Appreciative management in healthcare and its connection with intention to work outside Estonia

. Creating an attractive workplace in healthcare is an issue many countries will try to resolve because of a global shortage of healthcare professionals. This study aimed to describe how healthcare staff in Estonia assessed appreciative management and its connection to the country and workplace in which they would choose to work outside Estonia. A quantitative descriptive study was conducted via an electronic survey among healthcare staff. Over half of the respondents (53.7%, n = 151) had no intention of leaving the workplace; over three of five (64.4%, n = 181) did not intend to leave the profession within a year. Systematic management, equality, and promotion of well-being at work were weakly connected to moving to another country. The more systematic management, equality, and promotion of well-being at work, the less the respondents considered moving. Appreciation of know-how had no statistically significant connection to considering moving to another country. In conclusion, only a few healthcare professionals were willing to leave their workplace or their profession. Appreciative management may be one issue to further promote workplace attractiveness and reduce turnover. The workplaces in healthcare are part of their country and environment, meaning their international reputation is important when one wonders where to live and work. This study implied that most of the healthcare professionals were willing to stay in their workplace and/or profession in Estonia, positively acknowledging which factor to base healthcare development on in Estonia.


INTRODUCTION
How to create an attractive workplace in healthcare is a question many countries will try to answer. A pivotal question is whether the healthcare professional stays or leaves the workplace, country, or even the profession. Could appreciative management be an answer to the ques tion?
The reason for the question is current because of the global shortage of healthcare professionals, particularly nurses and midwives, who represent over half of the current shortage of health workers [1]. Concern about the shortage of healthcare professionals has grown in many countries with the baby boomer generation of physicians and nurses retiring. Many countries have sought to resolve the shortage in numerous ways, such as by increasing the number of students in medical and nursing education programs and hiring more foreign-born doctors and nurses [2]. The COVID-19 pandemic has also increased the need for nurses as there is a greater shortage of nurses in acute care, testing, vaccination, and mental health [3]. Some countries frequently lose a part of their educated workforce. Many nurses migrate from middle-developed countries to European countries because of income dissatisfaction, inhospitable working conditions, being overworked, in sufficient resources, and the desire to provide their children with better living conditions [4]. The factors that push internationally educated nurses to migrate and influence their workforce integration are job characteristics such as being a nursing professional, organizational characteristics like their primary work setting, and the feeling that one has achieved their career goals [5]. Employees with a strong sense of affective commitment intend to stay with the organization. This commitment arises when the committed person feels for, identifies with, and feels psychologically connected to their peers, superiors working with them, and the employer organization [6]. Several factors promoting job retention and commitment to work have been reported as part of appreciative management, such as systematic management, equality, appreciation of competence, and promotion of well-being at work. These are the four main categories of appreciative management. The concept of appreciative management has been developed by means of the stories of future management written by students and young nurses [7].
Systematic management consists of goal-oriented management, professional management, justice management, motivated management, and the criticality of a manager's management skills [8]. Studies have found that working with the nearest manager is meaningful for ma nag ing the workday [9]. Staffing and resource ad equacy are critical in clinical nurses' satisfaction [10]. In an inter national study, inadequate staffing significantly predicted absenteeism and the intent to leave [11].
Equality includes caring for employees' rights, accepting an employee for who they are, dividing work equally, and facilitating equality among different ages [8]. Taking care of employees' rights in countries like Finland, firstline nurse managers consider decision-making centralized and regulated, depending on the organization. Finnish healthcare organizations/workplaces are heavily influenced by law and the organizations' rules and instructions [12]. For integration of native-and foreign-born populations, a study found that workplaces seem crucial for diversity and interethnic friendship formation. Workplace diversity is also more strongly associated with the likelihood of hav ing immigrant friends than neighborhood diversity [13]. Being respected among physicians and colleagues and feeling comfortable asking questions and supporting each other in a workplace/workgroup increased work motiva tion and made it easier to solve challenging situ ations, develop thorough new knowledge, and learn independ ently during daily work or with other registered nurses [14].
Appreciating know-how encompasses rewarding work, corresponding with the professional skills of a newly graduated employee, and the independence of staff [8]. Professional autonomy has been seen as an essential part of an attractive work environment, enabling nurses to participate in decision-making and the planning and development of nursing through shared leadership to enhance recruiting and retaining a skilled workforce [15]. Lack of autonomy at work seems to be a factor causing nurses to become unsatisfied and consider leaving [16]. Developing competencies, continuously learning challenging and varied work tasks, social relations, the supervisor's behavior regarding reciprocal flexibility concerning timetables and working hours, and a good work-life balance are central desires for millennials, who expect their leader to be their coach [17].
Promoting well-being at work means considering working time preferences, health considerations in shift planning, flexible shift arrangements, good working conditions, and listening to employees' expectations and opinions concerning work [8]. Comfortable communication between nurses and managers is a foundation for workplace well-being. Nurses are more satisfied with the comfortable communication of their concerns to managers and the importance their managers attach to them [10]. Nurses hope for a good work-life balance and flexible work shifts. Today, work shifts are commonly 12 hours or even longer, which reduces nurses' work satis faction and increases burnout [18].
Although Estonian health professionals have been migrating for decades, especially to the Northern countries, the attractiveness of their Estonian workplace and the connection between appreciative management and choosing a country or a workplace has not been studied before. This study aimed to describe how healthcare staff in Estonia assessed appreciative management and its connection to the country and workplace in which they would choose to work outside Estonia.

