from turnover actions. It should place more emphasis on improving job satisfaction of RHWs through improving managers’ professional hospital administration and providing more opportunities for continual training and career development etc. Meanwhile, it’s essential to offer more attractive and competitive wages and benefit packages and introduce more effective payment mechanisms for RHWs and to improve their reward satisfaction. In addition, measures to reduce work stress also should be implemented under gradual implementation of new health care reform in China. Furthermore, the high-turnover-prone group of RHWs who were younger and working in THs should be paid more attention by recognizing and rewarding health workers who stay longer, improving motivation and commitment, providing non-monetary support, and improving working conditions of THs, etc.
Certain limitations of the study must be mentioned. First, RHWs in this study included different types of professions, such as doctors and nurses. However, it didn’t analyze the possible influence of the types of professions on RHWs’ turnover intentions. Second, the survey was conducted among RHWs in 11 provinces and the multilevel analysis should be used as a way of controlling for effects of provinces. Third, in-house instruments developed according to the practical situation of rural medical institutions in China were used to measure the job satisfaction and work stress of RHWs in this study. However, several very good instruments for these variables had been developed and validated. The measurement results on job satisfaction and work stress in our study might not be as effective as results measured by these instruments. Fourth, no comparison tests were performed for respondents and non-respondents because we did not collect the non-respondents’ information. Fifth, since the sense of obligation was important for Chinese, it should be introduced in the questionnaire and controlled for RHWs’ turnover intentions. Sixth, it did not provide definitive conclusions about the causal relationship between job satisfaction, work stress, and turnover intentions of RHWs because of the cross-sectional design. It could only show a static picture and could not circumvent the changes between the actual behavior and the stated turnover intentions of the RHWs; therefore, it could not further capture the factors affecting the actual turnover behaviors of RHWs.