The impact of the clinical department director’s leadership style on the turnover intention of clinical doctors: a systematic literature review

Introduction

Background

Medical institutions or healthcare systems worldwide are encountering significant challenges due to the increasing complexity of clinical decision-making, organization, quality maintenance, organization, quality maintenance, and financing. In future healthcare, clinical leadership will emerge as an essential concept to discuss. Clinical leadership refers to the leadership of clinicians without replacing their clinical roles and practice with formal management (1). It simply refers to broadening clinicians’ existing roles and responsibilities. In modern-day healthcare, several countries have developed significant National clinical leadership frameworks, for example, the Medical Leadership Competencies Framework (MLCF) in the UK, the Accreditation Council for Graduate Medical Education (ACGME) in the USA, CanMEDS in Canada, and many more (1).

In medical institutions, the clinical leadership framework inspires and improves clinical leaders to improve the overall management of clinical doctors and the quality of care. A study found that the quality of healthcare services and leadership is mediated by relationships where trust is a fundamental factor (2). Trust is the key to ensuring clinical engagement, clinical interactions, and meeting all the needs of patients, organizations, and teams of clinicians or doctors (2). It is observed that factors such as positive relationships, sound judgment, experience, and expertise of clinical leaders play a crucial role in managing doctors and patients in a complex healthcare structure. Therefore, it is understood that the relationship between the leadership of the clinical department and the clinical doctors is an essential factor in doctors’ turnover intentions.

Rationale and knowledge gap

Turnover intentions are identified as the psychological state before the actual leaving, which is also associated with the employed doctors’ unsatisfied job opportunities, poor management, quality of the institutions, and unmet expectations. Besides that, psychological problems and work pressure are also two factors that impact doctors’ turnover intentions. According to the research, approximately 3.2–53.7% of employed doctors have turnover intentions. The results of such a widespread shortage of doctors generate diverse adverse outcomes (3). The negative consequences may include the improper operation of the healthcare system, impede access to mass patients, and affect the quality of patient care and care (3). Additionally, doctor turnover involves organizational instability, financial losses, and reduced patient satisfaction (3). A similar study also shows that the turnover intention of employed clinical doctors is more meaningful as it somehow reflects the nature of medical institutions’ management (4). It is observed that turnover intentions or behavior are also associated with demographics, personal reasons, psychological factors, and working time behavior, which are associated with demographics, personal reasons, psychological factors, working time, and other profession-related aspects (5). Similarly, it highlighted the linkage between medical leadership and doctors’ turnover intentions in medical institutions (6). The style of leadership and its implementation are equated with employed doctors’ turnover rate (6). Uncertainty and a constantly changing environment are associated with increasing turnover, and effective leadership in healthcare institutions influences the outcome (7). Doctors’ turnover significantly impacts medical institutions and contributes to significant adverse consequences for the institutions and patient care (8). Turnover intentions of clinical doctors in the organization reflect management inefficiencies, which also question the abilities and relationship with the leadership department and the quality of institutions. Despite growing research on healthcare leadership, there is a limited understanding of clinical leadership and its impact on clinical doctors’ turnover intentions. This has created a significant literature gap, and this systematic review is conducted to bridge this gap.

Objective

The objectives of this review are:

• to examine the relationship between clinical leadership and clinical faculty on clinical doctors’ turnover intentions.
• to analyze other associated factors positively contributing to turnover intentions among clinical doctors.

We present this article in accordance with the PRISMA reporting checklist (available at https://jhmhp.amegroups.com/article/view/10.21037/jhmhp-24-124/rc).

Methods

Searching for the research method illuminates that systematic review holds strong credibility and better insights than any other method, such as the scoping method. A systematic review is effective for this research to address the gaps by investigating existing evidence and current improvements on the topic. The systematic review is further considered to identify the significance of the relationships between the doctor’s turnover intentions and the role of clinical departments’ leadership.

