Job satisfaction received attention from various scientific fields for decades and remains a focal point of research concerning management practice (Zhu, 2017). Measuring job satisfaction serves as an indicator for employees’ performance in terms of quality (Judge et al., 2020), productivity and commitment (Spector, 1997; Coetzee and Stoltz, 2015) as well as for turnover risks (Halter et al., 2017; Radford and Meissner, 2017; Yarbrough et al., 2017; De Simone et al., 2018; Judge et al., 2020; Koch et al., 2020; Labrague, 2020; Nikkhah-Farkhani and Piotrowski, 2020; Sillero-Sillero and Zabalegui, 2020). Additionally, research was able to show that satisfied employees are more likely to advocate for the organization (Judge et al., 2020). Concerning healthcare, job satisfaction is of paramount importance, because it is directly linked to patients’ satisfaction (Haas et al., 2000), patient safety (Aiken et al., 2002), and outcome (Katz, 1999). In consequence, physicians’ job satisfaction has an impact on national health outcomes (Oh et al., 2019).

A fundamental definition of job satisfaction refers to the way people feel about their job and whether they like or dislike it (Spector, 1997)—a rather simple definition frequently used and built upon (Moorman, 1993; Ajamieh et al., 1996; Armstrong, 2006; Giménez-Espert et al., 2020). If the employees have positive feelings and attitudes toward their jobs (Ajamieh et al., 1996; Giménez-Espert et al., 2020) and are enthusiastic and happy with their work (Kaliski, 2007), they report being satisfied with their job. Other research expands job satisfaction by adding the personal feeling of achievement (Statt, 2004; Mullins, 2005; Kaliski, 2007). Receiving rewards–equally intrinsically and extrinsically—are associated with job satisfaction, if they are perceived as rightfully received (Mullins, 2005; Rama-Maceiras et al., 2012; Dall’Ora et al., 2020). Furthermore, Davis and Newstrom (1989) state that job satisfaction deals with meeting or exceeding the employees’ expectations of the job. Moorman (1993) differentiates between affective and cognitive perspectives on job satisfaction. Cognitive satisfaction is a logical and rational evaluation of working conditions, which are crucial factors to be examined in order to understand job satisfaction (Rama-Maceiras et al., 2012; Heponiemi et al., 2014; Adriaenssens et al., 2015; Dall’Ora et al., 2015; Barken et al., 2018; Kao et al., 2018; Kim and Yi, 2019; Pishgooie et al., 2019; Tawfik et al., 2019; Bautista et al., 2020; Labrague et al., 2020; Rodríguez-García et al., 2021a,b).

There is evidence for various working conditions influencing job satisfaction. Among them are: Relatively high and fair salary (Kao et al., 2018), opportunities for promotion and social aspects of work (Pocztowski, 2003; Armstrong, 2006; Sypniewska, 2014), ethical and transformational leadership, (Kim and Yi, 2019; Pishgooie et al., 2019; Tawfik et al., 2019; Labrague et al., 2020; McKenna and Jeske, 2021) as well as sustainable relationships with supervisors (Rama-Maceiras et al., 2012; Dall’Ora et al., 2020), and co-workers (Kim and Yi, 2019; Dall’Ora et al., 2020). A good perceived atmosphere at work (Sypniewska, 2014; Tawfik et al., 2019) also results in high job satisfaction. Conversely, high workload and stress factors–like time pressure–have a negative impact on job satisfaction (Jermsittiparsert et al., 2021). Herzberg (1965) categorized working conditions influencing job satisfaction into external and internal factors: External or hygiene factors comprise wages, safety, and supervisors. Internal factors or motivators refer to higher needs, such as recognition by others, work performance, development, and accountability.

