Factors in turnover intention of cardiothoracic surgery residents

Abstract

Increasing numbers of cardiothoracic surgery residents are resigning, without completing their training. This study analyzes how their turnover intention is related to the training environment, and individual psychological factors. Responses by 57 Korean cardiothoracic surgery residents were analyzed. Their levels of depression, anxiety, grit, and empathy, working conditions, the effect of someone’s presence to discuss their concerns with, burnout, and turnover intention were identified as the research variables. Descriptive statistical analysis, correlation analysis, and structural equation modeling were used for data analysis. Burnout has the most significant relationship with turnover intention. It has a mediating effect on the influence of depression, grit (sustained interest), and working conditions, over turnover intention. Empathy, and the presence of someone to discuss concerns with, also affect turnover intention directly. The study also confirmed that grit and work satisfaction affect turnover intention indirectly, through burnout. The study identified both individual- and systemic-level factors for an effective training environment, to reduce cardiothoracic surgery residents’ tendencies of leaving the residency program, and supporting them for greater satisfaction with their career choice. In order to resolve negative emotions such as burnout and depression, and foster empathy, a human resource development program for the residents’ psychological support must be prepared. The program director should be adequately educated to take charge of the training program, oversee the residents’ education and welfare, and perform the roles of role-model and mentor.

Full text

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Factors in turnover intention
of cardiothoracic surgery residents
Ji Hye Yu
1,7, Hyun Woong Roh
2,7, Mi Ryoung Song
3, Jang Hoon Lee
4, Seokjin Haam
5* &
Miran Kim
6*
Increasing numbers of cardiothoracic surgery residents are resigning, without completing their
training. This study analyzes how their turnover intention is related to the training environment,
and individual psychological factors. Responses by 57 Korean cardiothoracic surgery residents were
analyzed. Their levels of depression, anxiety, grit, and empathy, working conditions, the eect of
someone’s presence to discuss their concerns with, burnout, and turnover intention were identied
as the research variables. Descriptive statistical analysis, correlation analysis, and structural equation
modeling were used for data analysis. Burnout has the most signicant relationship with turnover
intention. It has a mediating eect on the inuence of depression, grit (sustained interest), and
working conditions, over turnover intention. Empathy, and the presence of someone to discuss
concerns with, also aect turnover intention directly. The study also conrmed that grit and work
satisfaction aect turnover intention indirectly, through burnout. The study identied both individual-
and systemic-level factors for an eective training environment, to reduce cardiothoracic surgery
residents’ tendencies of leaving the residency program, and supporting them for greater satisfaction
with their career choice. In order to resolve negative emotions such as burnout and depression, and
foster empathy, a human resource development program for the residents’ psychological support
must be prepared. The program director should be adequately educated to take charge of the training
program, oversee the residents’ education and welfare, and perform the roles of role-model and
mentor.
Abbreviations
MBI-HSS Maslach Burnout Inventory-Human Services Survey
EE Emotional exhaustion
DP Depersonalization
PA Personal accomplishment
K-BDI-II Korean-Beck Depression Inventory-II
K-BAI Korean-Beck Anxiety Inventory
Grit-S Short Grit Scale
CI Consistency of interest
PE Persistence of eort
JSPE-HP Jeerson Scale of Physician Empathy-Health Professional
Residency training is one of the health care system’s important processes, for nurturing competent physicians1.
us, leaving the training course midway poses several problems for residents. e resultant loss of transition
and patients’ condence, and an unexpected lack of labor due to resignations, cause problems for the remain-
ing residents throughout the training period2,3. It has been found that during the training, many trainees faced
psychological health issues such as burnout and depression4. e relatively long training programs are the most
vulnerable periods for physicians to burnout, considering that these programs entail limited control over cir-
cumstances, tremendous responsibilities, excessive and unpredictable work hours, high degree of work-home
OPEN
1Department of Medical Education, Ajou University School of Medicine, Suwon, Korea. 2Department of Psychiatry,
Ajou University School of Medicine, Suwon, Korea. 3Department of Medical Education, Sungkyunkwan University
School of Medicine, Suwon, South Korea. 4Department of Pediatrics, Ajou University School of Medicine, Suwon,
South Korea. 5Department of Thoracic and Cardiovascular Surgery, Ajou University School of Medicine, 164
Worldcup-Ro, Yeongtong-Gu, Suwon 16499, South Korea. 6Department of Obstetrics and Gynecology, Ajou
University School of Medicine, 164 Worldcup-Ro, Yeongtong-Gu, Suwon 16499, South Korea. 7
These authors
contributed equally: Ji Hye Yu and Hyun Woong Roh. *email: haamsj@aumc.ac.kr; kmr5300@ajou.ac.kr
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imbalance, sleep-impairments, and possible mistreatment at the workplace5–7. In particular, excessive training
causes poor well-being and burnout at work, which ultimately lead to serious considerations of leaving the
training1,8.