Search strategy

The systematic review will follow the guidelines of “Preferred Reporting Items for Systematic review and Meta-Analysis (PRISMA)” to summarize the evidence related to the topic. The study considers credible sources such as Scopus, PubMed, and Web of Science (WOS) databases. To search the most related journals and research papers, “Leadership AND physician turnover”, “Leadership AND retention”, “Leadership AND doctor burnout”, “Leadership AND Physician Turnover Intention”, “Leadership AND Doctor Satisfaction”, “Doctors AND Retention”, “Healthcare leadership AND job satisfaction”, “Healthcare leadership AND Doctor retention” (Table 1). The selection of literature has been considered subsequent screening and standardized criteria to select the most relevant and authentic data for the systematic review. Contextually, choosing reputable databases like Scopus, PubMed, WOS, and going for only peer-reviewed ensured that the data used in this study are authentic. Initial screening involved titles and abstracts of the existing literature, which was broadened by evaluating other critical parts for collecting factual data.

Inclusion and exclusion criteria

The data collection for the literature considers specific criteria, such as inclusion and exclusion criteria, which are described in detail in the following sections.

Inclusion criteria

• As per the inclusion criteria, the papers published in English specifically focused on leadership and doctors’ turnover intention were considered for this systematic review. However, this turnover intention has been determined based on a few particular considerations and psychological processes in which the clinical doctors considered leaving their jobs and evaluated the possibility of resignation. All these studies have measured intention through self-reports, structured surveys, and standardized scales. The intention of the actual decision to leave involves a firm commitment to resign and the action of turnover, which is the physical act of leaving the organization.
• Research papers and journals were included between 2020 and 2024 to make relevance to the current context and contemporary issues in clinical leadership and to reflect on the latest advancements in the field.
• All collected data were significantly followed by systematic review, cross-sectional studies, and meta-analysis; however, empirical studies were also preferred. In this system review, qualitative and quantitative studies have also been included to understand the cause and effect relationships between doctor turnover and leadership interventions.

Exclusion criteria

• The exclusion criteria exclude irrelevant research papers, outdated articles, lesser-known journals. Research papers other than those published before 2020 in English are excluded. Besides that, a research paper, article, or journal without complete publication was excluded.
• Abstract screening was conducted to analyze whether the study met the inclusion criteria. The researcher was the sole participant and worked independently to screen the abstracts, but no automation tool was used in this process.
• The researcher was the only one who worked independently and obtained and confirmed data to design the PRISMA flow chart.

Quality assessment

The bias in the studies was assessed using multiple critical appraisal tools to ensure methodological rigor and validity. To determine the risk of bias for the included systematic reviews and meta-analyses, the researchers used the ROBIS tool. ROBIS is a widely used tool to evaluate bias in a review by designing signalling questions to determine specific concerns (9). The researcher worked independently to assess the risk of bias in the included study without using any automation tool. Similarly, the Joanna Briggs Institute (JBI) Checklists (10) were employed to evaluate observational and qualitative studies. For observational studies, the JBI checklist examined criteria such as sample selection, exposure measurement, confounding factors, and statistical analysis. Similarly, the JBI checklist assessed methodological congruence, ethical considerations, researcher influence, and participant representation for qualitative studies (10). Another checklist was for quantitative studies, focusing on study procedures, sample characteristics, ethical practices, and data handling (11). Finally, another checklist was applied to empirical studies, assessing multiple-study designs, random selection, data analysis, and statistical robustness (12). These tools collectively helped verify study reliability and potential biases.

Results

A total of 750 articles from PubMed, 412 from WOS, and 496 from Scopus were selected based solely on keyword searches. These are 1,658 articles with keywords as defined in Table 1. However, after checking the author names and titles of the studies, 357 duplicates were removed. Then, the abstract and finding sections were thoroughly studied for the remaining articles. After research, 984 records were excluded for being partially or wholly irrelevant to the study’s scope and objectives. Additionally, 68 records were unavailable, and 59 were excluded due to methodological issues. After screening 190 records, the bias and quality checks removed 134 records that did not meet predefined criteria. Of the 56 articles sought for retrieval, 12 were excluded because of findings redundancy. Ultimately, 44 reports were assessed for eligibility, with 7 more excluded due to outdated data and 14 for publication in lesser-known journals. This strategic selection process led to the final inclusion of 23 studies in the review, ensuring that only high-quality, relevant, and reliable sources contributed to the research findings (Figure 1).

