Quiet Quitting in Emergency Health Services: A Phenomenological Study on the Experiences of Lower-Level Managers

Quiet Quitting in Emergency Health Services: A Phenomenological Study on the Experiences of Lower-Level Managers | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Quiet Quitting in Emergency Health Services: A Phenomenological Study on the Experiences of Lower-Level Managers Gülhan GÖK This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7786716/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Objective This study identified the reasons, processes, consequences, and associated situations for quiet quitting among emergency healthcare workers. It also revealed why silent resignation is preferred over real resignation. Methods The study employed a phenomenological design, a type of qualitative research design. The study group consisted of low-level managers working in emergency healthcare units. Data were collected through semi-structured interviews conducted face-to-face or by telephone. A total of 17 participants were interviewed. The data were analyzed using thematic constructive content analysis. Results The analysis identified 5 subcodes, 38 codes, 14 subthemes, and 4 themes. The findings indicated that economic reasons were the most significant factor preventing emergency healthcare workers from resigning. Individual and work-related factors were identified as the primary reasons for quiet quitting. Participants were found to have adopted various practices to prevent quiet quitting, such as being fair, assigning tasks sequentially, and selecting volunteers. It was concluded that silent resignation has various negative effects on other employees, patients, and institutions. Conclusion The study concluded that the practices adopted by lower-level managers to prevent quiet quitting were inadequate. Some employees resigned silently for various reasons, and this increased the workload of other employees, decreased their motivation, and negatively impacted the atmosphere of the work environment and the quality of patient care. It also revealed that further research is needed on quiet quitting in healthcare. Quiet Quitting Emergency Healthcare Workers Managers Healthcare Institutions Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Introduction The Covid-19 pandemic, which originated in Wuhan, China and impacted the entire world, has impacted our social lives as well as our professional lives in many ways. To prevent the spread of the virus, some businesses adopted changes such as shorter working hours and working from home, while others provided their employees with additional protective equipment and expected them to work harder [ 1 ]. Some professional groups, particularly those forced to work intensively during the pandemic, experienced burnout due to poor work-life balance [ 2 ] and sought ways to re-establish this balance [ 3 ]. Quiet Quitting (QQ), a response to the hectic work lives during the pandemic, went viral on the social media platform TikTok [ 4 ]. The concept of QQ, which has become more prominent with the pandemic, refers to performing only the tasks that are included in the job description and are required to be performed, not exceeding the job requirements, and working only enough to avoid being fired [ 5 ]. Those who engage in QQ are dissatisfied with their workplace and, instead of expressing this dissatisfaction [ 6 ], they seek alternative employment [ 7 ]. However, employees cannot always find a job they desire. Therefore, many employees tend to stay at their current place of work and fulfill their basic responsibilities without exceeding expectations, rather than resigning [ 6 ]. In underdeveloped or developing countries, factors such as lower wages than expected and lack of job security lead to QQ [ 8 ], while in developed economies, the abundance of job opportunities results in real resignation [ 9 ]. Those who engage in QQ refuse to voluntarily spend more time at work, sacrifice their social life, take on more work, or dedicate their entire lives to their work, contrary to employer expectations [ 10 ]. While there are many reasons for this refusal, it is mostly associated with the attitudes and behaviors of their managers. Today, employees seek managers who coach them, value their ideas, focus on their strengths, support their development, and maintain constant communication [ 11 ]. They want their managers to trust them and empower them [ 12 ]. Managers' failure to establish the necessary balance in task distribution, assigning additional work to employees who perform better than others while being indifferent to those who perform less [ 9 ], can result in QQ. In some cases, employees who perform poorly are rewarded for reasons such as the employee's astuteness for workplace politics [ 13 ], the manager's favoritism towards certain employees [ 14 ], or unfairness and unethical behavior [ 15 ]. This leads to social learning, which results in other employees exhibiting the same attitudes and behaviors [ 16 ]. According to Adams's (1963) "Equity Theory," employees compare their own inputs and outputs with those of others. When these comparisons do not yield results to their advantage, they doubt the manager's