Several studies have shown that psychiatric issues are prevalent among up to 30% of residents, especially
among those performing surgery, emergency services, or intensive care rotations9–12. Corresponding to this trend,
it has been found that cardiothoracic surgery in South Korea faces a major challenge of low numbers of lled
residency positions, with a mean lling rate of 45.2% from 2009 to 2018, and the second highest attrition rate of
4.1% from 2017 to 202013. In order to become a cardiothoracic surgeon in South Korea, one has to graduate from
medical school, avail a job at a hospital, complete a year-long internship, apply to the department of thoracic and
cardiovascular surgery, and then train for four years. us, in South Korea, one obtains a specialized certicate
ve years aer graduating from medical school.
Unlike in other countries, in South Korea, one can go for cardiothoracic surgery without a surgical or special-
ist’s license. Although the eld’s low lling- and high attrition- rate are global trends, and not limited to South
Korea, the need to assess both residency training programs’ situational factors, and cardiothoracic surgery
residents’ individual factors, has increased in South Korea13,14.
e burnout of physicians and residents is complex in nature15. erefore, a multi-faceted approach is
required, not only for measuring burnout, but also assessing other possible mediating factors such as work
environment, a reliable training supervisor, symptoms of anxiety and depression, grit personality factor, and
subsequent outcomes, such as thoughts of leaving the residency program16,17.
Due to the high workload, complexity, high risks of surgery, and increased risks of being involved in a lawsuit,
there is a great social reluctance to low participation in the training course for cardiothoracic surgery, which is
not limited to Korea13. is challenge can result in a high dropout rate of cardiothoracic surgery residents and a
persistent low lling rate. erefore, it is very meaningful to identify variables that aect the turnover intention
of cardiothoracic surgery residents.
is study investigated burnout, possible mediators, and subsequent outcomes among cardiothoracic resi-
dents in South Korea. Although studies on the phenomenon of residents leaving their programs mid-way are
being steadily conducted, it is dicult to locate a study that comprehensively considers how environmental and
personal factors aect resignation. e quit intention has great explanatory power for turnover behavior17. It
helps understand the complex relationship between situational factors, individual factors, tendencies of leaving
residency programs, and burnout; the last is widely considered as an inuencing factor for turnover intention.
e study also considers possible ways of improving residents’ sense of mastery and meaningfulness, during
residency training programs18.
In this study, factors aecting cardiothoracic surgery residents’ turnover intention were divided into intrap-
ersonal factors and environmental factors, and intrapersonal factors were divided into risk factors and protective
factors. In order to nd out the eect of each factor on intention to resign, the following research hypothesis
was established.
Hypothesis 1 (H1): e higher the depression and anxiety of cardiothoracic surgery residents, the higher
the burnout and intention to resign.
Hypothesis 2 (H2): e higher the consistency of interest, persistence of eort, and empathy of cardiotho-
racic surgery residents, the lower the burnout and intention to resign.
Hypothesis 3 (H3): Cardiothoracic surgery residents’ positive perception of their working conditions and
presence of someone to discuss concerns with will reduce burnout and intention to resign.
In this study, three research models were set up and analyzed according to the research hypothesis.
Methods
Participants
e study participants included cardiothoracic residents at university hospitals in South Korea. An online sur-
vey was conducted with 103 residents, who participated in the Korean Society for oracic and Cardiovascular
Surgery’s resident training program, in May 2021. e online link to the Google survey was sent on the contact
information of all cardiothoracic residents in Korea, with the cooperation of the Korean Society for oracic
& Cardiovascular Surgery. In order to encourage participation, the questionnaire links were sent three times.
Responding to the survey required around 20min, and a total of 57 people responded; all of them responded
to each question diligently, resulting in complete data that could be used for analysis. Informed consent for
participation and use of their results was obtained from all subjects. e survey was conducted anonymously.
e steps taken for data protection and condentiality, to ensure secure storage and processing of data, were
included in the description provided to them. e study was carried out in accordance with relevant guidelines
and approved by the Institutional Review Board (IRB) of Ajou University Hospital (Ethics Consent No. AJIRB-
SBR-SUR-20-171, Date of IRB approval: June 23, 2020).
Measures
To identify the factors behind cardiothoracic residents’ turnover intention, items related to burnout, depression,
anxiety, grit, and empathy were considered individual factors, while items related to work environment, and the
presence of someone to discuss concerns with, were considered measurement items.
