Exit interviews to reduce turnover amongst healthcare professionals

Abstract

Background

Exit interviews are widely used in healthcare organisations to identify reasons for staff attrition, yet their usefulness in limiting turnover is unclear.

Objectives

To determine the effectiveness of various exit interview strategies in decreasing turnover rates amongst healthcare professionals.

Search methods

We searched the Cochrane EPOC Group Specialised Register; Cochrane Central Register of Controlled Trials (CENTRAL), Issue 11, 2012; MEDLINE, Ovid (1950‐ ); EMBASE, Ovid (1947‐ ); CINAHL, EbscoHost (1980‐ ), and PsycINFO, OVID (1806‐) between October 31 and November 6, 2012. We also screened the reference lists of included studies and relevant reviews; and searched trial registries for planned and on‐going studies. We did not restrict searches by language or publication date.

Selection criteria

Randomised controlled trials, controlled clinical trials, controlled before‐after studies and interrupted time series studies comparing turnover rates between healthcare professionals who had undergone one form of exit interview with another form of exit interview or with no interview.

Data collection and analysis

Two review authors independently assessed trial quality and extracted data.

Main results

The original search identified 1560 citations, of which we considered 19 potentially relevant. The two authors independently reviewed the abstracts of these studies and retrieved the full texts of eight studies. We excluded all eight following independent assessment; they were either interviews, commentaries on how to do an exit interview or descriptive studies about reasons for leaving. We found no studies that matched our inclusion criteria. For this first update, we screened 2220 citations and identified no new studies.

Authors' conclusions

Evidence about the effectiveness of exit interviews to reduce turnover is currently not available. However, exit interviews may provide useful information about the work environment which, in turn, may be useful in the development of interventions to reduce turnover.

Plain language summary

Exit interviews to reduce turnover

In many healthcare organisations, exit interviews are conducted to try to understand why staff are leaving the facility. These interviews may be held before the individual leaves or after they have left the organisation; they may be face‐to‐face interviews or conducted by telephone. The main purpose of the exit interview is to reduce the number of people who leave, by fixing problems that may be identified during the exit interview process. This review sought to determine if the exit interview was useful in achieving this purpose. However, after a wide search, no studies answering the question were found. Further research in this area is needed.

Background

Description of condition

Turnover is defined as "the process whereby staff resign from the organization or transfer within the hospital environment" (Bland Jones 1990). It is a problem that affects all organisations and has become a focus of healthcare institutions because of high replacement costs. In Wise 1993, this phenomenon is defined as an erosion of human resources within an organisation resulting in an increase in the cost of doing business. Unfortunately, when health care is involved the end result of turnover can impact on patient care and clinical outcomes. Turnover has been a focus of interest for organisations since the early 1900s (Cotton 1986). It can be viewed as beneficial to an organisation to a certain degree, stopping it from becoming stagnant and non‐productive (Weisman 1981). Tai et al suggest that in any organisation, trying to retain staff and keep turnover rates at an acceptable level is beneficial. In healthcare facilities turnover rates range between 10.1% and 50% (Tai 1998), however rates between 15% and 20% annually are considered acceptable to prevent an organisation becoming stagnant (Capko 2001).

Description of intervention

Exit interviews are conducted in many organisations to elicit reasons for employee turnover (Leahey 1991). The practice dates back over half a century (Melcher 1955; Moran 1956) and takes the form of either a formal or informal verbal interchange, conducted at a point between the time of resignation and the employee's last working day; a written questionnaire, completed either before or after leaving the organisation; or a combination of both approaches. The exit interview can be defined as "a widely used tool for gathering information from separating employees" (Giacalone 2003, p.398). An excellent summation of the process is "that the scope of inquiry is not simply why employees quit their jobs, but the impact of the total work environment on those who chose to stay" (Drost 1987, p.104). Although there is argument for and against the exit interview, it remains a recommended component of the exiting process. Well accepted reasons for conducting such interviews include: attempting to change the person's mind about leaving; using the interview as part of an 'image management' exercise (Lefkowitz 1969); documenting specific reasons for the resignation so that managers can use the information to improve the service (Erickson 1996; Leahey 1991; Neidermeyer 1987); and, more recently, to 'trend' reasons for turnover (Erickson 1996). An exit interview also provides organisational feedback about unethical or bad behaviour and information about current practices, working conditions, management and training programmes (Drost 1987; Giacalone 2003; Jackson 2002; Jurkiewicz 2001). In ideal circumstances the employee is interviewed by someone other than the line manager; information is then gathered and analysed and fed back to managers and executives in a timely manner.

Although the exit interview is widely used, the validity of the approach has been questioned (Jurkiewicz 2001; Lefkowitz 1969). There are often inconsistencies in the way the interview is managed, and it may be conducted by people who are unskilled in interview techniques. The exercise is costly and information may not be analysed and fed back in a timely manner, or may be disregarded completely. More importantly, the information elicited may not be accurate. For example, departing employees may wish to leave a good impression to improve chances of a positive future reference or re‐employment (Hinrichs 1971; Yourman 1965). They may feel intimidated about discussing the true reason for leaving, especially if conflict is involved and the interview is conducted well before the person's departure date; or they may feel that disclosing their real reason is a waste of time, based on previous experience with the service (Yourman 1965).

How the intervention might work

The intervention under consideration in this review is the exit interview and the primary outcome is staff turnover. In theory, the exit interview reduces turnover by alerting management about organisational deficits or problems that may be amenable to quality improvement activities. Responding to concerns raised during the exit interview provides the organisation with a reputation of caring, which may, in turn, contribute to staff retention.

Why it is important to do this review?

There is a worldwide shortage of healthcare professionals (WHO 2006), so many strategies have been utilised in an attempt to reduce this phenomena, the exit interview being just one of them. This review is timely and important because retaining healthcare professionals has become a priority for most countries around the world. To understand the organisational environment, the manager must be aware of the tools available to assist them in trying to reduce turnover and retain staff. The exit interview is one such tool, but whether it is effective in reducing turnover or the number of healthcare professionals who leave the profession is still disputed.

Objectives

To determine the effectiveness of various exit interview strategies in decreasing turnover rates amongst healthcare professionals working in healthcare organisations.

To address these objectives we planned the following comparisons.

1. Exit interviews compared to no exit interview.

2. We also planned to explore the effects of the following characteristics of the intervention on the magnitude of the effect across studies: method of delivery (face‐to‐face, telephone, self‐complied, electronic or postal).

3. Depending on the number and quality of studies found we also planned to explore the effects of the following characteristics of the intervention on the magnitude of the effect across studies:

   1. the timing of the interview in relation to the healthcare professional's resignation;

   2. the person who carries out the interview in relation to the employee's immediate work environment; and

   3. the location of the interview in relation to the employee's work environment.

Methods

Criteria for considering studies for this review

Types of studies

Randomised controlled trials, controlled clinical trials, controlled before‐after studies and interrupted time series studies comparing turnover rates between healthcare professionals who had undergone one form of exit interview with another form of exit interview or with no interview. We planned to include studies published in all languages.

Types of participants

Healthcare professionals (including medical, nursing and allied health) who have undergone any type of exit interview from a healthcare organisation.

Types of interventions

Any form of exit interview undertaken at the voluntary cessation of employment or at a prescribed time following departure from the organisation was eligible. These could be a face‐to‐face exit interview, a telephone exit interview, a self‐completed exit interview survey, electronic exit interview survey and mailed exit interview survey.