Martinussen et al. (2020) found that 21% of all hospital physicians have the intention to leave their current job. Furthermore, over 20% were indecisive. The COVID-19 pandemic has deepened the attrition crises (Alrawashdeh et al., 2021) and increased the intention to leave especially among physicians, who tend to be more mobile than nurses and find better paying jobs more easily (Jackson et al., 2018; Johna, 2018). However, most research results indicate that similar factors account for job satisfaction of physicians and nurses. The social climate was a factor favoring the nurses’ and physicians’ intentions to stay with their employer (Heponiemi et al., 2019; Martinussen et al., 2020; Nikkhah-Farkhani and Piotrowski, 2020). Leadership style had a decisive influence on physicians’ intentions to stay or to leave (Stagnitti et al., 2006; Suliman, 2009; Halter et al., 2017; Fontes et al., 2019; Pishgooie et al., 2019; Labrague et al., 2020; Lee and Jang, 2020; Magbity et al., 2020; Martinussen et al., 2020). Other factors pushing physicians’ and nurses’ intentions toward leaving their job were: Negative feelings when experiencing discrimination (Heponiemi et al., 2019), bullying (Adriaenssens et al., 2015; Edmonson and Zelonka, 2019; Park and Choi, 2019; Favaro et al., 2021), conflict with peers (Zaheer et al., 2019; Bautista et al., 2020; Lee and Kim, 2020), high workloads (Perkins et al., 2007; Bautista et al., 2020; Lee and Kim, 2020), understaffing (Sasso et al., 2019), emotional exhaustion (Hoonakker et al., 2013; Vandenbroeck et al., 2017; Sasso et al., 2019), long working shifts (Dall’Ora et al., 2015; Arslan Yürümezoğlu et al., 2019), and high stress (Hoonakker et al., 2013; Halter et al., 2017; Lee and Jang, 2020; Somville et al., 2020; Chen et al., 2021). Several factors affecting job satisfaction also influence physicians’ and nurses’ intention to stay: Fair pay (Kao et al., 2018), freedom to do the job (Barken et al., 2018), job autonomy (Stagnitti et al., 2006; Barken et al., 2018), and recognition (Yoder, 1995; Adriaenssens et al., 2015; Hämmig, 2018). Also, work-family conflicts or work-life imbalances (Hämmig, 2018; HakemZadeh et al., 2020; Nikkhah-Farkhani and Piotrowski, 2020) and perceived poor career perspectives (Yoder, 1995; Perkins et al., 2007) were found to be factors leading physicians and nurses to quit their jobs.

Although physicians and nurses do not differ in their perspective on work conditions in most aspects (Domagała et al., 2018; Heponiemi et al., 2019), some aspects are distinctive: Fair pay (Kao et al., 2018; Oh et al., 2019), management and leadership (Nassab, 2008; Martinussen et al., 2020), career development through specialization (Leigh et al., 2002) or social support, and social climate (Stagnitti et al., 2006; Adriaenssens et al., 2015; Dall’Ora et al., 2020) as well as good relationships with other colleagues (Stoddard et al., 2001; Sibbald et al., 2003; Domagała et al., 2018; Oh et al., 2019) and adequate communication among peers (Sibbald et al., 2003) are influencing physicians’ job satisfaction. Physicians value good relations with their patients as they tend to attest to higher job satisfaction if they have adequate time to spend with patients, and if they are able to maintain relationships with them (Stoddard et al., 2001; Oh et al., 2019). Job satisfaction is enhanced by a high level of professional autonomy and freedom, which is perceived as that and considered to be guaranteed (Stagnitti et al., 2006; Rama-Maceiras et al., 2012; Barken et al., 2018; Oh et al., 2019; Dall’Ora et al., 2020). Social status and reputation is an influencing factor, especially for physicians’ job satisfaction (Oh et al., 2019). In general, a good working environment over all, and flexible work conditions in particular have a positive effect on satisfaction (Stagnitti et al., 2006). In contrast, long and swing shifts (Grainger et al., 1995), high workload (Dall’Ora et al., 2015; Bautista et al., 2020), high job demands (Adriaenssens et al., 2015; Dall’Ora et al., 2020), low job control (Rama-Maceiras et al., 2012; Adriaenssens et al., 2015; Dall’Ora et al., 2020), and long working hours (Leigh et al., 2002; Dall’Ora et al., 2015; Oh et al., 2019; Dall’Ora et al., 2020) lower job satisfaction leading to job dissatisfaction as well as negative feelings and attitudes toward the job (Armstrong, 2006).