fairness and experience feelings of anger and tension [ 17 ]. In such situations, employees try to match their input-output ratios to those of others [ 5 ]. While those who work more are punished with additional work, less productive employees turn a blind eye and/or are rewarded, which negatively affects the motivation of other employees, reduces productivity, disrupts harmony in the work environment, reduces profitability, and poses an institutional threat [ 10 , 18 ]. Furthermore, conflicts between the goals and values ​​of employees and those ​​of organizations cause confusion in employees, reducing the sense of belonging and commitment to the organization [ 1 ]. Employees' QQ behavior can sometimes stem solely from the individual. Demographic characteristics, the employee's personality and concerns [ 18 ], feeling unvalued in the organization, not being able to establish a work-life balance, or simply not wanting to work for any reason are cited as individual reasons [ 9 ]. It has been reported that young people in particular refuse to sacrifice their personal time to spend more time at work. Young people are trying to achieve balance in their lives by moving away from the competitive work environment [ 19 , 20 ]. Some studies indicate that factors related to the work environment also lead to QQ. These studies indicate that emotional or physical fatigue resulting from work [ 21 ], workplace stress, relationships with managers, other employees, and customers, workplace culture, and workplace policies have an impact on QQ [ 18 ]. The QQ of healthcare workers has come to the fore with the Covid-19 pandemic. However, research on this topic is limited [ 22 ]. The pandemic has caused a sudden and rapid increase in demand for healthcare services [ 23 ]. Employee absence due to illness, increase in the number of patients, and implementation of additional preventative measures have further increased the workload of staff in the field, leading to fatigue [ 24 ] and burnout [ 22 ]. This has led many employees to question their expectations from work and life, and to believing that staying in a job for traditional gains such as salary, title, and promotion opportunities is meaningless [ 25 ]. Healthcare workers who cannot establish a work-life balance have exhibited QQ [ 26 ]. The labor-intensive nature of healthcare services, coupled with the impact of both the quantity and quality of care on patient outcomes, makes QQ important in the healthcare sector [ 27 ]. This study evaluated the pandemic-related QQ of emergency healthcare workers, who had to work much longer hours than those in other sectors during the pandemic. Studies in the literature have linked QQ to the attitudes and behaviors of managers [ 28 , 29 , 30 ]. Therefore, this study aimed to identify the opinions of managers of emergency healthcare workers responsible for daily activities and to uncover what they do to prevent QQ. We aimed to examine the studies in the literature from a different perspective. We aimed to determine how the pandemic affected QQ among employees working in different emergency healthcare units. Furthermore, based on the managers' experiences, we aimed to determine the causes of QQ in emergency healthcare workers working in emergency healthcare units, the managers' approach to those who engage in QQ, the consequences of QQ, and the circumstances associated with QQ. The study sought to answer the following questions: What do low-level managers in emergency healthcare units think of quiet quitting? What attitude to low-level managers in emergency healthcare units have towards their employees’ quiet quitting? Why do emergency healthcare workers not make a real resignation? Is there a link between emergency healthcare workers; quiet quitting and the pandemic? What are the consequences of emergency healthcare workers’ quiet quitting? What circumstances are associated with emergency healthcare workers’ quiet quitting? METHODOLOGY The study was designed using a qualitative approach, which helps understand the reasons behind individuals’ behavior, determine how they attribute meaning to events, and explore their perspectives on events [ 31 ]. There are different designs in the qualitative approach. Since this research focuses on participants’ experiences, a phenomenological design was used. Phenomenology is the process of revealing meanings by describing events, situations, and objects in a multifaceted and holistic manner [ 32 ]. In this design, the data source is composed of individuals or groups that can express the phenomenon [ 33 ]. The researcher examines the participant's experiences, perceptions, and how they make sense of events [ 34 ]. Study Group For the purpose of the study, individuals who had experienced the pandemic and were low-level managers in an emergency healthcare unit were selected as the study group. To investigate different characteristics related to the phenomenon under investigation, participants with varying experience levels were selected from different hospitals and stations. This approach aimed to maximize diversity. In this context, maximum diversity sampling was used [ 32 ]. The study group was selected on a voluntary basis. Furthermore, considering that relevant environmental factors would also influence the research topic, participants from different provinces and regions were selected. Descriptive information about the participants is provided in Table 1 . Table 1 Participant Descriptive Information Participants Age Gender Education Level Duration of Experience Duty Position Working During the Pandemic P1 42 Male Bachelor's Degree. 