Types of outcome measures

Primary outcome

• Turnover rate (defined as the proportion of the population that leaves the organisation in any given year or over the period of the study).

Secondary outcomes

• Organisational change as a result of the exit interview process (for example, evidence of policy change).

• Cost incurred as a result of voluntary cessation of an employee (for example, productivity losses incurred when the new employee is training and orientating, or any other costs reported by the author).

• Absenteeism (days of sickness absence during the study period. Sickness absence may be extracted from the employee attendance records, or may be self‐reported).

• Organisational job satisfaction measured by any validated job satisfaction instrument.

Changes in rates of absenteeism and organisational job satisfaction may be secondary to any organisational change, developed in response to exit interview information.

Search methods for identification of studies

Electronic searches

The search strategy for this update was revised by the EPOC Trials Search Co‐ordinator (TSC), M. Fiander, to broaden the scope of the search and to implement a new (post‐2008) EPOC Methodological Filter and validated Cochrane Randomised Controlled Trial Filter. The updated searches identified 1240 unique citations (1263 gross less 43 duplicates); since the search strategy was changed, searches were run retrospectively ‐ from database start date to October 2012 using the following databases.

• Cochrane Central Register of Controlled Trials (CENTRAL), Issue 11, 2012 [Nov 6, 2012]

• MEDLINE, 1946‐, In‐Process and other non‐indexed citations, OvidSP [Nov 2, 2012]

• EMBASE, 1947 ‐ , OvidSP [Nov 2, 2012]

• EPOC Group, Specialised Register, Reference Manager

• CINAHL (Cumulative Index to Nursing and Allied Health Literature), 1980‐ , EbscoHost [Nov 6, 2012]

• PsycINFO, 1806‐October <Week 5 2012> [October 31, 2012]

We used two methodological search filters to limit retrieval to appropriate study designs: the Cochrane Highly Sensitive Search Strategy (sensitivity‐ and precision‐maximizing version, 2008 revision) to identify randomised trials (Lefebvre 2011); and an EPOC methodology filter to identify non‐randomised controlled trial designs. See Appendix 1 for strategies used for this update, Appendix 2 for methodological filters and Appendix 3 for search strategies used in the original review.

Searching other resources

Trial Registries

We searched the following trial registries for the phrase exit interview:

The World Health Organization International Trial Registry Platform http://www.who.int/ictrp/en/ [accessed 7 December 2012]

The ISRCTN (International Standard Randomised Controlled Trial Number) Register http://www.controlled‐trials.com/isrctn/ [accessed 7 December 2012]

ClinicalTrials.gov http://clinicaltrials.gov/ [accessed 7 December 2012]

We handsearched those high‐yield journals and conference proceedings which had not already been handsearched on behalf of The Cochrane Collaboration. We checked the reference lists of all papers and relevant reviews identified. We planned to contact authors of papers meeting our inclusion criteria regarding any further published or unpublished work. We also searched the Internet for non‐peer reviewed reports (e.g. professional organisations and governmental agencies) using the phrase exit interview.

Data collection and analysis

Selection of studies

Both review authors independently screened all titles and abstracts identified through the search strategies to assess which studies met the inclusion criteria. We retrieved and assessed full‐text copies of all papers that were potentially relevant for inclusion. Any disagreement was resolved by discussion between the review authors.

Data extraction and management

We had planned to extract the following data where available (to be extracted by one author and checked by the second review author):

• details of trial/study (first author, year of publication, journal, publication status, period);

• setting and country of study;

• source of funding;

• inclusion and exclusion criteria;

• baseline characteristics of participants (age, sex);

• number of participants in each arm of the trial;

• description of intervention (type, duration);

• type of control intervention (type, duration);

• primary and secondary outcomes (by group);

• design/methodological quality data as per risk of bias criteria;

• unit of randomisation (where relevant);

• unit of analysis; and

• results and primary statistical analysis.

Assessment of risk of bias in included studies

Two review authors were to assess study risk of bias independently using the Cochrane Collaboration tool (Higgins 2011). This tool addresses six specific domains: sequence generation, allocation concealment, blinding, incomplete outcome data, selective outcome reporting and other issues (e.g. baseline imbalances). See Appendix 4 for details of the criteria on which judgements would have been based.

Measures of treatment effect

Primary analyses

We planned to base primary analyses on consideration of dichotomous outcome measures (for example, the proportion of healthcare professionals leaving). When studies reported more than one measure for each endpoint, we planned to extract the primary measure (as defined by the authors of the study) or the median measure identified. We planned to present the results for all comparisons using a standard method of presentation where possible. For comparisons of randomised controlled trials and other designs, such as controlled clinical trials and controlled before‐after studies we planned to report separately for each design:

• median effect across included study;

• inter‐quartile ranges of effect size across included studies; and

• range effect sizes across included studies.

We planned to report individual tables comparing effect sizes of interventions grouped according to EPOC taxonomy (structural, professional and organisational) (EPOC 2002).

Where appropriate, we would have used the standard statistical methods of The Cochrane Collaboration for pooling of data from randomised and quasi‐randomised controlled trials. For categorical and continuous data, we would have calculated the risk ratio (RR) and weighted mean difference (WMD) respectively with 95% confidence intervals (CIs). We would have used a random‐effects model to take into account the heterogeneity of the various studies.

Secondary analyses

No secondary analyses were possible.

Methods of re‐analysis

No re‐analysis was possible.

Unit of analysis issues

There were no unit of analysis issues.

Dealing with missing data

If outcome data had remained missing despite our attempts to obtain complete outcome data from authors, we would have performed an available‐case analysis, based on the numbers of participants for whom outcome data were known. If standard deviations were missing, we would have imputed them from other studies or, where possible, computed them from standard errors using the formula SD = SE x √N, where these were available (Higgins 2011).

Assessment of heterogeneity

We would have assessed heterogeneity using tables and bubble plots comparing effect sizes of studies grouped according to potential effect modifiers (timing of the interview, person carrying out the interview and location of the interview). A bubble plot graphically presents the relationship between the outcome of each study and a given effect modifier with the use of regression lines. Each study is represented by a bubble; the size of the bubble represents a study characteristic, often the size and quality of the study (Higgins 2002).

Assessment of reporting biases

We would have assessed reporting bias using the guidelines in the Cochrane Handbook for Systematic Reviews of Interventions (Sterne 2011).

Data synthesis

Where appropriate, we would have pooled the results of comparable studies and reported the pooled estimate together with its 95% CI. We planned to conduct a narrative review of eligible studies if statistical synthesis of data from more than one study was not possible or considered inappropriate.

Subgroup analysis and investigation of heterogeneity

We planned to analyse potential sources of heterogeneity using the following subgroup analysis: concealment of allocation (adequate versus not reported).

Sensitivity analysis

We planned to undertake sensitivity analysis to explore the effect of excluding studies where concealment of allocation was unclear.

Results

Description of studies

We found no studies meeting the inclusion criteria.

Results of the search

The initial search identified 1560 citations of which we considered 19 potentially relevant. We independently reviewed the abstracts of these studies and retrieved the full texts of eight studies. We excluded all eight following independent assessment; see Characteristics of excluded studies for the reasons for exclusion. For this update, we identified 1220 new citations. We found no studies that matched our inclusion criteria.

Included studies

No studies were included.

Excluded studies

The table Characteristics of excluded studies contains reasons for excluding eight potentially useful studies.

Risk of bias in included studies

No studies were included.

Allocation

No studies were included.

Blinding

No studies were included.

