Abstract
Orientation: In recent years, the healthcare sector in Nigeria has faced significant challenges, including high turnover rates among medical professionals. Previous studies have only focused on monetary reasons for turnover, but there is a gap in understanding how psychological factors predict turnover.
Research purpose: This study examined how psychological contract violation affects the intention to remain or leave among medical doctors in Nigeria.
Motivation for the study: Having an understanding of how medical doctors navigate the breach of their contract and their commitment is important for improving retention strategies and subsequent overall healthcare system in Nigeria.
Research approach/design and method: A cross-sectional survey research design was adopted and quantitative data were gathered from 362 medical doctors. More of the respondents (69.6%) were doing their residency.
Main findings: Findings revealed that employee retention had a significant relationship with perceived breach and feelings of violation (p < 0.01). The dimensions of psychological contract violation accounted for about 53% variance in employee retention [R2 = 0.53; F (2, 359) = 201.01; p < 0.01]; also, perceived breach and feelings of violation were significant independent predictors of employee retention.
Practical/managerial implications: The study recommends that the Ministry of Health in Nigeria consider reviewing the bond and terms of the working relationship between medical doctors and employers to reduce the brain drain of medical doctors.
Contribution/value-add: The study helps to connect psychological and organisational factors in the turnover rate of medical doctors, unraveling that non-monetary factors also play a crucial role.
Keywords: employee retention; psychological contract violation; perceived breach; feelings of violation; turnover intention; medical doctors; industrial psychology; resident doctors; brain drain.
Introduction
It is globally accepted that the role of medical doctors in every society cannot be overemphasised. The vital role of medical doctors was particularly evident during the coronavirus disease 2019 (COVID-19) pandemic, which began in late 2019 and persisted throughout 2020 (Gupta et al., 2021; Johnson & Butcher, 2021). Medical doctors treat and manage health-related problems and illnesses (Pusparini et al., 2024). Their roles also extend to preventing infections and diseases by providing medical advice and tips for survival (Pusparini et al., 2024). These responsibilities, among other things, make physicians highly valued in every society.
To further illustrate how vital medical doctors are in society, the World Health Organization (WHO) posits a ratio of one doctor to a maximum of 1000 people in the population (Kumar & Pal, 2018; WHO, 2016, 2024). According to Kumar and Pal (2018), this ensures that society is adequately catered to. However, most countries have found it both challenging and complex to meet the WHO’s doctor-to-patient standard ratio (Azevedo, 2017; Payerchin, 2022; Sirili et al., 2018). The world is estimated to be in shortage of over 6 million physicians (Boniol et al., 2022). It is also projected that the shortage of physicians and health workers will generally continue to increase to over 18 million by 2030 (Boniol et al., 2022; Lawson, 2022; WHO, 2016). The most affected regions are middle-income and low-income countries in Africa and Asia (Boniol et al., 2022). This is because, amid health worker shortages, physicians and health workers from Africa (inclusive of Nigeria) have continued to migrate to developed countries in Europe and America (Onah et al., 2022).
In recent years, the healthcare sector in Nigeria has faced significant challenges, including high turnover rates among medical professionals (Adebayo & Akinyemi, 2022). In 2021, as Adebayo and Akinyemi (2022) reported that more than the average number of resident doctors in South-West Nigeria (57.4%) intended to migrate abroad for work. Also, Onah et al. (2022) reported that in Nigeria, only about 19% of medical doctors indicated a willingness to continue practising, while the others had a clear intention to leave their current job. This has caused the doctor-to-patient ratio to drop significantly from one doctor to over 9000 people in the population (Aderinto et al., 2024; Balogun et al., 2022).
The turnover rate of medical doctors has presented a series of dangers for the public health and safety of the general populace, especially given the high burden of care associated with Nigeria (WHO, 2019). If unresolved within the shortest time frame, it increases the workload for the few serving medical doctors and society. Several factors have been identified to be contributing to the low retention of medical doctors, some of which are seeking better opportunities (Akinwumi et al., 2022), such as increased pay (Onah et al., 2022), better working conditions (Akinwumi et al., 2022; Onah et al., 2022), among others. These factors were considered independently through descriptives. The study identified this gap and, hence, examines how one of the critical factors, psychological contract violation, contributes to the retention of medical doctors in Nigeria.