21 Years 112 Emergency Health Station Station Manager Worked P2 30 Male Bachelor's Degree. 7 Years Public Hospital Emergency Service Manager Worked P3 30 Male Associate's Degree 6 Years 112 Emergency Health Station Station Manager Worked P4 30 Female Bachelor's Degree. 10 Years Training and Research Hospital Emergency Service Manager Worked P5 35 Male Associate's Degree 16 Years Private Hospital Emergency Service Manager Worked P6 32 Male Associate's Degree 15 Years Training and Research Hospital Emergency Service Manager Worked P7 32 Female Bachelor's Degree. 13 Years Public Hospital Emergency Service Manager Worked P8 44 Female Master's Degree 24 Years Public Hospital Emergency Service Manager Worked P9 32 Male Bachelor's Degree. 12 Years 112 Emergency Health Station Station Manager Worked P10 31 Male Bachelor's Degree. 6 Years 112 Emergency Health Station Station Manager Worked P11 38 Male Bachelor's Degree. 18 Years 112 Emergency Health Station Station Manager Worked P12 37 Female Associate's Degree 15 Years 112 Emergency Health Station Station Manager Worked P13 30 Female Master's Degree 10 Years 112 Emergency Health Station Station Manager Worked P14 32 Female Associate's Degree 14 Years 112 Emergency Health Station Station Manager Worked P15 42 Female Doctoral Degree 19 Years Public Hospital Emergency Service Manager Worked P16 35 Female High’s Degree 16 Years Private Hospital Emergency Service Manager Worked P17 29 Male Doctoral Degree 4 Years Public Hospital Emergency Service Manager Worked All of the participants in the study group were working during the pandemic. Eight of them worked in emergency medical stations and nine worked in hospital emergency services. The gender distribution of the participants was nine male and eight female, and the age range was 29–44. Data Collection Tools The researcher created an interview form appropriate for the purpose of the study. The questions in the interview form were determined through a literature review. The suitability of the interview questions for the purpose of the study was evaluated by two academics. Following this evaluation, the interview form was finalized. The interview form consisted of two parts. The first part addressed demographic characteristics (age, gender, education level, duration of experience, unit, and position). The second part included seven open-ended questions. These questions are as follows: How do your subordinates handle your requests for matters outside their job descriptions, calls outside of work hours, and requests to work overtime? How do they react? What do you do when your subordinates reject your requests for matters outside their job descriptions? What strategies do you follow? What do you think are the reasons why your subordinates reject your requests for matters that are outside their job descriptions? How do you think that your subordinates’ refusal of requests for work that falls outside their job descriptions can be prevented? How can employees be encouraged to take on more responsibility? What are your thoughts on the impact of your subordinates' refusal to accept requests for work outside their job descriptions? Who is affected by this situation and how? What do you think about the relationship between your subordinates' rejection of your requests for matters outside their job descriptions and the pandemic? Data Collection Research data were collected using a semi-structured interview technique. In this technique, respondents have the right to partially correct the questions prepared by the researcher and to make changes together with the researcher. However, additional questions can be asked of the study group to obtain more detailed information [ 34 ]. Participants were asked seven open-ended questions and additional questions if needed. The data collection process was terminated when the data started to become repetitive [ 33 ]. Before the interviews began, participants were informed about the research, the interview questions were shared, and verbal consent was obtained. Participants' consent and the interviews were recorded using a voice recorder. Data Analysis The interviews, recorded with a voice recorder, were transferred to the MAXQDA program. The total interview duration was determined to be 409 minutes and 8 seconds. The transcripts of the interviews are 104 pages. Different analysis techniques can be used in data analysis. Content analysis is a common analysis technique in qualitative studies. In content analysis, the researcher can both use existing materials and generate their own data [ 33 ]. In this study, thematic-constructive content analysis, a type of content analysis, was used. In this type of analysis, superordinate themes are often derived from the research question. Subthemes of each superordinate theme are created based on the research data. Sometimes, new themes can