Dissatisfaction and negative attitudes have a number of undesirable consequences: Decreased performances and loyalty, increased absenteeism (Aziri, 2011), and higher risk of employee turnover (Halter et al., 2017; Radford and Meissner, 2017; Yarbrough et al., 2017; De Simone et al., 2018; Judge et al., 2020; Koch et al., 2020; Labrague, 2020; Nikkhah-Farkhani and Piotrowski, 2020; Sillero-Sillero and Zabalegui, 2020). Patients’ safety may be affected: High workload, capacity shortages, and dissatisfaction of physicians have significant impacts on performance and patients’ safety (Aiken et al., 2002; Catalá-López, 2009). This may also lead to financial losses (Weninger Henderson, 2020). Job satisfaction of caregivers is directly linked to their intention to stay (Radford and Meissner, 2017; Yarbrough et al., 2017; Nikkhah-Farkhani and Piotrowski, 2020; Rodríguez-García et al., 2021a,b), whereas dissatisfaction was found to be a driving force for turnover intention (Hoonakker et al., 2013; Halter et al., 2017; De Simone et al., 2018; Koch et al., 2020; Labrague, 2020; Sillero-Sillero and Zabalegui, 2020). Turnover intention is not the opposite of intention to stay (Nanncarrow et al., 2014) because dissatisfaction and intentions to leave is not drawn from the same working conditions as satisfaction and intentions to stay (Perkins et al., 2007). For instance, physicians might want to stay with the employer because of the great communication between colleagues while simultaneously they may have the intention to leave because they find better career opportunities elsewhere.

Considering increasing skills shortages and endangered patients’ safety, it is crucial for hospitals to evaluate employees’ job satisfaction as well as their intentions to leave or stay via active retention management (Gerson, 2002). Employee retention helps to ensure competence continuity in critical care settings demanding high expertise and experience of caregivers (Shewchuk et al., 2006; Hahnenkamp et al., 2018). Experienced physicians are sought after within the labor market and often feel more attached to their profession than their employer (Martinussen et al., 2020). Therefore, employers have to provide convincing arguments for physicians to stay with them (Mano-Negrin and Kirschenbaum, 1999). Those arguments must target the aspects of high job satisfaction and low intention to stay.

The purpose of the three studies reported here is to find out what specific factors are relevant for the intention to stay and turnover intention of physicians in academic medicine –and what measures might have a positive impact on employee retention. This is not as easy as it seems considering the multitudinous research results. Reviews of this research (Halter et al., 2017; Fontes et al., 2019) show that most data are derived from standardized surveys based on certain models such as Leader-Membership-Exchange (LMX, Pishgooie et al., 2019; Labrague et al., 2020; McKenna and Jeske, 2021) or Job Demands-Resources model (JDR, Hoonakker et al., 2013). Moreover, the results refer to various perspectives, such as career development (Nassab, 2008), economic issues (Weninger Henderson, 2020), or employer attractiveness (Rodríguez-García et al., 2021a,b). In addition, a variety of work conditions, such as fair pay (Kao et al., 2018) shift work (Dall’Ora et al., 2015), and personal perceptions –e.g., concerning recognition (Adriaenssens et al., 2015) and autonomy (Barken et al., 2018)—as well as cohort effects (Gordon, 2017) play an important role to determine job satisfaction and satisfaction as well as its impact on intention to stay and turnover. In summary, despite the overwhelming amount of research data, there is a lack of individual perspectives, which are addressed in some case studies (Liedtka et al., 1998) or through participatory observation (Morrison and Korol, 2014). We want to bridge the gap between quantitative, model-based research based on standardized surveys and qualitative approaches and bring back the individual perspective to the design of retention programs in hospitals (Shewchuk et al., 2006). We combined quantitative and qualitative research in two different ways: (1) Indirect by combining a qualitative research line with interviews and a quantitative line with surveys and (2) direct by applying Repertory Grids as a method, which combines qualitative and quantitative elements (White, 1996).

Interviews and surveys carried out within the “FacharztPlus” project (further referred to as “PhysicianPlus”), a project financially supported by the German Ministry of Education and Research (BMBF) and aiming toward finding measures in order to retain physicians in hospitals (Hasebrook et al., 2016a). Physicians from German university hospitals, residents and physicians, in 15 departments of anesthesiology were interviewed and surveyed (Hinkelmann et al., 2017). The results were used to evaluate measures to increase job satisfaction in other industries which have to deal with shift work, a need for an adaptive and at least partly highly qualified workforce, such as professional services, harbor and airport logistics. Positively evaluated measures were adapted and tested in the participating hospitals (Hahnenkamp and Hasebrook, 2022).