Figure 1 PRISMA flow diagram. NA, not available.

Characteristics of the included studies

Of the 23 publications included in this review, 2 employed an empirical design (1,6). Four studies used qualitative data collection methods (2,13-15). These focused on in-depth perspectives of doctors and healthcare professionals across Finland, Australia, Nigeria, etc. Of the remaining publications, 7 employed quantitative methods (4,7,8,16-19). Five studies were observational, often based on real-time data collection or institutional records across hospitals or healthcare settings (3,20-23). Additionally, five publications were systematic or meta-analytic reviews (5,24-27), synthesizing evidence from numerous primary studies without collecting new empirical data. Most studies originate from Europe (8), followed by Asia (4) and North America (3), reflecting strong research interest in physician leadership and turnover in developed regions. In terms of data timing, the majority of primary data were collected prospectively, especially within the quantitative and observational studies, while the qualitative and review-based studies typically used retrospective or literature-based methods (Table 2).

Quality assessment of included studies

The ROBIS tool evaluation of five systematic reviews or meta-analyses (5,22,24,25,27) revealed a consistent low risk of bias across all assessed domains. Five observational studies (3,20-23) met key validity requirements, none of them identified or addressed confounding factors, potentially introducing bias in causal interpretations. Four qualitative studies (2,13-15) demonstrated a strong alignment between methodology and research objectives. However, some studies lacked transparency in locating the researcher theoretically or discussing their influence on the study, which could introduce interpretative bias. Seven quantitative studies (4,7,8,16-19) provided detailed descriptions of samples and measurement validity; they often failed to report missing data handling strategies, potentially affecting reliability. Two empirical studies (1,6) have met most of the requirements. Refer to Tables S1-S5.

Discussion

Key findings

Screening of the related databases, articles, and journals shows that the turnover intention of clinical doctors has a reciprocal relationship with the organizational management and departmental leadership in medical institutions. In managing complex healthcare and medical institutions, the emerging role of clinical leadership has significantly increased while dealing with rising costs, quality issues, and complex care issues. It is found that clinical leadership influences professionals’ decision-making within the organization and clinical practice. Clinical leaders empower professionals to make their own decisions while holding them accountable. Therefore, leadership capability is essential for clinical institutions to facilitate changes and transformation. Another study suggested that physician leadership development facilitates self-efficacy, self-awareness, skills, knowledge, and behavior associated with effective decision-making, communication, and teamwork (26). The study’s findings mainly advocate that building leadership capability is essential to improve job satisfaction among physicians, which influences the positive attitude and behavior towards senior management.

A cross-sectional survey study examined the impact of leadership behavior on physicians’ intention to leave (7). It was observed that physicians or doctors have a lower perception of their leader’s leadership styles and have a lower level of normative commitment (mainly refers to the sense of duty and moral responsibility of professionals) and affective commitment (it relates to the emotional attachment and involvement with the organization of a professional) (7). The medical doctors have the lowest level of normative commitment [mean =3.23; standard deviation (SD) =1.77] (7). Their calculative commitment (the concept of the cost of leaving the organization) becomes higher, ultimately leading to turnover intentions. It is also observed that the medical doctors showed the second-highest level of intention to leave, following nurses, about the organization’s leadership.

The role of leadership in doctors’ or physicians’ turnover intention and turnover rate in hospitals and medical organizations is growing. It is observed that the increasing awareness of the role of organizations, senior departments, and leadership in physicians’ protection and well-being in the practice environment compelled them to rationalize the relationships among clinical leaders and clinical doctors (7). Illuminating similar results show that among 953 physicians, about 200 physicians positively responded to having intentions for their current job, while 193 physicians said they were unsure about that (4). In their study (4), the authors use two sets of explanatory variables, one being leadership style. In addition to the leadership style, both social climate and engagement within the teams or working unit are also positive and essential aspects of reporting a low probability of turnover intentions. Similar findings have also been obtained from another research (25). The researchers explained, that along with leadership, the organizational context, such as poor work policies by the management, leadership, and a lack of supervision in quality areas, is also responsible for the increasing turnover of doctors. Besides that, institutional issues, financial constraints, and uncertainty in placement opportunities contribute to the increase in doctor turnover. Poor leadership in medical settings is attributed to a lack of teamwork, fragile working relationships, and communication barriers between doctors, nurses, and other service care providers, enhancing the chances of turnover within hospitals.