Incomplete outcome data

No studies were included.

Selective reporting

No studies were included.

Other potential sources of bias

No other source of bias.

Effects of interventions

The searches did not identify any studies that met the pre‐specified inclusion criteria for this review, nor were we able to identify any ongoing studies.

Discussion

Despite the large number of published articles about exit interviews, we have been unable to identify any trials or other high quality studies that have assessed the value of exit interviews to reduce turnover amongst healthcare professionals. We found some anecdotal accounts of reductions in turnover after the introduction of exit interviews, but no data were provided to substantiate these statements (Hawkins 2003). This is disappointing in view of the widespread nature of the practice.

Costs associated with replacing staff may be considerable and have been extensively studied (Mukamel 2009). It therefore seems intuitively sensible to question staff about their reasons for leaving, if this results in organisational changes that lead to lower turnover rates. However, the effectiveness of exit interviews remains unknown, as does the most appropriate method for conducting such interviews.

This review has identified an important gap in turnover research. There is an urgent need for high quality studies to provide managers with evidence to guide decisions about approaches to exit interviews.

Summary of main results

We found no studies meeting the inclusion criteria.

Overall completeness and applicability of evidence

The review is complete, based on the evidence available.

Quality of the evidence

No randomised controlled trials or other high quality studies were available.

Potential biases in the review process

We do not believe there were any biases in the review process. We conducted a careful literature search and none of the authors have any conflict of interest.

Agreements and disagreements with other studies or reviews

We were unable to compare results from this review with any other studies or reviews.

Authors' conclusions

Implications for practice.

Evidence for the effectiveness of exit interviews to reduce turnover is currently not available. Consequently, a range of uncertainties remain about the practice.

Implications for research.

Rigorous studies, designed to compare exit interview strategies, are required to inform decisions about healthcare interventions to reduce turnover. Any future studies should include participants from a variety of healthcare settings (e.g. acute, aged care, community), compare interviewers (line managers or independent) and involve interventions such as in‐depth interviews, phone interviews or paper‐based surveys administered before the person leaves the organisation; and interviews, either by phone or face‐to‐face, or paper‐based surveys after the person leaves the organisation. These interventions may be compared with each other or with no planned exit interview strategy. The inclusion of formal, planned economic analyses in any future trial would be very useful to healthcare administrators.

We acknowledge that studies linking exit interview strategies directly with turnover may be complex. Outcomes may be influenced by a variety of interventions which emerge from exit interview data. Consequently, it may be useful to undertake studies that evaluate the impact of exit interviews on intermediate and final outcomes, such as sick leave absence or measures of organisational culture, using an interrupted time series approach, in line with evaluations of other complex interventions. Any such interventions would need to be clearly documented and defined.

What's new

Date	Event	Description
1 August 2014	Amended	The review was amended to clarify errors or wording in the original text of the review. Changes were made to the following sections: 1. Searching other resources: we changed the wording in this section to clarify the methods used: "We checked the reference lists of all papers and relevant reviews identified. We planned to contact authors of papers meeting our inclusion criteria regarding any further published or unpublished work". Original text: We checked the reference lists of all papers and relevant reviews identified. We contacted authors of relevant papers regarding any further published or unpublished work. 2.Selection of studies: we removed the words "and methodological quality" from this section as this was an error in the original text. Original text: We retrieved and assessed full‐text copies of all papers that were potentially relevant for inclusion and methodological quality. 3. Results of the search: we removed the words "they were either interviews, commentaries on how to do an exit interview or descriptive studies about reasons for leaving" and added the words "see ‘Characteristics of excluded studies’ for the reasons for exclusion" as the full list is provided in that section of the review. Original text: We excluded all eight following independent assessment; they were either interviews, commentaries on how to do an exit interview or descriptive studies about reasons for leaving. 4. Effects of interventions: we removed "randomised controlled trials" and replaced with "studies that met the pre‐specified inclusion criteria for this review" to avoid any ambiguity in the text. Original text: “The searches did not identify any randomised controlled trials eligible for inclusion in this review nor were we able to identify any ongoing trials.” 5. Quality of the evidence: We changed the wording to be consistent with the first sentence of the Discussion. Additionally. throughout the review text, we replaced the words “trials” and “randomized controlled trials" with “studies” (except where referring to this specific study design) to avoid any ambiguity about the studies referred to as a number of specific study designs are eligible for inclusion.
10 March 2014	New citation required but conclusions have not changed	Change in authorship and additional details provided in Characteristics of excluded studies section

History

Protocol first published: Issue 3, 2007
 Review first published: Issue 1, 2011

Date	Event	Description
22 February 2013	New search has been performed	Searches updated in November 2012
22 February 2013	New citation required but conclusions have not changed	No new studies were identified in this update. Our conclusions remain unchanged
21 December 2009	Amended	Converted to new review format

Notes

To improve clarity the title has been changed from 'The use of the exit interview to reduce turnover amongst healthcare professionals' to 'Exit interviews to reduce turnover amongst healthcare professionals'.

Appendices

Appendix 1. Search strategies 2012

Ovid MEDLINE(R) In‐Process & Other Non‐Indexed Citations and Ovid MEDLINE(R) <1946 to Present>

1 exp Health Personnel/ or exp Health Occupations/ or Health Manpower/ or (physician? or general practitioner? or general practic$ or gp or nurs$ or dentist$ or pharmacy$ or paramedic$ or physiotherapy$ or physical therap$ or hospitalist? or medical technician? or medical technologist? or laboratory technician? or laboratory technologist? or occupational therap$).tw. (1911333)
 2 Job Satisfaction/ or "Attitude of Health Personnel"/ or Personnel Turnover/ or ((staff or employee or personnel) adj turnover).tw. or attrition.tw. (107357)
 3 Interviews as Topic/ or exit interview?.tw. or ((staff or employee or personnel) adj feedback).tw. (37405)
 4 1 and 2 and 3 (2081)

13 (exit interview? not (exit interview? adj10 (patient? or customer? or client? or student? or participant?))).ti,ab. and (employment or employee? or ((staff$ or nurse or nurses or nursing or physician? or clinician? or doctor? or practitioner? or RN or GP) adj2 (attrition or retention)) or turnover).ti,ab,hw. (39)
 14 (exit policy or exit policies or termination interview? or separation interview?).ti,ab. (8)
 15 (or/13‐14)(44)

18 RCT Filter = (754560)
 39 EPOC MEthodological Filter version 2.4 used in 2012 = (1912451)
 40 EPOC filter used in 2008 original review = (3154284)

(or/4,15 AND 18) [RCT Results = 43]

(or/4,15 and 39) [EPOC Filter 2.4 (2012) Results= 912]

(or/4,15 AND 40) [EPOC Filter (2008) Results = 284]