Residents’ characteristics
e survey considered the participants’ basic demographic items such as gender, age, year of training, and loca-
tion of training hospital.
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Burnout
e validated 22-item Maslach Burnout Inventory-Human Services Survey (MBI-HSS) was used to measure
burnout19. It comprises of three sub-scales for evaluating three domains of burnout: emotional exhaustion (EE),
depersonalization (DP), and reduced personal achievement (PA). Each item was scored on a 7-point Likert scale,
with response options ranging from “never” to “always.” Higher scores indicate frequent occurrences of burnout.
Cronbach’s α for the scale was 0.875.
Depression
e 21-item Korean-Beck Depression Inventory-II (K-BDI-II) was used to measure depression20. Each item was
scored on a 4-point Likert scale, from “never” to “very oen,” with higher scores representing higher levels of
depression. Cronbach’s α for the scale was 0.882.
Anxiety
e 21-item Korean-Beck Anxiety Inventory (K-BAI) was used to measure anxiety21,22. Each item was scored
on a 4-point Likert scale, from “not all” to “severely,” with higher scores representing higher levels of anxiety.
Cronbach’s α for the scale was 0.911.
Grit
e eight-item short grit scale (Grit-S) was used to measure perseverance and passion for pursuing long-term
goals23. e scale has two components: persistence of eort, and consistency of interest. Each item was scored
on a 5-point Likert scale, from “never” to “strongly agree,” with higher scores representing greater passion and
patience for achieving long-term goals. Cronbach’s α for the scale was 0.788.
Empathy
e 20-item Jeerson Scale of Physician Empathy-Health Professional (JSPE-HP) was used for measuring
empathy24. e scale has three components: perspective taking, compassionate care, and standing in a patient’s
shoes. Each item was scored on a 7-point Likert scale, from “never” to “strongly agree,” with higher scores rep-
resenting higher levels of empathy. Cronbach’s α for the scale was 0.851.
Working conditions
A scale developed by Wada etal.25 was used for assessing working conditions in the training hospitals. e scale
consists of 29 items related to personal time, relationships with patients, other physicians and sta, patient-care
issues, administrative work, income, resources, job satisfaction, and workload. is study measured each item on
a 5-point Likert scale, ranging from “never” to “strongly agree,” with higher scores representing better working
conditions. Cronbach’s α for the scale was 0.868.
Presence of someone to discuss concerns with
e presence of someone to discuss concerns with was assessed by the question, “When you have diculties or
concerns, is there anyone in the hospital you can discuss them with?” Participants were asked to respond with
1 (yes) or 2 (no).
Turnover intention
e degree of turnover intention was measured by the question, “Have you ever considered resigning during the
training period?” Responses were measured on a 5-point Likert scale, from “never” to “strongly agree.”
Statistical analysis
All analyses were conducted using JAMOVI 1.8.2.0. Descriptive statistics were calculated for the demographic,
as well as other research variables. en, a correlation analysis was conducted for exploring the relationship
between variables related to turnover intention. In addition, a structural equation model was conrmed for the
structural relationships among individual factors, working conditions, and turnover intention.
Ethical approval
is study was approved by the Institutional Review Board (IRB) of Ajou University Hospital (Ethics Consent
No. AJIRB-SBR-SUR-20–171, Date of IRB approval: June 23, 2020).
Informed consent
Consent was obtained from all the study participants.
Results
Demographic characteristics
e survey was completed by 57 participating residents. eir demographic characteristics are summarized
in Fig.1. Participants demonstrated a relatively even distribution, in terms of gender and year of residency.
More than half of the participants had undergone training in hospitals located in Seoul. e average age of the
respondents was 29.7years.
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Descriptive and correlation statistics of study variables
e descriptive statistics of, and correlations among, the variables are presented in Table1. eir skewness and
kurtosis values were checked to verify a normal distribution; the absolute value of skewness did not exceed 3,
and that of kurtosis did not exceed 1026.
Structural relationships among individual variables, working conditions, burnout, and turno-
ver intention
is study considered burnout as the major variable in intentions of resigning, and established a structural
equation model for analyzing the structural relationship between individual and situational variables aecting
turnover intention. A model was established with the individual factors, by dividing the variable that positively
aects turnover intention and burnout, and the variables that negatively aect grit. Among the individual vari-
ables, those that aect turnover intention and burnout positively and negatively were classied, and accordingly,
structural models were designed.
Figure1. Socio-demographics of cardiothoracic surgery residents’ sample (N = 57).
Table 1. Descriptive and correlation statistics of study variables. CI = Consistency of interest; PE = Persistence
of eort.