Study design
The study was conducted as a cross-sectional study.

Study instrument
The AMS (Appreciative Management Scale) 2.0 instrument, developed by Harmoinen et al. (2021) in several phases was used in this survey [8]. The phases developed in the first version AMS 1.0 were concept analysis, systematic literature review, and essays written by young students and nurses concerning workplaces in future. A two-round Delphi study was used for assessing the statements picked up from essays by essay writers. Also, an expert panel assessed the scale used in the instrument. The instrument (AMS 1.0 with 83 items) was pretested empirically and tested by a survey in Finland. The scale was further validated by confirmatory factor analysis (CFA) using SPSS Amos 23.0 by new data.
There were also questions whether the respondent intended to leave the workplace and the profession (Likert scale 1-5, AMS 2.0) and whether they had migrated to Estonia. Other questions included what country they would like to move to and where their knowledge of the country and a workplace came from. Respondents were also asked about choosing a country and a workplace that would attract them. Reasons for choosing a country included four subcategories (16 items): the country's reputation (5); services for immigrants (3); work benefits/ laws (3); per sonal views (5). Reasons for choosing a workplace had six subcategories (23 items): evidencebased nursing (4); im migrant services in healthcare (3); professional development (3); work relationship (6); near management (4); personal reasons (3). (Table 1).
Background variables were demographic variables like gender, age, mother tongue, professional status, workplace, and working in the workplace in years and months.

Ethical aspects
This study was conducted according to published international ethical guidelines of good scientific practice [19]. The University of Tartu Research Ethics Committee granted permission for the study to be conducted in Estonian healthcare organizations (No. 332/T-4). These organizations requested permission to conduct the research in which the staff voluntarily participated.
An instruction letter outlined the study's purpose, data collection process, the voluntariness of participation, and the anonymity of participants, and provided contact information for the researcher, described the purpose the data would be used for, detailed the preserva tion and subsequent use of the data, and stated the study's completion date. Participants were assured the question naire would be answered anonymously. Participation fol lowing this information was deemed informed consent.

Pretesting, sample, and data collection
The contact persons pretested and commented on the questionnaire. Based on the comments, some minor changes were made regarding content and technical issues. The population was healthcare staff in Estonia. Data were collected by an e-questionnaire from February 1, 2021, to April 30, 2021 (recalled twice). The healthcare staff was purposefully selected from one highest-level hospital, one central-level hospital, and two healthcare centers in one geographical area of Estonia. In the highest-level hospital, anesthesiology, psychiatric and internal medi cine clinics were included. In the central-level hospital and in healthcare centers, all clinics were included. In order to maintain anonymity, the total number of staff employed by these institutions was not disclosed. The contact per sons in each four healthcare institutions (n = 4) forwarded the researcher's email with the intro duction and the link to the survey directly to the staff in smaller collectives and to the heads and head nurses in larger collectives, who in turn forwarded the email to their staff. In total, the contact persons sent out 560 emails in the three clinics of the highest-level hospital, 107 emails in the central-level hospital and 48 emails in healthcare centers. In addition, one hospital had the possibility of accessing the link to this study on the staff's intranet. All the healthcare workers to whom an email link to the survey was sent had a possibility to answer it.

Data analysis
SPSS 27.0 analyzed the data. The data were imputed so that not one respondent was lost. Descriptive statisticsincluding frequencies, percentages, and means -analyzed background variables and components examining appreciative management. There were 12 average sum variables formed according to the main categories and subcategories of AMS 2.0 as well as the reasons for choosing a country and a workplace. Cronbach's alpha examined the internal consistency.
Correlations compared the connections among background variables and average sum variables (Pearson). Correlations also compared the connections among appreciative management and the reasons for choosing a country and a workplace. Connection among variables was assessed as weak if the correlation grade was < 0.3, moderate if between 0.3 and 0.7, and strong if > 0.7.