Embase Classic+Embase <1947 to 2012 November 05>

1 exp health care personnel/ (818592)
 2 exp medical profession/ or exp nursing as a profession/ or exp nursing career/ or exp paramedical profession/ (26290)
 3 paramedical personnel.ti,ab. (1040)
 4 ((health adj3 professional) or (health adj3 professionals) or (healthcare adj3 professional) or (healthcare adj3 professionals)).ti,ab. (60861)
 5 ((health adj3 paraprofessional) or (health adj3 paraprofessionals) or (healthcare adj3 paraprofessional) or (healthcare adj3 paraprofessionals)).ti,ab. (76)
 6 or/1‐5 (866438)
 7 exp job satisfaction/ (20263)
 8 exp health personnel attitude/ (121613)
 9 exp healthcare personnel management/ or personnel management/ (48753)
 10 (turnover or attrition).ti,ab. (92561)
 11 or/7‐10 (270240)
 12 exp interview/ (124716)
 13 (exit interview or exit interviews).ti,ab. (503)
 14 (employee feedback or staff feedback).ti,ab. (107)
 15 ((feedback adj3 organisation) or (feedback adj3 organization) or (feedback adj3 organisations) or (feedback adj3 organizations) or (feedback adj3 organisational) or (feedback adj3 organizational)).ti,ab. (109)
 16 ((organisational adj3 feedback) or (organizational adj3 feedback)).ti,ab. (31)
 17 or/12‐16 (125159)
 18 6 and 11 and 17 (4199)
 19 limit 18 to (human and embase) (1365)

22 ((exit interview? not (exit interview? adj10 (patient? or customer? or client? or student? or participant?))).ti,ab. and (employment or employee? or ((staff$ or nurse or nurses or nursing or physician? or clinician? or doctor? or practitioner? or RN or GP) adj2 (attrition or retention)) or turnover).ti,ab,hw.) or (exit policy or exit policies or termination interview? or separation interview?).ti,ab. (50)
 23 22 not 20 [Results identified by new terms 2012] (48)

(19 or 22) AND RCT filter results = 59
 (19 or 22) AND EPOC Filter 2.4 (2012) results=244

Cochrane Central Register of Controlled Trials, Wiley

Search Name:Exit Interview 2012
 Date Run:06/11/12 20:26:34.822
 
 #1MeSH descriptor: [Health Personnel] explode all trees 4609
 #2MeSH descriptor: [Health Occupations] explode all trees 13898
 #3MeSH descriptor: [Health Manpower] this term only 10
 #4"paramedical personnel" or paramedic 352
 #5(health* near/3 professional*) or (health* near/3 paraprofessional*) 3324
 #6#1 or #2 or #3 or #4 or #5 20230
 #7MeSH descriptor: [Job Satisfaction] this term only 144
 #8MeSH descriptor: [Attitude of Health Personnel] this term only 1202
 #9MeSH descriptor: [Personnel Turnover] this term only 18
 #10"job satisfaction":ti,ab 100
 #11turnover:ti,ab 2325
 #12attrition:ti,ab 787
 #13#7 or #8 or #9 or #10 or #11 or #12 4449
 #14MeSH descriptor: [Interviews as Topic] this term only 1095
 #15"exit interview*":ti,ab 65
 #16(feedback near/3 organisation*) or (feedback near/3 organization*) 29
 #17"employee feedback" or "staff feedback" 9
 #18#14 or #15 or #16 or #17 1185
 #19#6 and #13 and #18 26
 #20#19 to 2010 24
 #21#19 not #20 2 [1 was SR by authors; 1 trial

PsycINFO <1806 to October Week 5 2012

1 ((feedback adj3 organisation$) or (feedback adj3 organization$) or (exit interview$ or "staff feedback" or "employee feedback")).ti,ab,id. or ("interviews" or "job applicant interviews").hw. (7655)
 2 (attrition or turnover).ti,ab. or ("employee turnover" or "work (attitudes toward)" or "employee attitudes" or "job satisfaction").hw. (38325)
 3 employee turnover/ (3153)
 4 or/2‐3 (38325)
 5 "paramedical personnel".id. or ("health personnel" or "allied health personnel" or "occupational therapists" or "physical therapists" or "psychiatric aides" or "speech therapists" or "medical personnel" or "dentists" or "military medical personnel" or "nurses" or "psychiatric nurses" or "public health service nurses" or "school nurses" or "optometrists" or "pharmacists" or "physicians" or "family physicians" or "general practitioners" or "gynecologists" or "internists" or "neurologists" or "obstetricians" or "pathologists" or "pediatricians" or "psychiatrists" or "surgeons" or "psychiatric hospital staff" or "mental health personnel" or "clinical psychologists" or "psychiatric social workers" or "psychotherapists" or "hypnotherapists" or "psychoanalysts" or "school psychologists").hw. or ((health$ adj3 professional$) or (health$ adj3 paraprofessional$)).id. (98001)
 6 health personnel/ or exp allied health personnel/ or exp medical personnel/ or exp mental health personnel/ or counselors/ or home care personnel/ (98144)
 7 or/5‐6 (103537)
 8 and/1,4,7 (9)
 9 limit 8 to yr="1860 ‐ 2009" (8)
 10 8 and (18$ or 19$ or 200$ or "2010901").up. [Identifies citations added to database up to Sept 1‐2010] (8)
 11 9 or 10 [Results identified up to Sept 2010] (8)
 12 8 not 11 [Results for Nov 5, 2012 update search] (1)

CINAHL, EbscoHost, 1980‐

Set #	Search Query	Results
1	(MH "Health Personnel+")	282,141
2	(MH "Health Occupations+")	377,682
3	(MH "Health Manpower+")	286,930
4	(MH "Allied Health Personnel")	1,771
5	TI health* N3 professional* OR AB health* N3 professional*	28,607
6	TI health* N3 paraprofessional* OR AB health* N3 paraprofessional*	48
7	S1 or S2 or S3 or S4 or S5 or S6	634,478
8	(MH "Job Satisfaction+")	20,173
9	(MH "Attitude of Health Personnel+")	42,029
10	(MH "Employee Attitudes")	1,656
11	(MH "Personnel Turnover")	2,297
12	(MH "Personnel Retention")	5,800
13	TI "job satisfaction" OR AB "job satisfaction"	3,386
14	TI attrition OR AB attrition	1,552
15	TI turnover OR AB turnover	3,397
16	S8 or S9 or S10 or S11 or S12 or S13 or S14 or S15	70,150
17	(MH "Job Interviews+")	1,303
18	(MH "Employment Termination")	3,921
19	TI "exit interviews" OR AB "exit interviews"	104
20	TI ( ("employee feedback" or "staff feedback") ) OR AB ( ("employee feedback" or "staff feedback") )	41
21	TI ( (feedback N3 organisation* or feedback N3 organization* ) ) OR AB ( (feedback N3 organisation* or feedback N3 organization* ) )	40
22	S17 or S18 or S19 or S20 or S21	5,369
23	S22 and S16 and S7	256
24	S23	204
25	S23 not S24	52
26	( TI ( (exit interview? not (exit interview? N10 (patient? or customer? or client? or student? or participant?))) ) OR AB ( (exit interview? not (exit interview? N10 (patient? or customer? or client? or student? or participant?))) ) ) AND ( TI ( (employment or employee? or ((staff* or nurse or nurses or nursing or physician? or clinician? or doctor? or practitioner? or RN or GP) N2 (attrition or retention)) or turnover) ) OR AB ( (employment or employee? or ((staff* or nurse or nurses or nursing or physician? or clinician? or doctor? or practitioner? or RN or GP) N2 (attrition or retention)) or turnover) ) OR MW ( (employment or employee? or ((staff* or nurse or nurses or nursing or physician? or clinician? or doctor? or practitioner? or RN or GP) N2 (attrition or retention)) or turnover) ) )	15
27	TI ( (exit policy or exit policies or termination interview? or separation interview?) ) OR AB ( (exit policy or exit policies or termination interview? or separation interview?) )
28	S26 or S27	41
29	S28 not S24	36
	( S25 OR S29 ) AND 38 [RCT FIlter Results]	0
	( S25 OR S29 ) AND S63 [Results of EPOC Filter]	22