1 2 3 4 4_1 4_2 5 6 7
1. Turnover intention —
2. Burnout 0.63*** —
3. Empathy −0.26 −0.04 —
4 Grit −0.18 −0.09 0.34** —
4_1. CI −0.27* −0.25 −0.15 0.31* —
4_2. PE −0.27* −0.09 0.36** 0.91*** 0.27* —
5. Depression 0.51*** 0.52*** −0.17 −0.33* −0.43*** −0.30* —
6. Anxiety 0.40** 0.5*** −0.02 −0.24 −0.37** −0.20 0.67*** —
7. Working condition −0.43*** −0.42** 0.3* 0.27* 0.29* 0.38** −0.54*** −0.32* —
8.Presence of
someone to discuss
concerns with −0.39** −0.21 0.21 0.16 0.45*** 0.18 −0.48*** −0.27* 0.08
M(SD) 2.54(1.13) 4.46 (0.56) 5.04 (0.64) 3.05 (1.03) 3.50 (0.70) 2.97 (0.83) 9.7 (6.95) 8.3 (7.94) 3.34 (0.44)
Skewness (< 3) 0.15 0.39 0.25 0.41 −0.23 0.05 1.16 2.05 −0.62
Kurtosis (< 10) −0.85 0.06 −0.46 −0.70 −1.03 −0.40 1.75 6.45 2.58
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Relationships among depression, anxiety, burnout, and turnover intention
Figure2 presents the structural model of relationships among depression, anxiety, burnout, and turnover inten-
tion. e model t was χ2 = 23.87 (df = 23, p < 0.05), χ2/df = 1.15, CFI = 0.98, TLI = 0.97, RMSEA = 0.05 (90% CI
0.00–0.11), which is considered adequate.
e path coecients between the structural model’s variables are listed in Table2. Among the individual
factors, depression has a signicant positive eect on burnout (β = 0.75, p < 0.01), and in turn, burnout has a
signicant positive eect on turnover intention (β = 0.80, p < 0.01). e bootstrap condence interval was used to
verify the mediating eect’s statistical signicance, based on the meaningful path. It was found that the higher a
resident’s level of depression, the greater was the exhaustion. is, in turn, heightened their intention of resign-
ing, thereby conrming the signicance of an indirect eect (β = 0.60, 95% CI [0.11, 2.36]).
Relationships among grit, empathy, burnout, and turnover intention
Figure3 presents a structural model of the relationships among grit, empathy, burnout, and turnover inten-
tion. e model t was χ2 = 13.72(df = 10, p < 0.001), χ2/df = 1.37, CFI = 0.95, TLI = 0.93, RMSEA = 0.08 (90% CI
0.00–0.18), which is considered adequate.
e path coecients between the structural model’s variables are listed in Table3. Consistency of interest,
which is a sub-factor of grit, has a signicant negative eect on burnout (β = −0.28, p < 0.05), and in turn, burnout
has a signicant positive eect on turnover intention (β = 0.57, p < 0.001). In addition, empathy has a signicant
negative eect on turnover intention (β = −0.22, p < 0.05).
By conrming the mediating eect’s statistical signicance, it was found that as grit (consistency of inter-
est) decreased, burnout increased, which heightened intentions of resigning, and conrmed the signicance of
burnout’s indirect eect (β = −0.16, 95% CI [−0.35, −0.02]).
Relationships among working conditions, presence of someone to discuss concerns with,
burnout, and turnover intention
Figure4 presents a structural model of the relationships among working conditions, presence of someone to
discuss concerns with, burnout, and turnover intention. e model t was χ2 = 77.133 (df = 58, p < 0.05), χ2/
df = 1.33, CFI = 0.90, TLI = 0.86, RMSEA = 0.08 (90% CI 0.01–0.12), which is considered adequate.
Table4 presents the structural model’s path coecients. Working conditions have a negative eect on burnout
(β = −0.40, p < 0.05), and in turn, burnout has a positive eect on turnover intention (β = 0.56, p < 0.001). Fur-
ther, the lack of someone in the hospital to discuss concerns with heightened intentions of resigning (β = 0.24,
p < 0.05); however, this presence or absence did not aect burnout signicantly. In addition, it was conrmed
that the indirect eect of burnout as a mediating variable was signicant in the relationship between working
conditions and turnover intention (β = −0.22, 95% CI [−0.44, −0.03]).
Figure2. Structural model of depression, anxiety, burnout, and turnover intention.