be added to the superordinate theme list based on the data [ 35 ]. In this study, the interview transcripts were read several times to ensure familiarity with the data and identify important sections. Thematic superordinate categories were then created. Codes associated with these themes were identified. These codes were combined to create subthemes. To prevent data loss, the interview transcripts were re-examined according to the identified themes and codes. Reliability and Validity In qualitative research, different strategies such as triangulation, participant verification, appropriate and sufficient participation in the data collection process, and expert review are used to ensure research validity. In this study, Merriam's "triangulation," "participant verification," "appropriate and sufficient participation in the data collection phase," "maximum diversity," and "expert review" strategies were followed [ 34 ]. In line with these strategies, the data obtained from the interview transcripts were first checked by comparing them with concepts in the literature and the participants' statements. Participants' statements were reflected back and confirmed during the interviews. The study group included people from different hospitals and stations. The research codes and the generated themes were evaluated with two experts. As a result of the evaluations, the names of one theme and three codes were changed. A new code was also added. Two codes that could not be reconciled were removed from the research data. Results This section presents findings regarding the reasons for QQ, its consequences, and the reasons for not resigning based on the experiences of lower-level managers involved in the provision of emergency health services. The study identified three categories, four themes, 14 subthemes, 38 codes, and five subcodes. The categories for the themes of the research are in Table 2 . Table 2 Quiet Quitting Category, Theme, Sub-Theme Grouping Categories Themes Sub-Themes Predisposing Factors Reasons for Not Resigning Economic Factors Work-Related Factors Individual Factors Reasons for Quiet Quitting Individual Factors Managerial Factors Work-Related Factors Pandemic-Related Factors Political Factors Process Attitudes and Behaviors Regarding Extra Requests Managerial Attitudes and Behaviors Employee Attitudes and Behaviors Consequences Consequences of Quiet Quitting Reflected on Employees Reflected in the Work Environment Reflected on the Patient Reflected on the Institution Theme 1: Reasons for Not Resigning This theme was created to identify why participants' subordinates chose QQ instead of a real resignation. This theme consists of 10 codes and 3 subthemes (Fig. 1 ). Some of the participant expressions that were effective in creating the codes are given below. Economic Factors P4: “Currently, very few people can survive on a single salary.” P14:” She/He has to work; she/he needs money. She/He has no chance of retirement.” Work-Related Factors P8: ”I don't like inpatients... In the wards, they're always busy with secretarial work, document recording. But we have a secretary in the emergency room. All they do is nursing.” P9: “Also, since it is a shift system, the personnel working 24 hours a day have the opportunity to rest for 72 hours.” Individual Factors P11: “No one wants to give up a steady income, even if they don't enjoy their profession. And then what happens? It becomes a habit. “ P15: “It's not a profession you can do without love. After a while, that love becomes a habit.” Theme 2. Reasons for Quiet Quitting In this theme, which determined the factors that influence the QQ of healthcare workers providing emergency healthcare services, 5 subcodes, 16 codes and 5 subthemes were determined by analyzing the participants' responses to the questions (Fig. 2). * This code was created to draw attention to some positive developments during the pandemic process. Figure 2. Reasons for Quiet Quitting of Emergency Health Services Workers Some of the participant expressions that were influential in creating the codes are given below. Individual Factors P1: “Everyone has their own choice... It's a passion. If you have the passion and desire, you can do the extra tasks.” P16: “People who have been on duty a little longer, that is, those who are close to retirement, are already fatigued.” P17: “No one who doesn't love their job can do it. People who are not responsible cannot do this job.” Work-Related Factors P4: “We cannot do it ourselves because our workload is high, so we ask our staff to do it. They don't do it because it's outside their job description.” P10: “Even if they make the staff do different jobs, they should give them what they deserve. They should give them what they're entitled to in terms of wages and leave.” P15: “You know, everyone is trying to make sure that there is no work left and that patients do not suffer.” Managerial Factors P2: “I go and tell their manager. Sometimes some problems are solved. After all, it's on a personal level... Some problems may not be solved..” P7: “It's not our job to enter documents, let the medical secretary do it...” P8: “He/she doesn't work. He/she thinks, "Nothing will happen to him/her, so I won't work