Appendix 2. Search filters

Cochrane RCT Filter 6.4.d Sens/Precision Maximizing, used in 2012 [MEDLINE]

16 (randomized controlled trial or controlled clinical trial).pt. or randomized.ab. or placebo.ab. or clinical trials as topic.sh. or randomly.ab. or trial.ti. (816489)
 17 exp animals/ not humans.sh. (3799732)
 18 16 not 17 (754560)

EPOC FIlter 2.4, used in 2012 [MEDLINE]

19 intervention?.ti. or (intervention? adj6 (clinician? or collaborat$ or community or complex or DESIGN$ or doctor? or educational or family doctor? or family physician? or family practitioner? or financial or GP or general practice? or hospital? or impact? or improv$ or individuali?e? or individuali?ing or interdisciplin$ or multicomponent or multi‐component or multidisciplin$ or multi‐disciplin$ or multifacet$ or multi‐facet$ or multimodal$ or multi‐modal$ or personali?e? or personali?ing or pharmacies or pharmacist? or pharmacy or physician? or practitioner? or prescrib$ or prescription? or primary care or professional$ or provider? or regulatory or regulatory or tailor$ or target$ or team$ or usual care)).ab. (136617)
 20 (pre‐intervention? or preintervention? or "pre intervention?" or post‐intervention? or postintervention? or "post intervention?").ti,ab. [added 2.4] (7946)
 21 (hospital$ or patient?).hw. and (study or studies or care or health$ or practitioner? or provider? or physician? or nurse? or nursing or doctor?).ti,hw. (667647)
 22 demonstration project?.ti,ab. (1790)
 23 (pre‐post or "pre test$" or pretest$ or posttest$ or "post test$" or (pre adj5 post)).ti,ab. (55909)
 24 (pre‐workshop or post‐workshop or (before adj3 workshop) or (after adj3 workshop)).ti,ab. (510)
 25 trial.ti. or ((study adj3 aim?) or "our study").ab. (530502)
 26 (before adj10 (after or during)).ti,ab. (326569)
 27 ("quasi‐experiment$" or quasiexperiment$ or "quasi random$" or quasirandom$ or "quasi control$" or quasicontrol$ or ((quasi$ or experimental) adj3 (method$ or study or trial or design$))).ti,ab,hw. (91812)
 28 ("time series" adj2 interrupt$).ti,ab,hw. (784)
 29 (time points adj3 (over or multiple or three or four or five or six or seven or eight or nine or ten or eleven or twelve or month$ or hour? or day? or "more than")).ab. (7432)
 30 pilot.ti. (34085)
 31 Pilot projects/ (74131)
 32 (clinical trial or controlled clinical trial or multicenter study).pt. (593081)
 33 (multicentre or multicenter or multi‐centre or multi‐center).ti. (25174)
 34 random$.ti,ab. or controlled.ti. (666896)
 35 (control adj3 (area or cohort? or compare? or condition or design or group? or intervention? or participant? or study)).ab. not (controlled clinical trial or randomized controlled trial).pt. (362491)
 36 "comment on".cm. or review.ti,pt. or randomized controlled trial.pt. (2686775)
 37 (rat or rats or cow or cows or chicken? or horse or horses or mice or mouse or bovine or animal?).ti. (1286132)
 38 exp animals/ not humans.sh. (3799732)
 39 (or/19‐35) not (or/36‐38) [EPOC Methods Filter 2.4 Medline] (1912451)

EPOC Filter, used in 2008 [MEDLINE]

17 Randomized Controlled Trial.pt. (247715)
 18 random$.tw. (395118)
 19 control$.tw. (1609905)
 20 intervention$.tw. (276149)
 21 evaluat$.tw. (1276609)
 22 or/17‐21 (3016872)
 23 16 and 22 (389)
 24 animal/ (4175942)
 25 human/ (10063227)
 26 24 not (24 and 25) (3154284)

RCT Filter, used in 2012 [EMBASE]

24 controlled clinical trial/ or controlled study/ or randomized controlled trial/ [EM] (3977116)
 25 (book or conference paper or editorial or letter or review).pt. not randomized controlled trial/ [Per BMJ Clinical Evidence filter] (3834480)
 26 (random sampl$ or random digit$ or random effect$ or random survey or random regression).ti,ab. not randomized controlled trial/ [Per BMJ Clinical Evidence filter] (47318)
 27 (animal$ not human$).sh,hw. (3770394)
 28 24 not (or/25‐27) [Trial filter per BMJ CLinical Evidence] (2609939)

EPOC Filter 2.4, used in 2012 [EMBASE]

29 intervention?.ti. or (intervention? adj6 (clinician? or collaborat$ or community or complex or DESIGN$ or doctor? or educational or family doctor? or family physician? or family practitioner? or financial or GP or general practice? or hospital? or impact? or improv$ or individuali?e? or individuali?ing or interdisciplin$ or multicomponent or multi‐component or multidisciplin$ or multi‐disciplin$ or multifacet$ or multi‐facet$ or multimodal$ or multi‐modal$ or personali?e? or personali?ing or pharmacies or pharmacist? or pharmacy or physician? or practitioner? or prescrib$ or prescription? or primary care or professional$ or provider? or regulatory or regulatory or tailor$ or target$ or team$ or usual care)).ab. (175478)
 30 (pre‐intervention? or preintervention? or "pre intervention?" or post‐intervention? or postintervention? or "post intervention?").ti,ab. [added 2.4] (10263)
 31 (hospital$ or patient?).hw. and (study or studies or care or health$ or practitioner? or provider? or physician? or nurse? or nursing or doctor?).ti,hw. (1446058)
 32 demonstration project?.ti,ab. (2222)
 33 (pre‐post or "pre test$" or pretest$ or posttest$ or "post test$" or (pre adj5 post)).ti,ab. (80475)
 34 (pre‐workshop or post‐workshop or (before adj3 workshop) or (after adj3 workshop)).ti,ab. (682)
 35 trial.ti. or ((study adj3 aim?) or "our study").ab. (726079)
 36 (before adj10 (after or during)).ti,ab. (439257)
 37 (time points adj3 (over or multiple or three or four or five or six or seven or eight or nine or ten or eleven or twelve or month$ or hour? or day? or "more than")).ab. (9915)
 38 pilot.ti. (44167)
 39 (multicentre or multicenter or multi‐centre or multi‐center).ti. (34511)
 40 random$.ti,ab. or controlled.ti. (841341)
 41 review.ti. (286195)
 42 (animal$ not human$).sh,hw. (3770394)
 43 *experimental design/ or *pilot study/ or quasi experimental study/ (5351)
 44 ("quasi‐experiment$" or quasiexperiment$ or "quasi random$" or quasirandom$ or "quasi control$" or quasicontrol$ or ((quasi$ or experimental) adj3 (method$ or study or trial or design$))).ti,ab. (119948)
 45 ("time series" adj2 interrupt$).ti,ab. (911)
 46 (or/29‐40,43‐45) not (or/41‐42) [EPOC Methods Filter 2.4 EMBASE] (2982542)