The psychological contract refers to an unwritten set of expectations between employers and employees regarding mutual obligations (Ngobeni et al., 2022; Yu, 2022). When these expectations are violated – whether through unmet job promises, lack of support or inadequate working conditions – employees may experience a sense of betrayal, leading to decreased job satisfaction and increased intentions to leave their positions (De-Clercq & Pereira, 2023). The psychological contract violation can manifest in various ways, including unmet expectations (Sischka et al., 2021), poor working conditions (Topa et al., 2022), feelings of being neglected (Yu et al., 2022), inadequate compensation (Topa et al., 2022; Yu et al., 2022), among others. These expressions are also applicable to other medical professionals.
Recently, a series of events linked to the massive migration of medical doctors has unfolded in the Nigerian medical profession landscape. This brain drain is mainly connected with the government’s actions and policies in response to the massive migration of medical doctors and other healthcare professionals to developed countries. As identified earlier, more medical doctors intend to migrate, apart from those who have already migrated (Onah et al., 2022). These left a massive vacuum in the healthcare sector, making the federal government propose a bill through the national assembly that ensures the medical doctors stay and practice within the country for an extended period before migrating to other developed countries (Ogundipe, 2023). During the first quarter of 2023, members of the national assembly proposed a bill that seeks to deny Nigeria-trained medical practitioners from getting full licenses to practice outside the country until they have practised within the country for 5 years (Ogundipe, 2023). This is to ‘forcefully’ retain medical doctors and reduce the rate of brain drain in the healthcare sector.
To most medical doctors in Nigeria, the move by the national assembly is an attempt to trample on their right to free movement, as guaranteed by the International Organization for Migration (IOM) (Shemang, 2023). This move, with existing push factors such as poor working conditions, remuneration (Sischka et al., 2021; Topa et al., 2022; Yu et al., 2022) as well as other pull factors such as better working environment and others, may together have combined to predict the turnover rate or intention to migrate among medical doctors in Nigeria. However, this remains to be empirically tested in the Nigerian context – hence, this study.
A series of studies have examined the link between psychological contract violations and employees’ turnover or retention within the organisation. For instance, Snyman et al. (2023) examined the relationship between psychological contracts and retention strategies in several South African higher education institutions. Their findings show that psychological contracts and staff retention are both significantly correlated. As the relationship suggests a positive correlation, retention practices are likely to improve as the psychological contracts are honoured. Additionally, Rehman et al. (2019) found that psychological contract violations had a noteworthy and detrimental impact on the healthcare professionals’ retention in employment. Compared to healthcare workers who perceived lower levels of breach of psychological contract violation, those with high levels of perceived psychological contract breach indicated a lower level of intention to remain in the role. The social exchange theory, which highlights the necessity of trade between employers and employees, is consistent (Alnajim, 2021). Employees’ intention to remain in employment diminishes if they believe that their efforts and those of the employer are not matched in both written and unwritten agreements.
Furthermore, Collins and Beauregard (2020) found a substantial correlation between the intention to stay at work and a psychological contract breach. The negative link indicated that medical practitioners’ intentions to remain on the job are inversely correlated with perceived psychological contract violations. Other studies, such as Deas and Coetzee (2020), Van Den Heuvel et al. (2017), Jacoby (2020) and Obakpolor (2020) reported a similar trend of the link between the psychological contract and employee retention or turnover intention.
Based on the reviewed studies, this study hypothesises that there will be a significant and negative relationship between psychological contract violation and the retention of medical doctors in Nigeria. By examining these factors, this research aims to provide insights that can inform strategies to enhance workforce retention, improve job satisfaction and ultimately contribute to a more stable healthcare system in Nigeria.
Research design
This section presents the overall procedure for executing the research.
Research method
The study adopted a cross-sectional survey research design to examine the role of psychological contract violation (comprising perceived breach and feelings of violation) in the retention of medical doctors in Nigeria. The design enables researchers to gather data at a single point in time from a large sample of participants with similar characteristics. The independent variable was psychological contract violation (comprising perceived breach and feelings of violation), while the dependent variable was employee retention. The population sample consists of medical doctors practising in the south-western region of Nigeria.