Table 2. Path coecients of the structural model of relationships among depression, anxiety, burnout,
and turnover intention. Model t: χ2 = 23.87(df = 23, p < .05), χ2/df = 1.15 CFI = .98, TLI = .97, RMSEA = .05
(90% CI .00–.11). S.E. = Standard Errors; C.R. = Critical Ratio. **p < .01, ***p < .001; Number of bootstrap
samples = 2000; LL = lower limits; UL = upper limits; CI = condence interval.
Direct eects B β S.E C.R
Depression → burnout 2.63 .75 .94 2.81**
Anxiety → burnout .75 .09 2.03 .37
Burnout → turnover intention .98 .80 .33 2.99**
Depression → turnover intention .65 .15 1.27 .51
Anxiety → turnover intention 2.10 .21 2.27 .93
Indirect eects B β Bootstrapped 95% CI
depression → burnout → turnover intention 2.58 .60 .11–2.36
anxiety → burnout → turnover intention .74 .07 −.78–0.72
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Figure3. Structural model of grit, empathy, burnout, and turnover intention.
Table 3. Path coecients of the structural model of relationships among grit, empathy, burnout, and turnover
intention. Model t: χ2 = 13.72 (df = 10, p < .001), χ2/df = 1.37, CFI = .95, TLI = .93, RMSEA = .08 (90% CI
.00 − .18). S.E. = Standard Errors; C.R. = Critical Ratio.
Direct eects B β S.E C.R
Grit (consistency of interest) → bur nout −.25 −.28 .11 −1.98*
Grit (persistence of eort) → burnout .01 .01 .10 .10
Empathy → burnout −.07 −.08 .12 −.57
Burnout → turnover intention 1.19 .57 .20 5.84***
Grit (consistency of interest) → turnover intention −.21 −.13 .17 −1.22
Grit (persistence of eort) → turnover intention −.14 −.10 .15 −.89
Empathy → turnover intention −.40 −.22 .19 −2.12*
Indirect eects B β Bootstrapped 95% CI
grit (consistency of interest) → bu rnout → turnover intention −.25 −.16 −.35 to −.02
grit (persistence of eort) → burnout → turnover intention .01 .01 −.19–.20
empathy → burnout → turnover intention −.08 −.05 −.21–.11
Figure4. Structural model of working conditions, presence of someone to discuss concerns with, burnout, and
turnover intention.
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e test results from H1 to H3 set in this study are summarized as follows.
H1 (e higher the depression and anxiety of cardiothoracic surgery residents, the higher the burnout and
intention to resign.): e higher the depression, the higher the burnout, and in turn, the higher the burnout,
the higher the turnover intention. Anxiety was found to have no statistically signicant eect on burnout and
turnover intention.
H2 (e higher the consistency of interest, persistence of eort, and empathy of cardiothoracic surgery
residents, the lower the burnout and intention to resign.): e higher the consistency of interest, the lower the
burnout, and in turn, the lower the burnout, the lower the turnover intention. Persistence of eort was found to
have no signicant eect on burnout and turnover intention. Empathy was found to have no signicant eect
on burnout, but it was found to have a negative eect on turnover intention, indicating that the higher the level
of empathy in the patient-physician relationship, the lower the intention to resign.
H3 (Cardiothoracic surgery residents’ positive perception of their working conditions and presence of
someone to discuss concerns with will reduce burnout and intention to resign.): A positive perception of
working conditions lowered burnout, which sequentially lowered the intention to resign. And the presence
of someone to discuss concerns with was found to have no signicant eect on burnout, but the absence
of someone to discuss concerns was found to increase the intention to resign.
Discussion
is study analyzed the eects of individual and environmental factors on South Korean cardiothoracic surgery
residents’ turnover intention. e results reveal that burnout has the highest positive correlation with turnover
intention. Previous studies have also found burnout to be a major variable in increased turnover intention227–29.
Surgeons and trainees were particularly reported as being more frequently burnt out than others. us, car-
diothoracic surgery residents can be considered quite vulnerable to burnout4,30. Reducing their burnout would
lower turnover intention.
It is necessary to reduce the risk factors for burnout, and strengthen the protective factors against it. e rst
step is identifying the factors that cause burnout. Among the individual factors, depression was found to have a
signicant eect on turnover intention, by mediating burnout. e higher the residents’ level of depression, the
greater was the degree of burnout, in turn leading to heightened intentions of resigning. is can be understood
within the same context as that of a study by Chaukos etal.31, which shows that burnt out residents showed more
depressive symptoms, than those who were not burnt out. e present ndings conrm that reducing depression
among residents is necessary to lower burnout and turnover intention.