either.” Pandemic-Related Factors P3: “During the pandemic, I distributed medicine from village to village by ambulance. I don't think that should be the role of an emergency healthcare vehicle. That wasn't my job. So, I can't claim to have done my job during the pandemic.” P16: “During the pandemic, there was a decrease in the number of patients coming to the Emergency Department because they were more need-based. Since patients who really needed it came, the service provided to them became better.” Political Factors P2: “The increasing wage gap between professional groups or the fact that a nurse working here earns exactly the same money as a medical secretary, that’s also something that’s questioned.” P13: “When they stopped working on cases that provided professional satisfaction and instead started working on empty cases, work started to become a chore. People could not enjoy professional satisfaction either.” Theme 3. Attitudes and Behaviors Regarding Extra Demands This theme was created to explore how lower-level managers react when their subordinates are asked to perform tasks outside their job descriptions, and what managers do to address these reactions. The theme contains 15 codes and two subthemes (Fig. 3 ). Some of the participant expressions that were effective in creating the codes are given below. Managerial Attitudes and Behaviors P1: “When there are no volunteers, I assign them by lottery and in turns. Everyone has to do it. There is such a duty, there is no monetary reward, but there is such a duty.” P14: “You can't call everyone anyway. You call those you can, depending on your relationship. You call those you won't get a negative reaction from, but they still might not answer. Ultimately, if I can't find anyone, I have to do it myself, whether I'm available or not.” Employee Attitudes and Behaviors P8: “I mean, they generally don't want to come, but there's no one else. Someone has to come. I tell them to decide among themselves or to draw lots, they come inevitably.” P16: “We can't get them to do something they doesn't accept as their duty; we're having a hard time. A report is kept, it's reported to upper management, and the process takes a bit longer.” P17: “It just remains what I said. If I can get it done that day, it's done. If I don't have it done, it won't be done for 2 or 3 days. Other colleagues don't care much about it either. That's why it takes a little longer, of course, inevitably.” Theme 3. Consequences of Quiet Quitting The study aimed to determine the results of the QQ of emergency healthcare workers. For this purpose, the responses to the questions were examined, and as a result of the analysis, 12 codes and 4 sub-themes were identified (Fig. 4 ). Some of the participant expressions that were effective in creating the codes are given below. Reflected on Employees P7: “Colleagues generally refuse extra tasks because they don't want their workload to increase.” P10: “While everyone's job description says to work that day, no one works, we're the ones working. We get nothing in return.” Reflected in the Work Environment P1: “First of all, you explain the situation nicely, but if you can't find a solution, it can turn into an argument.” P4: “After a while, we get upset with our colleagues and become antagonistic towards each other. Issues on which we could agree and compromise now seem very distant to us.” P10: “If you quit quietly, no one will want to come to you or keep watch with you. In other words, he/she says, “I don't want to keep watch with this person.” Reflected on the Patient P8: “So, of course, he's/she’s not behaving openly or eagerly (towards the patient). He's/she’s just doing his/her job. In other words, he's/she’s only doing what he/she has to.” P16: “They don't show a friendly face to the patient, or they raise their voice a bit when they need to say something. Inevitably, patients are affected by this situation (tension in the work environment).” Reflected on the Institution P2: “Some employees experience lower morale and lower motivation when they work longer hours. They don't want to come to work. They start selecting people. They request a change of location.” P3: “Of course, it can disrupt the workflow (rejection of extra tasks).” P7: “Of course, when you do things reluctantly, there will inevitably be a problem. I mean, there will definitely be a problem.” Code-Relationship Matrix Findings Within the scope of the research, a code relationship matrix was created to determine the circumstances related to QQ. To reveal the relationships between codes in this matrix, intersections above two were evaluated as the frequency limit. Related codes are defined by. The findings of the analyses are presented in Fig. 5 and Fig. 6 . As seen in Fig. 5 , during the pandemic, there is a relationship between emergency services and congestion and unnecessary use codes, and between stations and increased workload and congestion codes. According to managers' experiences, older employees are associated with work burnout and avoiding responsibility, while younger employees are associated with disliking their job and avoiding responsibility. There are relationships between the perceived injustice, increased workload, social learning, workplace