Respondents of the survey
Altogether, 281 respondents participated in this survey. Most were women in a permanent relationship who had dependent children. Most spoke Estonian as their native language. The biggest professional group was nurses from different levels (57.3%, n = 161), then physicians (14.6%, n = 41), and finally primary nurses (8.5%, n = 24). Most respondents worked in the highest-level hospital (34.5%, n = 148). Most respondents had worked in their workplace for 6-10 years (31.6%, n = 232), followed by 11-20 years (27.1%, n = 199). Those who had worked in the present workplace for less than a year numbered 14 (1.9%).

Intention to leave the workplace and profession
The intention not to leave the workplace at all within a year was over half (53.7%, n = 151), much intention to leave (6.0%, n = 17), and very much (6.8%, n = 19). The level was the same the next year (6.0%, n = 17 and 4.6%, n = 13). Within the next five years, there was much intention to leave; within the next ten years, there was much (10.7%, n = 30) or very much intention to leave (12.8%, n = 36).
The intention not to leave the profession within a year was almost two-thirds (64.4%, n = 181). Those who had much (3.6%, n = 10) or very much intention to leave were scant (3.9%, n = 11). The numbers were almost equal regarding much and very much intention to leave within the next year (3.2%, n = 9 and 2.8%, n = 8) but bigger within the next five years (6.8%, n = 19 and 7.5%, n = 21).
Finland was the preferred country where the respondents would move for work, followed by Sweden and Norway. Knowledge about the country was mostly received from friends or mates, who received their information from official websites, regarded as the best information source. The most important way to obtain knowledge about a workplace was based on personal views, which was also the most important reason for choosing a workplace (41.3%, n = 116).

Reasons for choosing a country and a workplace
The most noteworthy reason for choosing a country was the high quality of social welfare and public health services of the destination country, followed by the income level and safety that surpassed those of the departure country ( Table 1).
The most noteworthy reason for choosing a workplace was the fluency of multi-professional cooperation, followed by low hierarchy, appropriate workload ratio to the number of staff, and an existing desire to work in that workplace ( Table 1).

The connections between appreciative management and the choice of the country and workplace
Systematic management, equality and its subcategories as well as the promotion of well-being at work were connected to considering moving to another country. Thus, the more systematic management, equality, and promotion of well-being at work there was, the less the respondents considered leaving. Appreciation of know-how had no statistically significant connection to the consideration of moving to another country.

Systematic management
Systematic management was connected to reasons for choosing a country based on its reputation. Services for immigrants were also connected.
Systematic management was connected to choosing a workplace; connections were evidence-based nursing, immigrant services in healthcare, professional devel opment, work relationship, and personal reasons ( Table 2).

Equality
Choosing a workplace in a new country based on the country's reputation was connected to overall equality and the equality between managers and workers. This equality was connected to evidence-based nursing as well as im migrant services in healthcare and equality among workers ( Table 2).
Overall equality and equality among workers were connected to professional development equality as well as near management. The equality between managers and workers was also connected to personal reasons for choosing a workplace ( Table 2).

Appreciation of know-how
Appreciation of know-how had no statistically significant connection in considering moving to another country.
There was a connection between appreciating knowhow and the chosen country's reputation, services for immigrants, and work benefits. A workplace's appreciation of know-how was connected to evidence-based nursing, immigrant services in healthcare, professional development, work relationship, near management, and personal reasons ( Table 2).

Promotion of well-being at work
Promoting well-being was connected to the consideration of moving to another country, so the more that well-being was promoted at work, the less the move was considered. A weak connection existed between promoting well-being at work and the chosen country's reputation. There were also connections between the reasons for choosing a workplace: evidence-based nursing, immigrant services in healthcare, work relationship, near management, and personal reasons ( Table 2).