The absence of mutual respect in the interdisciplinary team is another factor associated with ethical decision-making. At the same time, work hours for a week have also contributed to the intent to leave (21). In comparison, senior physicians who worked for hours have a higher intention to leave.

Long working hours show the inability of upper management and senior doctor leaders to manage schedules. Excessive working hours for doctors raise significant concerns about their health, well-being, and work-life balance, detrimental to their job satisfaction (25). Moreover, job satisfaction reduces the intention to leave (5). It is found that an environment with high job pressure can contribute to lower job satisfaction.

The impact of leadership effectiveness is an essential factor in the workplace satisfaction of physicians in healthcare organizations. Results showed that male physicians rated more in favor of their leaders than female physicians. The results also represented the relationship between organizational leadership and physicians’ burnout, which is 57% higher in female physicians (20).

A study was conducted as a cross-sectional study with 298 participants, where more than half, that is 51.01% of the participants, were doctors (17). Results show no significant direct relationship between organisational support for career development (OSCD) and turnover intention. Meanwhile, it has a positive relationship with the organization and commitment. Simultaneously, it is also seen that organizational commitment has a negative relationship with turnover intention (17). Therefore, an indirect effect of organization support and career development has been identified with turnover intention mediated by the organization’s commitment.

Data from the survey of 971 active physicians and dependent variables such as organizational climate (social climate, innovation climate, and engagement) and leadership style are used as central independent variables to analyze turnover intentions (5). With 1,060 participants, about 80.7% were physicians; a mediation analysis showed that the perceived quality of care impacts the intention to leave (18). The authors use the Copenhagen Psychosocial Questionnaire (COPSOQ) scale to determine the intentions to go, and results show that low quality of leadership (68.9% SD) was a significant factor for intention to go (18).

A semi-structured interview was conducted with 33 doctors in Nigerian public hospitals (15). Results showed that overwhelming workload, non-participatory engagement, and centralized communication contribute to turnover intentions. The workload is managerially driven, imposes work-related challenges, and results in subsequent turnover intentions (15). It has also been seen that lack of engagement, involvement, and participation affects job satisfaction (15). Lack of participation and a less supportive environment within the organization can be related to poor organizational leadership (16) because it affects organizational decision-making and inconsistency across practice areas. Besides that, effective communication in the workplace between clinical managers and clinical doctors is fundamental to ensuring a healthy relationship. Therefore, the existence of a centralized communication system delegates to a non-participatory environment that constitutes inefficiencies of leadership and Human Resource Management (HRM) policies and practices (16).

The comprehensive observation shows that poor working environment, limited leadership support, overworked hours, inadequate support from management, and working relationships with colleagues are key factors in turnover (5). In support of this view, another study demonstrated that the two key factors, perceived organization and support, and transformation of leadership styles, mainly contribute to turnover intentions (26).

There are also associated factors, such as workplace violence and education level, work tenure, poor health status, sleep quality, health history, income, and other psychological factors, that influence the turnover intention of emergency physicians.

Strengths and limitations

Strengths

This systematic review demonstrated significant contributing factors to doctors’ turnover intention regarding organizational leadership. As such, it uses relatively comprehensive research on clinical doctor turnover intention, particularly focusing on leadership and associated factors.

Limitations

However, the review is dominated by other systematic reviews and quantitative and cross-sectional studies, which significantly portray concerns over the existing research’s explanatory depth when making causal links. Besides, the systematic review’s lack of inclusion of in-depth studies limits the addition of lived experiences.