CINAHL EPOC FIlter 2012

S63	S39 or S40 or S41 or S42 or S43 or S44 or S45 or S46 or S47 or S48 or S49 or S50 or S51 or S52 or S53 or S54 or S55 or S56 or S57 or S58 or S59 or S60 or S61 or S62	379,243
S62	TI ( (time points n3 over) or (time points n3 multiple) or (time points n3 three) or (time points n3 four) or (time points n3 five) or (time points n3 six) or (time points n3 seven) or (time points n3 eight) or (time points n3 nine) or (time points n3 ten) or (time points n3 eleven) or (time points n3 twelve) or (time points n3 month*) or (time points n3 hour*) or (time points n3 day*) or (time points n3 "more than") ) or AB ( (time points n3 over) or (time points n3 multiple) or (time points n3 three) or (time points n3 four) or (time points n3 five) or (time points n3 six) or (time points n3 seven) or (time points n3 eight) or (time points n3 nine) or (time points n3 ten) or (time points n3 eleven) or (time points n3 twelve) or (time points n3 month*) or (time points n3 hour*) or (time points n3 day*) or (time points n3 "more than") )	1,347
S61	TI ( (control w3 area) or (control w3 cohort*) or (control w3 compar*) or (control w3 condition) or (control w3 group*) or (control w3 intervention*) or (control w3 participant*) or (control w3 study) ) or AB ( (control w3 area) or (control w3 cohort*) or (control w3 compar*) or (control w3 condition) or (control w3 group*) or (control w3 intervention*) or (control w3 participant*) or (control w3 study) )	41,234
S60	TI ( multicentre or multicenter or multi‐centre or multi‐center ) or AB random*	88,312
S59	TI random* OR controlled	30,013
S58	TI ( trial or (study n3 aim) or "our study" ) or AB ( (study n3 aim) or "our study" )	73,438
S57	TI ( pre‐workshop or preworkshop or post‐workshop or postworkshop or (before n3 workshop) or (after n3 workshop) ) or AB ( pre‐workshop or preworkshop or post‐workshop or postworkshop or (before n3 workshop) or (after n3 workshop) )	283
S56	TI ( demonstration project OR demonstration projects OR preimplement* or pre‐implement* or post‐implement* or postimplement* ) or AB ( demonstration project OR demonstration projects OR preimplement* or pre‐implement* or post‐implement* or postimplement* )	1,191
S55	(intervention n6 clinician*) or (intervention n6 community) or (intervention n6 complex) or (intervention n6 design*) or (intervention n6 doctor*) or (intervention n6 educational) or (intervention n6 family doctor*) or (intervention n6 family physician*) or (intervention n6 family practitioner*) or (intervention n6 financial) or (intervention n6 GP) or (intervention n6 general practice*) Or (intervention n6 hospital*) or (intervention n6 impact*) Or (intervention n6 improv*) or (intervention n6 individualize*) Or (intervention n6 individualise*) or (intervention n6 individualizing) or (intervention n6 individualising) or (intervention n6 interdisciplin*) or (intervention n6 multicomponent) or (intervention n6 multi‐component) or (intervention n6 multidisciplin*) or (intervention n6 multi‐disciplin*) or (intervention n6 multifacet*) or (intervention n6 multi‐facet*) or (intervention n6 multimodal*) or (intervention n6 multi‐modal*) or (intervention n6 personalize*) or(intervention n6 personalise*) or (intervention n6 personalizing) or (intervention n6 personalising) or (intervention n6 pharmaci*) or (intervention n6 pharmacist*) or (intervention n6 pharmacy) or (intervention n6 physician*) or (intervention n6 practitioner*) Or (intervention n6 prescrib*) or (intervention n6 prescription*) or (intervention n6 primary care) or (intervention n6 professional*) or (intervention* n6 provider*) or (intervention* n6 regulatory) or (intervention n6 regulatory) or (intervention n6 tailor*) or (intervention n6 target*) or (intervention n6 team*) or (intervention n6 usual care)	36,648
S54	TI ( collaborativ* or collaboration* or tailored or personalised or personalized ) or AB ( collaborativ* or collaboration* or tailored or personalised or personalized )	33,761
S53	TI pilot	10,293
S52	(MH "Pilot Studies")	26,572
S51	AB "before‐and‐after"	15,296
S50	AB time series	1,570
S49	TI time series	218
S48	AB ( before* n10 during or before n10 after ) or AU ( before* n10 during or before n10 after )	29,013
S47	TI ( (time point*) or (period* n4 interrupted) or (period* n4 multiple) or (period* n4 time) or (period* n4 various) or (period* n4 varying) or (period* n4 week*) or (period* n4 month*) or (period* n4 year*) ) or AB ( (time point*) or (period* n4 interrupted) or (period* n4 multiple) or (period* n4 time) or (period* n4 various) or (period* n4 varying) or (period* n4 week*) or (period* n4 month*) or (period* n4 year*) )	44,180
S46	TI ( ( quasi‐experiment* or quasiexperiment* or quasi‐random* or quasirandom* or quasi control* or quasicontrol* or quasi* W3 method* or quasi* W3 study or quasi* W3 studies or quasi* W3 trial or quasi* W3 design* or experimental W3 method* or experimental W3 study or experimental W3 studies or experimental W3 trial or experimental W3 design* ) ) or AB ( ( quasi‐experiment* or quasiexperiment* or quasi‐random* or quasirandom* or quasi control* or quasicontrol* or quasi* W3 method* or quasi* W3 study or quasi* W3 studies or quasi* W3 trial or quasi* W3 design* or experimental W3 method* or experimental W3 study or experimental W3 studies or experimental W3 trial or experimental W3 design* ) )	10,891
S45	TI pre w7 post or AB pre w7 post	8,019
S44	MH "Multiple Time Series" or MH "Time Series"	1,201
S43	TI ( (comparative N2 study) or (comparative N2 studies) or evaluation study or evaluation studies ) or AB ( (comparative N2 study) or (comparative N2 studies) or evaluation study or evaluation studies )	9,402
S42	MH Experimental Studies or Community Trials or Community Trials or Pretest‐Posttest Design + or Quasi‐Experimental Studies + Pilot Studies or Policy Studies + Multicenter Studies	30,735
S41	TI ( pre‐test* or pretest* or posttest* or post‐test* ) or AB ( pre‐test* or pretest* or posttest* or "post test* ) OR TI ( preimplement*" or pre‐implement* ) or AB ( pre‐implement* or preimplement* )	6,201
S40	TI ( intervention* or multiintervention* or multi‐intervention* or postintervention* or post‐intervention* or preintervention* or pre‐intervention* ) or AB ( intervention* or multiintervention* or multi‐intervention* or postintervention* or post‐intervention* or preintervention* or pre‐intervention* )	131,711
S39	(MH "Quasi‐Experimental Studies")	5,248

CINAHL Trial Filter 2012

S38	S30 OR S31 OR S32 OR S33 OR S34 OR S35 OR S36 OR S37	136,932
S37	TI controlled AND TI ( trial or trials or study or experiment* or intervention )	15,778
S36	AB ( (multicent* n2 design*) or (multicent* n2 study) or (multicent* n2 studies) or (multicent* n2 trial*) ) or AB ( (multi‐cent* n2 design*) or (multi‐cent* n2 study) or (multi‐cent* n2 studies) or (multi‐cent* n2 trial*) )	5,848
S35	TI multicentre or multicenter or multi‐centre or multi‐center	3,854
S34	TI ( cluster N2 trial* or cluster N2 study or cluster N2 group or cluster N2 groups or cluster N2 cohort or cluster N2 design or cluster N2 experiment* ) OR AB ( cluster N2 trial* or cluster N2 study or cluster N2 group or cluster N2 groups or cluster N2 cohort or cluster N2 design or cluster N2 experiment* )	1,441
S33	TI ( control group or control groups OR control* experiment* or control* design or controlled study ) OR AB ( control group OR control groups or control* cohort* or controlled experiment* controlled design or controlled study)	44,562
S32	TI random* or AB random*	97,366
S31	TI ( “clinical study” or “clinical studies” ) or AB ( “clinical study” or “clinical studies” )	6,281
S30	(MM "Clinical Trials+")	7,527