In this research model, anxiety was found to have no signicant eect on burnout, but anxiety, along with
depression, appeared to be an intrapersonal variable with the highest correlation with burnout. However, anxi-
ety showed a lower correlation with burnout than depression. In a previous study that analyzed the relationship
between burnout, depression, and anxiety, similar to the results of this study, both depression and anxiety were
found to have a signicant association with burnout, but anxiety had a lower correlation with burnout than
depression32. Since anxiety has a relatively lower correlation with burnout than depression, it can be inferred
that when anxiety and depression are included together in the research model, anxiety does not have a signi-
cant eect on burnout because its inuence on burnout is relatively small. However, in this study, anxiety had a
signicantly high correlation with depression and burnout, so it is necessary to consider the level of anxiety of
cardiothoracic surgery residents and introduce a practical program to reduce anxiety.
is study also found that grit (consistency of interest) aects turnover intention, by mediating burnout. A
resident doctor who can maintain interest in the task to be accomplished experiences less burnout, which lowers
the intention to resign. is can be understood in the same context as that of a previous study17 on emergency
medicine residents, which nds that burnt out residents scored signicantly lower on grit, than those who were
not burnt out. Furthermore, empathy was found to have a signicant positive eect on turnover intention, with-
out mediating burnout. is suggests that the greater the empathy in patient-doctor relationships, the lower is
Table 4. Path coecients of the structural model of relationships among working condition, presence of
someone to discuss concerns with, burnout, and turnover intention. Model t: χ2 = 77.133(df = 58, p < .05),
χ2/df = 1.33, CFI = .90, TLI = .86, RMSEA = .08 (90% CI .01 − .12). S.E. = Standard Errors; C.R. = Critical Ratio.
*p < .05, ***p < .001; Number of bootstrap samples = 2000; LL = lower limits; UL = upper limits; CI = condence
interval.
Direct eects B β S.E C.R
Working condition → burnout −.32 −.40 .14 −2.24*
Presence of someone to discuss Concerns with → burnout −.01 −.01 −.06 .96
Burnout → turnover intention 1.14 .56 .22 5.16***
Working condition → turnover intention −.10 −.06 .24 −.40
Presence of someone to discuss concerns with → turnover Intention .75 .24 .37 2.02*
Indirect eects B β Bootstrapped 95% CI
Working condition → burnout → turnover intention −.85 −.22 −.44 − −.03
Presence of someone to discuss concerns with → burnout → turnover intention −.57 −.01 −.18 − .13
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the intention to resign. Studies on the relationship between empathy and burnout have contradictory results;
however, most studies report that empathy and burnout have a negative relationship33.
Working conditions, including personal time, relationships with others (patients, physicians, stas), patient-
care issues, administrative work, income, resources, job satisfaction, and workload, were found to have a signi-
cant eect on turnover intention, by mediating burnout. Job satisfaction and positive perception of working con-
ditions leads to less burnout, which in turn, lowers turnover intention. Studies on healthcare professionals27,29,34
report that high levels of burnout are related to increased work pressure, and less satisfaction with one’s work
and workspace; this is consistent with the present study’s results. In addition, this study found that the presence
or absence of someone inside the hospital, to discuss concerns with, has a direct signicant eect on turnover
intention, without mediating burnout. e intention to resign is relatively low when there is someone in the
hospital to discuss concerns with, as compared to when there is no one. A well-organized mentoring system is
essential and recommended for residents to adapt well during training course, be satised with training programs,
and have successful career development35 Mentorship is recognized as an important factor in increasing interest
in specialty and preventing burnout during the training process, and is also associated with retention36,37. Previ-
ous studies have shown that formal education on mentorship and programs for developing mentorship skills
are insucient in cardiothoracic surgical training36. Formal education on mentorship should be provided at the
individual level and at the institutional level to eectively support cardiothoracic surgery residents during the
training process. Social support is a decisive factor in employees’ engagement in an organization38, and provides
a context for understanding the present study’s results. is study is signicant for its empirical investigation of
the relationship between variables aecting turnover intention of cardiothoracic surgery residents. e results
conrm the importance of reducing burnout, improving empathy, and having someone in the hospital to discuss
concerns with, for reducing residents’ turnover intention, and nurturing medical professionals specializing in
cardiothoracic surgery. To particularly reduce burnout, which is highly related to turnover intention, it is neces-
sary to diagnose psychological issues such as depression, and provide necessary support. Moreover, the working
environment in cardiothoracic surgery departments also needs improvement. In addition, residents’ satisfaction
with their eld, and interest in work, can also help reduce burnout.
is study has certain limitations, which should be noted. First, the sample size was small. It included around
56% of all cardiothoracic surgeons in Korea. erefore, it is dicult to draw generalizations from it. However,
as important as the size of the survey sample, is the presence of biases in sampling. is study’s sample did not
concentrate on a specic gender, year of training or age, rather, it was a relatively even sample. is may some-
what compensate for the small sample size. Second, the survey was conducted during the COVID-19 pandemic.
erefore, psychological and environmental variables related to COVID-19 might have inuenced the survey
responses, but the study’s analysis did not consider this. ird, the survey was conducted via self-reporting
questionnaires. In the future, qualitative research methods can be employed for in-depth understanding of the
factors inuencing intentions of resigning. Fourth, this study was cross-sectional, and therefore, could not con-
rm changes in related variables such as turnover intention and job burnout, throughout the residents’ training
period. Future research could comprise of longitudinal studies for determining causal relationships between
turnover intention and related variables.