Comparison with similar research

This systematic review aimed to analyze how the clinical departments’ leaderships influence the turnover intentions of clinical doctors in medical institutions. It has been identified from the results that notable reasons revolve around the leadership aspect that enhances the intention of doctors to leave their current institutions or workplaces. Such results are also consistent in a few studies demonstrating the significant impact of leadership quality on doctors’ professional fulfillment and burnout (20). A well-established association between leadership and burnout of doctors manifests the inverse relationship with turnover intentions. Therefore, this review has identified that leaders’ poor behavior in medical institutions strongly relates to the doctors’ intention to leave.

Similarly, it has been observed that leadership style is one of the most contributing factors that determine doctors’ intention to leave (22). It is identified that the leadership style is associated with the quality of management and supervisory support within the workplace (22). Without leaders’ support, doctors can perceive that they are not heard, recognized, and valued (14). The findings from Byrne et al. and de Vries et al. are consistent with this study, identifying that lower levels of job satisfaction, poor organizational environment, and management practices are linked to turnover intentions among hospital doctors (5,14).

The systematic review has identified several avenues connecting to the leadership aspect of the medical institution or healthcare, advancing knowledge on turnover intention. It has been seen that a lack of organization and leadership support affects the increasing values of doctors, affecting their organizational commitment and work engagement (23,25). This factor remained important compared to the work shift pattern (21). The outcome of a systematic review confirmed that female physicians for doctors are more likely to have a higher intention to leave their current jobs. This is illustrated by the association between job satisfaction, availability of resources, and professional fulfillment (5). Research also identified that a lack of professional fulfillment is somewhat related to the support of clinical supervisors or leaders. The authors also highlighted similar observations denoting that supervisors’ inability to lead the team and create order and unity resulted in perceived dissatisfaction among the physicians, and they portrayed an intention to leave in the next two years (20). Notably, in this systematic review, most studies showed that female physicians or doctors have negatively rated their supervisor’s or clinical leaders’ leadership behavior.

The leadership style is also evaluated by the organizational climate in hospitals and medical institutions, it based on the views of a physician. Low leadership quality affects physicians’ perceived quality of care, and their job satisfaction intensifies their turnover intentions (21). The result of a study determines the relationship between leadership style and organizational climate, stating that the priorities of clinical leaders set the professional standards for physicians and quality in patient care (8). Similarly, a lack of engagement can cause futile employment relations, triggering turnover intentions in the medical sector (15). In contemporary times, medical organizations require more dynamic leadership due to increasing demands for health services. Therefore, clinical leaders and managers are typically given more autonomy and freedom to influence others than before. More research has identified the theory of “hybridization” that explains the willing adoption of managerial, financial, and accounting discourses by medical professionals and accounting discourses by medical professionals, which considers professionalism and managerial logic (8). On the other hand, the polarization thesis demonstrated that the culture of managerialism prevents medical professionals from safeguarding professional autonomy and clinical values (8). Instead, this review confirmed a separate notion highlighting clinical leaders’ administrative and financial responsibilities, leaving the profession unchanged.

Along with the organizational climate, the ethical decision-making climate in a pressurized working environment is also illustrated as an associated reason for turnover intention (27). It is understood that distrust in interdisciplinary teams, lack of collaboration, and disrespectful communication increase physicians’ moral distress and job dissatisfaction. These poor working conditions are due to a lack of organizational support, followed by a lack of leadership (27). Lack of managerial support and leadership orientation further affects moral integrity by infringing on doctors’ core values and obligations. Not merely that, a lack of integrity and mutual respect interrupts the ethical decision-making capacity of doctors and increases their intention to leave (21). In this situation, senior physicians should act as role models to improve mutual respect within the team and promote change. They can implement a system for respectful feedback, facilitate communication and collaboration, and encourage and empower junior physicians to promote an ethical climate and consideration of difficult decisions promptly to open discussions.

Concerning different leadership styles, two primary leadership logics emerge: economic-operational leadership style and professional-supportive leadership style. The economic-operational leadership style mainly emphasizes economic management and strict adherence to formal administration. On the other hand, the professional-supportive leadership style emphasizes the quality of treatment and care and the well-being of professionals and patients (4).