Appendix 3. Search strategies 2007

Cochrane Library (Issue 4 2007)

Search conducted 01/11/07 (12 results)

 

#1 MeSH descriptor Health Personnel explode all trees

#2 MeSH descriptor Health Occupations explode all trees

#3 MeSH descriptor Health Manpower, this term only

#4 (paramedical personnel)    #5 (health* near/3 professional*) or (health* near/3 paraprofessional*)

#6 (#1 OR #2 OR #3 OR #4 OR #5)

#7 MeSH descriptor Job Satisfaction, this term only

#8 MeSH descriptor Attitude of Health Personnel, this term only

#9 MeSH descriptor Personnel Turnover, this term only

#10 “job satisfaction”:ti or “job satisfaction”.:ab

#11 turnover :ab or turnover:ti

#12 (attrition):ab and (attrition):ti

#13 ( #7 OR #8 OR OR #9 OR #10 OR #11 OR #12)

#14 MeSH descriptor Interviews, this term only

#15 (exit interview*):ab or (exit interview*):ti

#16 (feedback near/3 organisation*) or (feedback near/3 organization*)

#17 “employee feedback” or “staff feedback”

#18 (#14 OR #15 OR #16 OR #17)

#19 (#6 AND #13 AND #18)

OVID Medline (1950 – October week 4)

Search conducted 01/11/07

 

1     exp Health Personnel/

2     exp Health Occupations/

3     Health Manpower/

4     paramedical personnel.mp. [mp=title, original title, abstract, name of substance word, subject heading word]

5     health$ adj3 (professional$ or paraprofessional$)

6     1 or 2 or 3 or 4 or 5

7     Job Satisfaction/

8     "job satisfaction".ab,ti.

9     "Attitude of Health Personnel"/

10     Personnel Turnover/

11     turnover.mp.

12     attrition.ab,ti.

13     7 or 8 or 9 or 10 or 11 or 12

14     Interviews/

15     "exit interview$".mp. [mp=title, original title, abstract, name of substance word, subject heading word]

16     (feedback adj3 (organisation$ or organization$)).mp. [mp=title, original title, abstract, name of substance word, subject heading word]

17     "employee feedback".mp. [mp=title, original title, abstract, name of substance word, subject heading word]

18     "staff feedback".mp. [mp=title, original title, abstract, name of substance word, subject heading word]

19     14 or 15 or 16 or 17 or 18

20     6 and 13 and 19 (1078)

CINAHL via EbscoHost

Search conducted 01/11/07

S23	( S22 and S16 and S7 )
S22	( S21 or S20 or S19 or S18 or S17 )
S21	feedback N3 organisation* or feedback N3 organization*
S20	"employee feedback" or "staff feedback"
S19	"exit interviews"
S18	(MH "Employment Termination")
S17	(MH "Job Interviews+")
S16	( S15 or S14 or S13 or S12 or S11 or S10 or S9 or S8 )
S15	AB turnover or TI turnover
S14	AB attrition or TI attrition
S13	"job satisfaction"
S12	(MH "Personnel Retention")
S11	(MH "Personnel Turnover")
S10	(MH "Employee Attitudes")
S9	(MH "Attitude of Health Personnel+")
S8	(MH "Job Satisfaction+")
S7	( S6 or S5 or S4 or S3 or S2 or S1 )
S6	health* N3 paraprofessional*
S5	health* N3 professional*
S4	"paramedical personnel"
S3	(MH "Health Manpower+")
S2	(MH "Health Occupations+")
S1	(MH "Health Personnel+")

 

PsycInfo (CSA) (1806 – present)

Search conducted  1/11/07

 

((KW=((feedback within 3 organisation*) or (feedback within 3 organization*))) or (KW=((exit interview*) or ("staff feedback") or ("employee feedback"))) or (DE=("interviews" or "job applicant interviews"))) and ((TI=(attrition or turnover) or AB=(attrition or turnover)) or (DE="employee turnover") or (DE=("work attitudes toward")) or (DE=("employee attitudes" or "job satisfaction"))) and (("paramedical

personnel") or ((DE=("health personnel" or "allied health personnel" or "occupational therapists" or "physical therapists" or "psychiatric aides" or "speech therapists" or "medical personnel" or "dentists" or "military medical personnel" or "nurses" or "psychiatric nurses" or "public health service nurses" or "school nurses" or "optometrists" or "pharmacists" or "physicians" or "family physicians" or "general practitioners" or "gynecologists" or "internists" or "neurologists" or "obstetricians" or "pathologists" or "pediatricians" or "psychiatrists" or "surgeons" or "psychiatric hospital staff" or "mental health personnel" or "clinical psychologists" or "psychiatric social workers" or "psychotherapists" or "hypnotherapists" or "psychoanalysts" or "school psychologists")) or

((health* within 3 professional*) or (health* within 3 paraprofessional*))))

Embase.com 1974 – present

Search conducted 02/11/07

 

#1.  'health care personnel'/exp      

#2.  'medical profession'/exp OR 'nursing as a profession’/exp

      OR 'nursing career'/exp OR 'paramedical profession’/exp

 #3.  'paramedical personnel':ab,ti                             

#4.  'health *3 professional':ab,ti OR 'health *3 professionals’:ab,ti     

      OR 'healthcare *3 professional':ab,ti OR 'healthcare *3 professionals':ab,ti

 #5.  'health *3 paraprofessional':ab,ti OR 'health *3 paraprofessionals':ab,ti OR 'healthcare *3 paraprofessional':ab,ti OR 'healthcare *3 paraprofessionals’:ab,t

 #6.  #1 OR #2 OR #3 OR #4 OR #5                           

#7.  'job satisfaction'/exp

#8.  'health personnel attitude'/exp

#9.  'health care personnel management'/exp OR 'personnel management'/de      

#10. turnover:ab,ti OR attrition:ab,ti                      

#11. #7 OR #8 OR #9 OR #10                                  

#12. 'interview'/exp

#13. 'exit interview':ab,ti OR 'exit interviews':ab,ti         

#14. 'employee feedback':ab,ti OR 'staff feedback':ab,ti        

 #16. 'feedback *3 organisation':ab,ti,ab,ti OR 'feedback *3 organization':ab,ti,ab,ti OR 'feedback *3 organisations':ab,ti,ab,ti OR 'feedback *3 organizations':ab,ti,ab,ti 

 OR 'feedback *3 organisational':ab,ti OR 'feedback *3 organizational':ab,ti

 #17. 'organisational *3 feedback':ab,ti OR 'organizational *3 feedback':ab,ti         

 #18. #12 OR #13 OR #14 OR #16 OR #17                      

#19. #6 AND #11 AND #18                                        

#20. #6 AND #11 AND #18 AND [humans]/lim AND [embase]/lim       

Appendix 4. Criteria for judging sources of bias

1. Was the allocation sequence randomly generated?

Yes, low risk of bias.
 A random (unpredictable) assignment sequence. Examples of adequate methods of sequence generation are computer‐generated random sequence, coin toss (for studies with two groups), rolling a dice (for studies with two or more groups), drawing of balls of different colours, dealing previously shuffled cards.