The research within the PhysicianPlus project was guided by four research questions:

Answers to these research questions should help to reflect on practical implications and to develop and test measures to improve intention to stay and reduce turnover intention of highly qualified staff in hospitals.

We used qualitative and quantitative methods in a convergent parallel mixed-method design (Alrawashdeh et al., 2021). Our mixed-method approach integrates qualitative and quantitative methods at multiple steps of research (Teddlie and Yu, 2007; Fetters et al., 2013; Moseholm and Fetters, 2017; Alrawashdeh et al., 2021; cf. Figure 1).

In the first study, semi-structured individual interviews were used as a tool for data collection (Supplementary Appendix 1). In a first study chief physicians were interviewed about their experiences concerning keeping or leaving jobs in academic hospitals. The answers were protocolled, segmented into statements and these statements were aggregated with the help of a hierarchical cluster analysis (Husson et al., 2010).

In a second study residents talked about strengths, weaknesses, and potential improvements of working conditions in their hospital within the framework of open, semi-structured interviews. Answers were recorded, segmented into statements, and assigned to the cluster items obtained from the first study. Additionally, all physicians rated their recommendation concerning work environment, career, education, and intention to stay applying the NPS procedure.

In a third study, residents from four university hospitals participated in a brief interview including a computer-led Repertory Grid procedure. We asked the participants to respond to eight elements: 1. “nurses” and 2. “physicians” (their profession), 3. “clinic today” and 4. “clinic in 5 years’ time” (present and future or their workplace), 5. “hospital today” and 6. “hospital in 5 years’ time” (present and future of the institution) as well as 7. “clinic management,” and 8. “hospital management” (their direct management and general management of the institution). In a first run of the computer-led survey, participants were asked to name a typical feature for each element, e.g., “nurses—team cohesion” or “physicians—high expertise.” They were also asked to state whether this feature is positive or negative, e.g., “team cohesion” = positive, and describe the opposite, e.g., “team conflict” = negative. In a second run, the participants responded to pairs of elements, such as “nurses—physicians.” They were given their statements from the first run as a scale from 1 = negative to 10 = positive and evaluated each element on this individual scale, e.g., “Nurses—1 = team conflict to 10 = team cohesion” and “Physicians—1 = team conflict to 10 = team cohesion.” As a result, all elements were individually described by each participant with its most relevant features, and the valence of all elements was evaluated on scale from negative = 1 to positive = 10.

We found that negative interviews statements clearly outweigh positive ones and mostly address the quality of professional training, duty and vacation scheduling, and aspects of culture and work atmosphere in the clinic. Correlation patterns indicate that the evaluation of work environment is mainly influenced by the quality of duty scheduling and other administrative issues. Workload depends on the quality of cooperation and is seen directly according to the salary paid for it. Career perspectives are linked to the quality of the onboarding process and quality of supervision depends on a sufficient staff capacity. This is very much in line with other research findings [overview in Coomber and Barriball (2007), Aziri (2011), Domagała et al. (2018)].

Individual statements, negative (weaknesses) and positive (strengths) are connected to the individual valuation of work and training quality and the intention to stay. The frequency of positive items found in the interviews had a significant positive impact on all NPS ratings concerning work, training, and intention to stay. In contrast, negative items showed only significant main effect on retention and a significant interaction. The more positive and less negative items were counted, the higher was work satisfaction. In summary, all aspects with high frequency of positive mentions play supportive role for the intention to stay. However, the factor “salary” shows only a negative impact on the intention to stay if the frequency of negative mentions is high. This finding supports the function of “salary” as dissatisfier or hygiene factor (Herzberg, 1965; Kao et al., 2018).

Individual valuations of working conditions are clearly affected by cohort effects, such as work experience and career stage. Work experience had a great influence on work satisfaction and retention, whereas the specific position did not have a significant impact: The longer employees stayed with the clinic, the lower the amount and the ratio of negative items. Our study suggests, NPS ratings of physicians employed in academic medicine are low in comparison to other studies: A low positive NPS can be expected from 0% up to + 15% (West et al., 2009; Sieja et al., 2019). However, in this study the NPS concerning intention to stay was always rated negative regardless how high or low job satisfaction was (NPS from −26 to −70% with an average intention to stay of −42%).