Conclusion
Cardiothoracic surgery residents’ individual and environmental variables aect their turnover intention, either
directly or indirectly. Among the individual variables, burnout and empathy heightened and lowered their inten-
tions of resigning from the program, respectively. In addition, it was conrmed that residents’ depression and grit
(consistency of interest) have an indirect eect on turnover intention, through burnout. Among the situational
variables, the presence of someone in the hospital to discuss concerns with has a direct positive eect on turnover
intention, while satisfaction with the working environment mediated burnout and aected turnover intention.
In order to resolve negative emotions such as burnout and depression, and foster empathy, a human resource
development program for residents’ psychological support must be prepared. e program director should be
adequately educated to take charge of the training program, oversee the residents’ education and welfare, and
perform the roles of role-model and mentor.
Data availability
e datasets used and/or analyzed during the current study available from the corresponding author on reason-
able request.
Received: 15 December 2022; Accepted: 2 November 2023
References
1. Dyrbye, L. & Shanafelt, T. A narrative review on burnout experienced by medical students and residents. Med. Educ. 50, 132–149
(2016).
2. Zhang, Y. & Feng, X. e relationship between job satisfaction, burnout, and turnover intention among physicians from urban
state-owned medical institutions in Hubei, China: a cross-sectional study. BMC Health Serv. Res. 11, 235 (2011).
3. Longo, W. E. et al. Attrition of categoric general surgery residents: Results of a 20-year audit. Am. J. Surg. 197, 774–778 (2009).
4. Dyrbye, L. N. et al. Burnout among U.S. medical students, residents, and early career physicians relative to the general U.S. popula-
tion. Acad. Med. 89, 443–451 (2014).
5. Hu, Y. Y. et al. Discrimination, abuse, harassment, and burnout in surgical residency training. N. Engl. J. Med. 381, 741–752 (2019).
6. omas, N. K. Resident burnout. JAMA 292, 2880–2889 (2004).
7. Trockel, M. T. et al. Assessment of physician sleep and wellness, burnout, and clinically signicant medical errors. JAMA Netw.
Open. 3, e2028111 (2020).
Content courtesy of Springer Nature, terms of use apply. Rights reserved

9
Vol.:(0123456789)
Scientic Reports | (2023) 13:20243 | https://doi.org/10.1038/s41598-023-46588-w
www.nature.com/scientificreports/
8. Jennings, M. L. & Slavin, S. J. Resident wellness matters: Optimizing resident education and wellness through the learning environ-
ment. Acad Med. 90, 1246–1250 (2015).
9. L azarescu, I. et al. Prevalence of burnout, depression and job satisfaction among French senior and resident radiation oncologists.
Cancer Radiother. 22, 784–789 (2018).
10. Lebensohn, P. et al. Resident wellness behaviors: Relationship to stress, depression, and burnout. Fam. Med. 45, 541–549 (2013).
11. Peterlini, M. et al. Anxiety and depression in the rst year of medical residency training. Med. Educ. 36, 66–72 (2002).
12. Toews, J. A. et al. Analysis of stress levels among medical students, residents, and graduate students at four Canadian schools of
medicine. Acad. Med. 72, 997–1002 (1997).
13. Park, S. J. et al. Cardiothoracic surgery training in South Korea: Challenges and new hopes. J. orac. Cardiovasc. Surg. 159, 205–214
(2020).
14. Dodson, T. F. & Webb, A. L. Why do residents leave general surgery? e hidden problem in today’s programs. Curr Surg. 62,
128–131 (2005).
15. Patel, R. S. et al. Review on strategies to manage physician Burnout. Cureus. 11, e4805 (2019).
16. Brateanu, A. et al. Higher grit scores associated with less burnout in a cohort of internal medicine residents. Am. J. Med. Sci. 360,
357–362 (2020).
17. Dam, A. et al. e relationship between grit, burnout, and well-being in emergency medicine residents. AEM Educ. Train. 3, 14–19
(2019).