Sample and population
The study population was medical doctors in the south-western region of Nigeria. Specifically, the study focused on resident doctors and house officers in selected teaching hospitals in south-western Nigeria. There are six states in Nigeria’s south-western region: Ekiti, Lagos, Ogun, Ondo, Osun and Oyo states. The six states combined to have nine teaching hospitals: University College Hospital (Ibadan, Oyo State), Lagos State University Teaching Hospital, Lagos University Teaching Hospital, Obafemi Awolowo University Teaching Hospital, Olabisi Onabanjo University Teaching Hospital, Ekiti State University Teaching Hospital, University of Medical Sciences Teaching Hospital (Ondo state), Ladoke Akintola University Teaching Hospital and Federal Teaching Hospital, Ido-Ekiti (MDCN, 2022). The breakdown of the total population of medical doctors in the south-western region of Nigeria is presented in Table 1.
| TABLE 1: Distribution of medical doctors in south-west Nigeria. |
As presented in Table 1, there are 4901 medical doctors across the six states in the south-western region of Nigeria. Using the Raosoft online sample size calculator at a 95% confidence level, 5% margin of error and 50% response distribution, a total of 357 samples of medical doctors was determined. To address attrition, 10% (approximately 36) of the calculated sample size was added to 357. However, after data gathering and cleaning, 362 responses were considered valid for the study and utilised for subsequent analysis.
The convenience sampling technique was utilised to sample medical doctors across six teaching hospitals, systematically selected through a ballot system, ensuring one teaching hospital from each of the six teaching hospitals in the south-western region of Nigeria.
Measuring instruments
The study gathered data using a well-structured questionnaire comprising standardised scales of measurement. The instrument has three sections: Section A, Section B and Section C.
Section A: Demographic information
This section contains demographic information on medical doctors. This includes gender (male or female), age (measured on a continuous scale of measurement), professional status (resident doctor or house officer), marital status (single, married, divorced, separated or widowed) and years of working experience (measured on a continuous scale of measurement).
Section B: Employee retention scale
This section features a nine-item employee retention scale developed by Govaerts et al. (2010), designed to assess employees’ willingness to remain in their current positions. Respondents indicate their agreement using a five-point Likert scale, ranging from Strongly Disagree (1) to Strongly Agree (5). Among the nine items, three (item 7, item 8 and item 9) were reverse-scored to measure turnover intention precisely. Govaerts et al. (2010) reported an internal consistency of 0.82 for the scale items and a full-scale reliability of 0.79. An example item from the scale is: ‘If I wanted to pursue another job or role, I would first explore opportunities within my current organisation’. In this study, the scale demonstrated a Cronbach’s alpha of 0.77 and a full-scale reliability of 0.81, indicating strong consistency within the study population.
Section C: Psychological contract violation scale
This section comprises nine items to measure psychological contract violations among medical doctors. The scale was developed by Robinson and Wolfe Morrison (2000) to measure the extent to which employees perceive that their contract has been breached. To precisely capture the construct, two dimensions were determined through factor analysis by Robinson and Wolfe Morrison (2000). The dimensions were perceived breach (Items 1–5) and feelings of violation (Items 6–9). Response to the scale items ranged on a five-point Likert response format, ranging from strongly disagree (1) to strongly agree (5). Items 1–3 were reverse-scored. The perceived breach items had factor loadings ranging from 0.70 to 0.87 and an internal consistency of 0.80.
In contrast, feelings of violation had factor loadings from 0.79 to 0.89 and an internal consistency of 0.78. Divergent validity with other opposite variables ranged from 0.70 to 0.89. A sample of an item is ‘My employer has broken many of the promises to me, even though I’ve upheld my side of the deal’.
Research procedure
With permission from the regulatory body of resident doctors and house officers in Nigeria, the researcher designed an online survey link comprising the survey questions. This was decided by considering the busy schedules of the medical doctors. After that, the study recruited the services of four research assistants representing each of the selected states. The researcher visited each of the teaching hospitals at least twice. The first was to establish rapport with the leadership of resident doctors and house officers in each teaching hospital, while the second and subsequent meetings were to facilitate the responses to the survey, shared via their WhatsApp platforms. The exact process was replicated at each of the teaching hospitals. Data collection took about 4 weeks. Although 378 responses were returned, only 362 were retained for data analysis. The other 16 were removed because of incomplete responses (responses were not completed for some sections of the research instrument).