No, high risk of bias.
 ‐ Quasi‐randomised approach: examples of inadequate methods are alternation, birth date, social insurance/security number, date in which they are invited to participate in the study, and hospital registration number.
 ‐ Non‐random approaches: allocation by judgement of the clinician; by preference of the participant; based on the results of a laboratory test or a series of tests; by availability of the intervention.

Unclear.
 Insufficient information about the sequence generation process to permit judgement.

2. Was the treatment allocation adequately concealed?

Yes, low risk of bias.
 Assignment must be generated independently by a person not responsible for determining the eligibility of the participants. This person has no information about the persons included in the trial and has no influence on the assignment sequence or on the decision about whether the person is eligible to enter the trial. Examples of adequate methods of allocation concealment are: central allocation, including telephone, web‐based and pharmacy‐controlled randomisation; sequentially numbered drug containers of identical appearance; sequentially numbered, opaque, sealed envelopes.

No, high risk of bias.
 Examples of inadequate methods of allocation concealment are: alternate medical record numbers; unsealed envelopes; date of birth; case record number; alternation or rotation; an open list of random numbers any information in the study that indicated that investigators or participants could influence the intervention group.

Unclear.
 Randomisation stated but no information on method of allocation used is available.

3. Was knowledge of the allocated interventions adequately prevented during the study?

Was the participant blinded to the intervention?

Yes, low risk of bias.
 The treatment and control groups are indistinguishable for the participants or if the participant was described as blinded and the method of blinding was described.

No, high risk of bias.
 Blinding of study participants attempted, but likely that the blinding could have been broken; participants were not blinded, and the non‐blinding of others likely to introduce bias.

Unclear.
 Insufficient information to permit judgement of 'yes' or 'no'.

Was the care provider blinded to the intervention?

Yes, low risk of bias.
 The treatment and control groups are indistinguishable for the care/treatment providers or if the care provider was described as blinded and the method of blinding was described.

No, high risk of bias.
 Blinding of care/treatment providers attempted, but likely that the blinding could have been broken; care/treatment providers were not blinded, and the non‐blinding of others likely to introduce bias.

Unclear
 Insufficient information to permit judgement of 'yes' or 'no'. 

Was the outcome assessor blinded to the intervention?

Yes, low risk of bias.
 Adequacy of blinding should be assessed for the primary outcomes. The outcome assessor was described as blinded and the method of blinding was described.

No, high risk of bias.
 No blinding or incomplete blinding, and the outcome or outcome measurement is likely to be influenced by lack of blinding.

Unclear.
 Insufficient information to permit judgement of 'yes' or 'no'. 

4. Were incomplete outcome data adequately addressed?

Was the drop‐out rate described and acceptable?

The number of participants who were included in the study but did not complete the observation period or were not included in the analysis must be described and reasons given.

Yes, low risk of bias.
 ‐ If the percentage of withdrawals and drop‐outs does not exceed 20% for short‐term follow up and 30% for long‐term follow up and does not lead to substantial bias (NB. these percentages are arbitrary, not supported by literature).
 ‐ No missing outcome data.
 ‐ Reasons for missing outcome data unlikely to be related to true outcome (for survival data, censoring unlikely to be introducing bias).
 ‐ Missing outcome data balanced in numbers across intervention groups, with similar reasons for missing data across groups.
 ‐ Missing data have been imputed using appropriate methods.

No, high risk of bias.
 Reason for missing outcome data likely to be related to true outcome, with either imbalance in numbers or reasons for missing data across intervention groups.

Unclear.
 Insufficient reporting of of attrition/exclusions to permit judgement of 'yes' or 'no'.

Were all randomised participants analysed in the group to which they were allocated? (intention to treat (ITT) analysis)

Yes, low risk of bias.
 Specifically reported by authors that ITT was undertaken and this was confirmed on study assessment, or not stated but evident from study assessment that all randomised participants are reported/analysed in the group they were allocated to for the most important time point of outcome measurement (minus missing values) irrespective of non‐compliance and co‐interventions.

No, high risk of bias.
 ‐ Lack of ITT confirmed on study assessment (patients who were randomised were not included in the analysis because they did not receive the study intervention, they withdrew from the study or were not included because of protocol violation) regardless of whether ITT reported or not.
 ‐ ‘As‐treated’ analysis done with substantial departure of the intervention received from that assigned at randomisation; potentially inappropriate application of simple imputation.

Unclear.
 Described as ITT analysis, but unable to confirm on study assessment, or not reported and unable to confirm by study assessment.

5. Are reports of the study free of suggestion of selective outcome reporting?

Yes, low risk of bias.
 If all the results from all prespecified outcomes have been adequately reported in the published report of the trial. This information is either obtained by comparing the protocol and the final trial report, or in the absence of the protocol, assessing that the published report includes enough information to make this judgment. Alternatively a judgement could be made if the trial report lists the outcomes of interest in the methods of the trial and then reports all these outcomes in the results section of the trial report.

No, high risk of bias.
 ‐ Not all of the study’s prespecified primary outcomes have been reported.
 ‐ One or more primary outcomes is reported using measurements, analysis methods or subsets of the data (e.g. subscales) that were not prespecified.
 ‐ One or more reported primary outcomes were not prespecified (unless clear justification for their reporting is provided, such as an unexpected adverse effect).
 ‐ One or more outcomes of interest in the review are reported incompletely so that they cannot be entered in a meta‐analysis.
 ‐ The study report fails to include results for a key outcome that would be expected to have been reported for such a study.

Unclear.
 Insufficient information to permit judgement of 'yes' or 'no'.

6. Other sources of potential bias

Yes, low risk of bias.
 The study appeared to be free of other sources of bias.

No, high risk of bias.

There is at least one important risk of bias. For example the study:

• used an inappropriate study design;

• was stopped early due to some data‐dependent process;

• had extreme baseline imbalances; or

• has been claimed to be fraudulent.

Unclear.
 There may be a risk of bias but there is insufficient information to permit judgement of whether other risks of bias exist.

Characteristics of studies

Characteristics of excluded studies [ordered by study ID]

Study	Reason for exclusion
Fottler 1995	Survey of nurses exiting from an American hospital. (Inclusion criteria not met so the author was not contacted)
Hawkins 2003	Survey of nurses exiting from an Australian hospital. (Inclusion criteria not met so the author was not contacted)
Kelly 1988	Survey of nurses exiting from an Australian hospital. (Inclusion criteria not met so the author was not contacted)
Melcher 1955	Survey of exiting nurses. (Inclusion criteria not met so the author was not contacted)
Moran 1956	Inclusion criteria not met so the author was not contacted.
Morrell 2007	A survey of 'leavers' from eight hospitals in England, with collection of data at one time point. (Inclusion criteria not met so the author was not contacted).
Webster 2009	In‐depth interviews with nurses exiting from an Australian hospital.
Weisman 1981	Study of reasons given by exiting nurses, plus a study comparing characteristics of remaining nurses with those leaving the organisation. (Inclusion criteria not met so the author was not contacted).

Differences between protocol and review

A number of secondary outcomes were removed. They were related to reasons for leaving (e.g. stress) rather than useful organisational outcome measures.

Contributions of authors

Anndrea L Flint (ALF) and Joan Webster (JW) prepared the protocol. JW conducted the searches for the first update. ALF and JW applied the inclusion criteria. ALF prepared the report and JW commented on and edited it. JW responded to reviewers comments.

Declarations of interest

JW and ALF authored one of the excluded studies.

Edited (no change to conclusions)