18. Grieth, R. W., Hom, P. W. & Gaertner, H. S. A meta-analysis of antecedents and correlates of employee turnover: Update, modera-
tor tests, and research implications for the next millennium. J. Manag. 3, 463–488 (2000).
19. Hipp, D. M. et al. “Back to bedside”: Residents’ and fellows’ perspectives on nding meaning in work. J. Grad. Med. Educ. 9, 269–273
(2017).
20. Maslach, C., Jackson, S. E. & Leiter, M. Maslach Burnout Inventory Manual (3rd ed. Palo, A.). (Consulting Psychologist Press,
1996).
21. Lim, S. Y. et al. e validation study of Beck Depression Scale 2 in Korean version. Anxiety Mood 7, 48–53 (2011).
22. Beck, A. T. & Steer, R. A. In: Manual for the Beck Anxiety Inventory. (e Psychological Corporation, 1993).
23. Yook, S. P. & Kim, J. H. A clinical study on the Korean version of Beck Anxiety Inventory: Comparative study of patient and non-
patient. Kor. J. Clin. Psychol. 16, 185–197 (1997).
24. Duckworth, A. L. & Quinn, P. D. Development and validation of the short grit scale (Grit-S). J. Pers. Assess. 91, 166–174 (1997).
25. Hojat, M. et al. Physician empathy: denition, components, measurement, and relationship to gender and specialty. Am. J. Psy-
chiatry 159, 1563–1569 (2002).
26. Wada, K. et al. Factors on working conditions and prolonged fatigue among physicians in Japan. Int. Arch. Occup. Environ. Health
82, 59–66 (2008).
27. Kline, R. B. Principles and Practice of Structural Equation Modeling. (e Gilford Press, 2005).
28. Scanlan, J. N. & Still, M. Job satisfaction, burnout and turnover intention in occupational therapists working in mental health.
Aust. Occup. er. J. 60, 310–318 (2013).
29. Wang, H. et al. Job satisfaction, burnout, and turnover intention among primary care providers in rural China: Results from
structural equation modeling. BMC Fam. Pract. 21, 12 (2020).
30. Hong, E. & Lee, Y. S. e mediating eect of emotional intelligence between emotional labour, job stress, burnout and nurses’
turnover intention. Int. J. Nurs. Pract. 22, 625–632 (2016).
31. Dyrbye, L. et al. Association of clinical specialty with symptoms of burnout and career choice regret among US Resident Physi-
cians. JAMA 320, 1114–1130 (2018).
32. Chaukos, D. et al. Risk and resilience factors associated with resident burnout. Acad. Psychiatry 41, 189–194 (2017).
33. Koutsimani, P., Montfomery, A. & Georganta, K. e relationship between burnout, depression, and anxiety: A systematic review
and meta-analysis. Front. Psychol. 10, 284 (2019).
34. Wilkinson, H. et al. Examining the relationship between burnout and empathy in healthcare professionals: A systematic review.
Burn Res. 6, 18–29 (2017).
35. Geurts, S., Schaufeli, W. & De Jonge, J. Burnout and intention to leave among mental health-care professionals: A social psycho-
logical approach. J. Soc. Clin. Psychol. 17, 341–362 (1998).
36. Miller, E. M. et al. Current resident and faculty mentorship satisfaction and important mentee functions in orthopedic surgery:
and American orthopedic association north American traveling fellowship project. J. Surg. Educ. 78, 1735–1754 (2021).
37. Reich, H. J. et al. Mentorship eectiveness in Cardiothoracic Surgical Training. Ann. orac. Surg. 112, 645–651 (2021).
38. Vaporciyan, A. A. et al. Factors aecting interest in cardiothoracic surgery: Survey of North American general surgery residents.
Ann. orac. Surg. 87, 1351–1359 (2009).
39. Shanafelt, T. D. & Noseworthy, J. H. Executive leadership and physician well-being: Nine organizational strategies to promote
engagement and reduce burnout. Mayo Clin. Proc. 92, 129–146 (2017).
Acknowledgements
We would like to thank the Korean Society for oracic and Cardiovascular Surgery for its administrative sup-
port in collecting data, and all the cardiothoracic surgery residents for their participation.
Author contributions
Y.J.H., R.H.W. substantially contributed to the study’s conception and design, and draing of the manuscript.
S.M.R., L.J.H. substantially contributed to data acquisition and analysis. K.M.R., H.S.J. substantially contributed
to the study’s conception and design, made critical revisions to the manuscript, and supervised the study.
Competing interests
e authors declare no competing interests.
Additional information
Correspondence and requests for materials should be addressed to S.H.orM.K.
Reprints and permissions information is available at www.nature.com/reprints.
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