Data analysis
Descriptive and inferential statistics were used to analyse the gathered data. Specifically, simple frequencies and percentages were used to analyse the socio-demographic information of respondents. Descriptive statistics were also used to determine the average age, years of experience and distribution of the study variables (employee retention and psychological contract violation). The zero-order correlation was used to analyse the relationship between employee retention and psychological contract violation. Regression analysis was used to test the influence of psychological contract violation on employee retention.
Ethical considerations
Ethical clearance to conduct this study was obtained from the University of the Western Cape Biomedical Science Research Ethics Committee (BM23/9/5). The research ethics certificate and a letter of introduction from the Department of Industrial Psychology were supporting documents to gain respondents’ access and trust to participate in the study. Throughout the research, ethical considerations were strictly adhered to. Apart from obtaining ethical clearance to conduct the study from the ethical committee at the University of Western Cape, South Africa, the principles of confidentiality, voluntary participation, beneficence and non-maleficence were strictly adhered to. Participants consented through a written format before they proceeded with giving responses to the survey questions. Responses supplied by respondents were kept confidential in secure files and emails (only the researchers have the password to access the data). No form of unique identity was required from the participants such as name, email address or other personal information. The data gathered were encrypted with a password known only to the researcher.
Results
This section presents the results of gathered data on the role of psychological contract violations in Nigeria’s retention of medical doctors. The results are presented in the subsections.
Socio-demographic information
Table 2 presents the results from the study of the socio-demographic distribution of medical doctors in relation to employee retention.
| TABLE 2: Socio-demographic distribution and employee retention. |
Table 2 presents the results of the descriptive analysis of demographic information with employee retention of medical doctors in selected teaching hospitals in the south-western region of Nigeria. The gender distribution revealed that 205 (56.6%) of the medical doctors were male. However, there are no significant gender differences in employee retention (f = 1.28; p > 0.05). Although the majority of the medical doctors, 265 (73.2%), were aged between 25 years and 34 years, those aged between 35 years and 44 years reported a higher retention tendency (Mean = 22.73; standard deviation [SD] = 6.28), as age was found to be a significant determinant of employee retention (f = 4.41; p < 0.01).
Regarding professional status, most of the medical doctors (252 [69.6%]) were resident doctors, while the remaining 110 (30.4%) were house officers. Further, there exists a significant difference between the two professional cadres (f = 29.17; p < .01), with resident doctors reporting a greater intention to remain in their role (Mean = 21.28; SD = 7.09).
A larger proportion of the medical doctors, 104 (28.7%) had 2 years of working experience, followed by 92 (25.4%) with 3 years, 77 (21.3%) with 4 years, 50 (13.8%) with 5 years and 35 (9.7%) with 1 year of working experience. While the remaining only 4 (1.1%) had 6 years of working experience. Years of working experience were found to have a significant influence on employee retention (f = 7.96; p < 0.01).
Finally, in terms of marital status, 184 (50.8%) of the medical doctors were single. However, marital status did not have a significant influence on employee retention (f = 2.09; p > 0.05).
Inter-correlation between the variables
This section presents results on the relationship between the studied variables. The relationship was tested using the Pearson’s r correlation, as presented in Table 3.
| TABLE 3: Pearson r correlation summary table showing results on the relationship between employee retention and psychological contract violation. |
Table 4 presents results on the relationship between workforce retention and psychological contract violation among medical doctors. Psychological contract violation was measured using its dimensions: perceived breach and feelings of violation. It is shown that employee retention had a significant relationship with perceived breach (r = −0.60; p < 0.01) and feelings of violation (r = −0.69; p < 0.01) among medical doctors in Nigeria. The relationship’s direction is negative, implying that the higher the perceived breach and feelings of violation, the lower the employee retention.
| TABLE 4: Multiple regression analysis summary table showing results on psychological contract violations as a predictor of employee retention. |
It could be deduced that medical doctors who perceive that the contract specifying the working conditions and agreement with the employer has been breached tend not to see any reason for continued working relationships and, hence, begin scheming to leave their jobs for better opportunities. The same deduction can be made regarding the negative relationship between feelings of violation and employee retention. In other words, when medical doctors feel their agreement has been violated, they start thinking of leaving their jobs for a better one.