DISCUSSION
This study aimed to describe how healthcare staff in Estonia assessed appreciative management and its connection to the country and workplace in which they would choose to work outside Estonia.
Most of the health professionals were willing to stay in their workplace and profession in Estonia, but if they were considering moving to another country, the most noteworthy reasons for choosing a country were the high quality of social welfare and public health services of the destination country, followed by the income level and safety that surpassed those of the departure country (Table 1). These reasons are related to pull factors that attract people, including higher wages, better employment opportunities, a higher living standard, and educational op portunities [20]. The most noteworthy reasons for choos -ing a workplace were the fluency of multi-profes sional cooperation, followed by low hierarchy, appropriate workload ratio to the number of staff, and an existing desire to work in that workplace. These results are parallel to the study of the effectiveness of strategies in creating positive work environments on nurse satisfaction, auton omy, participative management structure and support for educational/professional development. Staffing and re source adequacy play pivotal roles in clinical nurses' satisfaction and reduce leaving [10].
The results about appreciative management, reasons for choosing a workplace, and their connections to appreciative management can show light and inspire to dis -  ) ")2)3493;) !)2)343:9) ) ) ")2)343;7) !)2)34986) cuss how to develop appreciative management in a workplace. Fluent multi-professional co-operation and low hier archy (Table 1) motivate discussions about the equality between the manager and the worker and among workers. The connection, though light, between appreci ative manage ment and professional development, near management, and immigrant services in workplace (Table 2), in turn, challenges to discuss and advance managers and staff in tandem career development, management issues, and foreign workers' work conditions. Appreciative management and its main categories were connected to the chosen country's reputation ( Table 2). This finding can give new means of attracting foreign workers to the country.
In this study, respondents decided about a new workplace based also on their personal views; knowledge received from friends and mates was important. Examples of a good reputation are magnet hospitals, which are reputed to successfully recruit and retain a highly qualified nursing workforce [21]. Magnet hospitals have a less hierarchical hospital structure, where nurses have higher autonomy and influence in workplace decision-making [11]. Hospital leaders, who are regularly visible and present, encourage employees to use their voice [22]. Visibility creates familiarity between employees and their leaders, allowing trusting relationships to develop [23].
Based on the results, the respondents liked moving to the Northern countries the most, if anywhere. Nursing man agers in Finland seem to understand they must improve the attractiveness of their organizations to get new nursing workers. Nursing managers in eight Finnish specialized medical care hospitals considered attracting immigrant nurses important through shifting from hierarchical leader ship to shared governance, increasing focus on pro active and systematic work, developing evidence-based prac tices, and improving the organization's attractiveness and effectiveness [24].
Staying in the present workplace or leaving the present employer or even healthcare are pivotal questions. One earlier study done among three Western countries proved that working part-time hours, overtime, and long commuting time decreased one's intention to stay with the same employer. Also, wage-related characteristics demonstrate that low-wage employees or those with low wage satisfaction are less likely to express an intention to stay [25]. In countries where nurse wages are low, such as Finland [26] and Estonia [27], understanding that wage satisfaction is an essential part of nurses' staying in their workplace and a magnet trait to foreign staff is essential. This study's respondents received knowledge about a possible country to migrate to mostly from friends or mates. According to a study, investigating the young generation moving to and within Europe, sustainable development was found to be important to them [28].

Validity and reliability
The validity of the scale AMS 2.0 assessed before was found valid [8,29]. Based on the phases previously undertaken, AMS 2.0 can discriminate appreciative management concepts from other concepts.
The scale's internal consistency was assessed via the Cronbach alpha coefficient. Values were seen at the good or excellent level. The Cronbach's alpha of the whole scale was 0.955. The lowest value was 0.731 (appreciating know-how), and the highest was 0.929 (systematic management). Internal consistency is deemed acceptable if Cronbach's alpha levels are measured at 0.7 or higher [30]. In the studies published before [8,28], values were at the same level as in this study. Internal consistency of the average sum variables describing the reasons for choosing a country (0.839) and for choosing a workplace (0.916) were at a very good level ( Table 2).

CONCLUSIONS
Most of the healthcare professionals were willing to stay in their workplace and profession in Estonia. This observation positively acknowledges what Estonian healthcare development should be based on. Taking care of appreciative management in Estonian healthcare organizations may further promote healthcare professionals to stay working in their home country.
If a healthcare organization is known by appreciative management, it attracts new workers to choose this workplace and may encourage them to stay in this organization. Reasons to choose a workplace seem to connect lightly to ap preciative management, meaning that appreciative management may strengthen workplace attractiveness in healthcare.
By taking care of the good reputation of a country and healthcare organizations, it is possible to compete more strongly for healthcare professionals internationally, attract ing them to come and work from foreign countries.

Implications
Appreciative management may be one issue to further promote workplace attractiveness and the staff's intention to stay. Workplaces in healthcare are part of their country and environment, meaning the international reputation of all three is relevant when one is wondering where to live and work. Appreciative management education for nurs ing managers is recommended to be added to their cur ricula because appreciative management is a new manage ment model. A follow-up study on implementing appreci ative leadership and its connection to low turnover is appropriate.

Limitations
The survey was conducted during the Covid-19 pandemic, which may have reduced the number of respondents because of, e.g., the staff getting sick or, with the new demands, the staff not having the opportunity to respond to the study. Further, electronic surveys have generally had a weak response. The topic of this study may have been so new for the Estonian healthcare staff that they did not know how to relate to it.