We summarized positive and negative interviews items in a polarity satisfaction scale. It is noteworthy that all significant intercorrelations of the polarity satisfaction scale between the items of the satisfaction scale were positive, suggesting that all items are positively connected to a general concept of job satisfaction. The item with the highest intercorrelations with almost all other items was “regard of personal goals,” whereas the item “reliability of promises kept” was not significantly interconnected to other items. This may indicate that in employees’ opinions a clinic regarding personal goals causes a positive attitude toward work whereas broken promises are singular events playing a negative role as “hygiene factor” (Herzberg, 1965; Domagała et al., 2018; Jackson et al., 2018; Johna, 2018).

The “mental maps” generated from the Repertory Grid procedure revealed that persons with high intention to stay had a more positive perception of the university hospital’s future than employees with low intention to stay. They connected the hospital’s future with positive features (e.g., “future oriented”) as compared to skeptics, who chose characteristics with negative connotations (e.g., “economic efficiency”). Comparing “job promotors” to “job skeptics” by repertory grids indicates that an important difference between these two groups may lie in a “hope for a better future” and high affinity for the employer on the one hand and hopelessness as well as a notion of extraneousness at work on the other. Highly trained and qualified physicians, like the subjects in this study, are more attached to their profession and their discipline than to the actual clinic or hospital, for which they work (Choi et al., 2011). Moreover, the mental maps generated by Repertory Grids procedures in our study show that the very same factors may be seen as negative by some individuals and positive by others (Younge and Marx, 2016; Mathimaran and Kumar, 2017).

Open interviews can lead to new insights because the range of questions and answers is not limited. Standardized instruments measuring job satisfaction and job retention limit the factors and interactions, which can be identified (e.g., Singh, 2019; Rombaut and Guerry, 2020). Several standardized tools are available from scientifically validated tests (e.g., Van Saane et al., 2003) and commercial testing packages (e.g., Riechmann and Stahl, 2013). All standardized tools necessarily operate with a standard set of questions or items restricting the range of potential answers and justifying the use of our interview format for explorative purposes. In the interviews reported here, the participants did not bring up many new topics and interrelations, and the results mostly support existing research findings. However, self-reports are an important source for a more differentiated understanding of quantitative research results (Choi et al., 2011; Alrawashdeh et al., 2021). Unfortunately, conducting and evaluating qualitative interview data is a highly resource intensive task and cannot be implemented as a routine evaluation process. As a result, the relatively low number of subjects, especially in Study 1 (n = 20) and Study 2 (n = 46), is a limitation of our research. We investigated physicians in university hospitals. On the one hand, this limits the scope of our research because results cannot easily be transferred to other clinical settings or healthcare workers. On the other hand, it adds to a better understanding of the specific working conditions and needs in academic medicine (Hahnenkamp et al., 2018).

In order to combine standardized quantitative and open qualitative study methods we applied Repertory Grids as a quantitative method to describe qualitative data. The results derived from this computer-led survey technique very much depend on the usability and visual front-end of the software applied. In summary, employee surveys need careful planning in view of how efficient and standardized the inquiry may be and how open and explorative it has to be.

Our studies are not sufficient to measure the impacts of various factors influencing job satisfaction and intentions to stay as well as the impacts of interrelations due to the methods used. We were only able to identify the factors generally impacting the matter. For distinguishing the different impacts of factor, e.g., whether high workload has a bigger impact on job dissatisfaction than unpredictable staff planning, further research with alternative methodical approaches is necessary. It should also be noted that the study has been conducted prior to and in preparation of an intervention study. This setting may have biased the interviews, especially the suggestions for improvements.

The most popular suggestions for improvements from the physicians in our studies were optimization of employee appraisals, more transparent career prospects, longer assignments for a certain position in the clinic, niches for specializations, financial support for further training, and planned discussions about target agreements. This suggests that the focus of improvements does not lay in individual support but in structural adaptations. During the PhysicianPlus project four aspects to foster intention to stay and to lessen turnover intention were developed and afterward implemented: (1). Employee appraisal, (2). training in fellowship programs, (3). computer-assisted duty and vacation scheduling, and (4). corporate benefits.