Table 3 also shows a significant and positive relationship between perceived breach and feelings of violation among medical doctors (r = 0.61; p < 0.01).
Regression analysis on the influence of psychological contract violation on employee retention
This section presents results on the influence of psychological contract violations (perceived breach and feelings of violation) on employee retention among medical doctors in Nigeria. The hypothesis was tested using regression analysis and the results were presented in Table 4.
Table 4 illustrates the joint and independent predictors of psychological contract violation dimensions – specifically, perceived breach and feelings of violation – on employee retention among medical doctors in Nigeria. The findings indicate that these dimensions serve as significant joint predictors of employee retention, with results showing (R = 0.72; R2 = 0.53; f [2, 359] = 201.01; p < 0.01). Notably, perceived breach and feelings of violation accounted for approximately 53% of the variance in employee retention. This further implies that the combined effect of perceived breach and feelings of violation is substantial, meaning that addressing these dimensions is essential for improving the retention rate of medical doctors. The other 47% could be attributed to other variables not considered in this study.
Furthermore, both perceived breach (β = −0.29; t = −6.28; p < 0.01) and feelings of violation (β = −0.51; t = −11.18; p < 0.01) emerged as significant independent predictors of employee retention among medical doctors in Nigeria. The negative beta values indicate that as perceived breach (β = −0.29) and feelings of violation (β = −0.51) increase, the intention of medical doctors to remain in their positions decreases. In other words, medical doctors who feel a breach and violation of their psychological contract are less likely to stay in their positions. This further highlights the importance of employers in fulfilling the agreements signed with medical doctors to ensure their retention.
Discussion
The study examined the role of psychological contract violation in the retention of medical doctors in Nigeria. Psychological contract violation was measured using a 2-dimensional scale (perceived breach and feelings of violation), while employee retention was measured using a uni-dimensional scale. It was found in the study that psychological contract violation through the dimensions had a significant and negative relationship with the retention of medical doctors in Nigeria. The direction of the relationship shows that the higher the perceived breach and violation medical doctors feel, the lower their intention to remain on the job. Also, it was unravelled, through regression analysis that both perceived breach and feelings of violation were significant, independent and joint predictors of employee retention among medical doctors.
About the findings, Saeed (2019) investigated the association between psychological contract violation and software engineer turnover intention in Lahore, Pakistan. It was revealed that there is a significant association between turnover intention and psychological contract breach among software developers. The relationship is positive, meaning the more critical the psychological contract violation, the greater the turnover intention. In other words, software engineers want to leave their jobs when they believe their agreement with their employer has changed. Adiguzel et al. (2017) found a similar pattern, reporting a strong relationship between psychological contract violation and intention to leave among employees.
Furthermore, it was discovered that psychological contract violation considerably and favourably affected the intention to leave work. This suggests that the bigger the psychological contract violation, the greater the desire to quit. In other words, employees with high levels of reported psychological contract violation are more likely to leave their jobs than those with low levels of perceived psychological contract violation. In addition, Fajariyanti et al. (2022) investigated the relationship between psychological contract breach and turnover intention among nurses in selected public hospitals in Surakarta, Indonesia. According to reports, the bigger the perceived psychological contract violation, the greater the intention to leave among nurses. In other words, breaching nurses’ psychological contracts diminishes their chances of retention. According to Azeem et al. (2020), a significant correlation exists between psychological contract breaches and turnover intention among banking managers. As a result, the link is positive, implying that the greater the psychological contract violation of bank managers, the greater the turnover intention. In their study, Heffernan and Rochford (2017) discovered that psychological contract breaches had a significant and favourable influence on turnover intention among Irish defence forces officers. Officers with high degrees of psychological contract violation reported higher turnover intention than those with low levels of psychological contract breaches.