Changes in formal medical organizations have been seen in the implementation of feedback systems, open communication, such as the implementation of feedback systems, open communication, and collaboration, substantially changing the leadership style and central regulation, which correspond to the management practices and professional support. It was also identified that inappropriate management styles, such as lack of delegation, resource support and scheduling and unethical leadership style are one style such as lack of delegation, resource support and scheduling, and unethical leadership style, are some of the top reasons for employees’ intention to leave (6). Another study found that in many organizations, leadership has boundaries and structure to perform organizational structure and management responsibilities without interfering with administrative aspects (4). In contrast, another study stated that the lack of management skills of clinical doctors in leadership affects their administration abilities (13). Hence, it can be confirmed that professionally supportive leadership styles in medical institutions are indeed essential to reducing clinical doctors’ turnover intentions.

Explanations of findings

Extensive research helps to understand that various clinical leadership styles exist in medical institutions that significantly impact employed doctors and other healthcare staff (24). Clinical leadership is a multidisciplinary role where clinical leaders are expected to address healthcare challenges, the increasing complexity of clinical problems, healthcare quality, organizational climate, operations, and financing (2). It has been found that clinical leadership development is linked to managerial and professional outcomes in a medical setting (1). Therefore, the research conveyed that clinical leadership plays a significant role in improving professional outcomes.

Along with the leadership style, several associated factors significantly influence doctors’ intentions to leave their current organization. Besides the leadership and organizational climate, it is identified that factors such as age, gender, work tenure, health status, psychological conditions, and working hours are some contributing factors to turnover intentions (3). All the associated factors are related to doctors’ job satisfaction and professional fulfillment at the workplace. A higher level of job dissatisfaction is proportional to a higher level and strong intentions to leave.

Implications and actions needed

Clinical doctors’ or physicians’ turnover is a crucial global challenge that many medical institutions face. The study of doctor turnover within medical organizations is well-established. This review indicated several variables that predominantly affect clinical doctors’ turnover intentions. First, the review sets a well-developed and broader view of clinical leadership about medical institutions’ or hospitals’ doctors or physicians. The review provides a holistic view of leadership culture within medical organizations and precisely states its relationship with doctor turnover intentions. From the review, it can be concluded that leadership of medical institutions indeed matters as it dramatically influences professional traits and professional relationships with the workplace and determines the quality of care.

From the extensive review, it can be understood that the leadership aspect within medical institutions is also integrated with the formal and economic responsibilities of the institutions. Therefore, a leadership style that is more supportive and emphasizes professionalism is associated with better social outcomes and engagement. On the other hand, leadership, which is more economically operationally oriented, is related to poorer social outcomes and needs.

Conclusions

The review broadly recognizes that more stress, burnout, and lack of job satisfaction at the workplace positively influence turnover intention. Increasing burnout, work stress, and lower levels of job satisfaction are associated with increased turnover intentions. It has also been observed that a poor organizational climate results in a lack of communication and collaboration between professionals, adversely affecting the relationships and professionalism of professionals and doctors. The reason is interlinked with a lack of leadership capacity or a less supportive leadership orientation. In addition, the review also covered the factors associated with turnover intentions, such as age, gender, working hours, work relationships, work tenure, workplace violence, income, and other psychological conditions. It was defined that poor leadership behavior results in doctors’ burnout and low professional fulfillment (16).

Therefore, it can be concluded that a positive relationship between a healthy and responsive organizational climate and professional-supportive leadership is required to reduce the turnover intentions of doctors. In addition, organizational support for performing roles and responsibilities is vital to enhance job satisfaction. Clinical leaders can reduce their turnover intentions by creating a positive working environment regarding quality of care and treatment avenues, regardless of direction. Future research can be built on the idea of collective doctor turnover, as the current review only emphasized that clinical doctors’ broadening the scope of the research would advance knowledge and help decipher interesting facts about turnover intentions. Future research may focus on gender-specific turnover intentions among clinical doctors due to the impact of clinical leadership.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the PRISMA reporting checklist. Available at https://jhmhp.amegroups.com/article/view/10.21037/jhmhp-24-124/rc

Peer Review File: Available at https://jhmhp.amegroups.com/article/view/10.21037/jhmhp-24-124/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jhmhp.amegroups.com/article/view/10.21037/jhmhp-24-124/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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