Recommendations
Having made a series of findings, the following recommendations were made:
- Firstly, it is recommended that the Ministry of Health in Nigeria should consider reviewing the bond and terms of working relationship between medical doctors and employers. In doing this, the union management of the Nigerian Medical Association should be invited to work with the ministry in designing a mutually beneficial agreement for both the parties. It is required that there will be sacrifices between the two parties. Also, inviting the Nigerian Medical Association to the table to make such agreements and decisions will give medical doctors a sense of belonging. The agreement should be followed by an action plan that tracks the progress of the implementation. This will increase the trust of medical doctors in the ministry and, by extension, the government, increasing the retention rate of medical doctors.
- Secondly, there should be an urgent examination of the existing labour law that governs the medical profession. Working conditions, allowances and other perks for medical physicians should be examined and honoured. This is because it was discovered that more medical doctors believed their contracts had been breached on average, resulting in a low retention rate. Identifying areas of default in the breach will accelerate redemption and, as a result, increase medical doctors’ trust in the government and other relevant authorities. This could also be accomplished by encouraging the trade union in-charge of the profession to establish and participate in collective bargaining with the government.
- Thirdly, it is recommended that more studies should be carried out on other links between psychological contract violation and the retention of medical doctors. This will help proffer more practical solutions to retain medical doctors.
Practical implications
The findings from this study underscore the critical role of healthcare organisations (both public and private) in fulfilling psychological contracts with medical doctors (and other healthcare workers). Clear communication, addressing conflicts and grievances as well as recognising the contributions of medical doctors, are some of the ways by which feelings of breach and violation can be avoided. These proactive measures subsequently make medical doctors key figures or factors in the organisation. This fosters trust and commitment, subsequently increasing the intention to remain on the job.
In addition, considering that 53% of the retention rate is explained by perceived breach and violation, the Ministry of Health and other agencies in-charge of medical professionals could develop retention strategies related to the specific needs of medical doctors, which might differ from one person to another.
In addition, the findings have implications for the need for constant communication and a cordial employer-employee relationship. This form of relationship opens up a channel where medical doctors can communicate with management whenever they feel their contract has been breached or violated.
Limitations of the study
These findings revealed a series of limitations. Firstly, the study focused on medical doctors in federal teaching hospitals only, leaving out doctors in other private hospitals. This limits the generalisation of the findings to medical doctors only in different teaching hospitals in Nigeria. Future studies should consider a mix of participants across available cohorts in the population.
Secondly, while the quantitative research method has its strengths, especially in being able to generalise findings and help quantify results, it presents a limitation in restricting responses to just indicated options. Future studies should consider mixed-method research, where findings from the quantitative method can be further substantiated by qualitative research.
Finally, the research sampled resident doctors and house officers, whose work experience ranged from 1 year to 6 years. This implies that the findings should not be generalised to consultants and other medical doctors with more years of work experience.
Conclusion
The study concludes that when medical doctors perceive their rights as being violated or breached, they are inclined to leave their workstations. This aligns with Homans’ (1958) social exchange theory, which states that employees who do not receive matching compensation or treatment for their efforts become dissatisfied, drop their performance and wish to leave their jobs. In the present study, when medical doctors feel that the exchange of their efforts is incongruent with how they are treated, they intend to leave their jobs.
Acknowledgements
This article is partially based on the author, T.M.F.’s PhD dissertation entitled, ‘The development and empirical evaluation of a workforce retention model for Nigeria’s healthcare sector’, towards the degree of Doctor of Philosophy in the Department of Industrial Psychology, University of the Western Cape, South Africa, with supervisor Professor John Kolawole Aderibigbe.
Competing interests
The authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article.
Authors’ contributions
T.M.F. was responsible for developing the first draft as well as running the analysis. J.K.A. was responsible for writing the methodology, discussion and contributed in large amount to other sections of the article.
Funding information
This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.
Data availability
The data that support the findings of this study are available from the corresponding author, T.M.F., upon reasonable request.
Disclaimer
The views and opinions expressed in this article are those of the authors and are the product of professional research. They do not necessarily reflect the official policy or position of any affiliated institution, funder, agency or that of the publisher. The authors are solely responsible for this article’s results, findings and content.
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