unrest, ambiguity in job descriptions, pay inequality, and loss of motivation codes. Social learning is associated with lack of sanctions; nature of the work is associated with ambiguity in job descriptions; and avoidance of responsibility is associated with ambiguity in job descriptions and increased workload. Among the attitudes and behaviors during the QQ process, the code for objecting to/not performing extra duties is related to the codes for advanced age, avoiding responsibility, social learning, workload, reporting to a superior, and ambiguity of job descriptions. The code for ambiguity of job descriptions is related to the codes for reluctance, forced fulfillment (of tasks), nature of work, intensity, and evading responsibility. There are relationships between the code for forced fulfillment (obligation) and the codes for reluctance, ambiguity of job descriptions, sequential assignment, and reporting to a superior (Fig. 6 ). Discussion Emergency healthcare services address sudden, life-threatening situations that may arise if not addressed within 24 hours. These services are extremely complex, intensive, tiring, and stressful. They sometimes require performance and dedication beyond expectations. However, some team members, for various reasons, perform below expectations and do not go beyond their job descriptions. This situation has numerous negative impacts on patients, other employees, and organizational outcomes. This study has revealed the state of QQ, its causes, process, and results, and why employees choose QQ instead of physical resignation among emergency health service workers. Participating managers in the study found that economic factors were the most frequently cited as a contributing factor to their subordinates' refusal to resign. According to participants, employees in emergency healthcare units receive additional benefits, and their wages are higher than those offered in other sectors. However, it has been understood that the limited job opportunities and job security in the country prevent real resignation. It has been determined that factors such as less paperwork, shift work, rapid patient turnover, and peace in the work environment in units providing emergency health services are effective in encouraging employees to continue working in these units. In a study conducted on this subject, it was determined that although participants' expectations from their organizations differed among generations X, Y, and Z, wage practices, work environment, and communication were among the common expectations [ 36 ]. As a result of research conducted by Gün, it was determined that the effect of economic factors on QQ for the healthcare workers participating in the research was greater than other factors (work-related factors, administrative factors) [ 37 ]. These factors have been highlighted in many studies on QQ. Reasons such as lack of job security [ 38 , 39 ], and lower salaries in different jobs [ 37 , 40 , 41 ] have been associated with employees choosing QQ rather than a real resignation. Çelik and Kaya evaluated the results of 40 studies on QQ written in Turkish and found that the reasons for QQ were, respectively, low wages, going beyond job descriptions, irregular overtime payments, and lack of job security [ 42 ]. The results of this study and other studies in the literature indicate that economic factors are an important factor in real resignation. Employee resignations should be prevented due to their various negative impacts on organizations. To achieve this, economic improvements, ensuring the work-pay balance for employees, and ensuring job security are considered crucial. On the other hand, it's understood that employees often resort to QQ rather than real resignation when their economic expectations are not met and job opportunities are limited. Considering the negative impact QQ has on organizations, it's crucial to prevent employee QQ. Therefore, all businesses should identify the causes of QQ and develop solutions. In this study, data was collected based on the opinions and experiences of lower-level managers, and it was determined that participants most frequently cited factors related to their subordinates (individual factors). While studies in the literature prioritize managerial factors as the causes of QQ [ 36 , 43 ], some studies place managerial factors lower [ 37 ]. In some studies, the key factors influencing QQ vary across generations. Accordingly, the most important factor for Generation X is related to managers' skills while for Generation Y, lack of appreciation is seen as more important, and for Generation Z, working conditions are seen as more important [ 36 ]. The main reason for the discrepancy in the results of the studies in the literature may be due to differences in study groups. This study aimed to provide a different perspective on the studies in the literature by identifying the causes of QQ from the perspective of managers. The research results demonstrate the necessity of this approach. It can be said that managers and employees have different opinions about the causes of QQ. Employees emphasize manager-related factors, while managers seem to emphasize employee-related factors. This result can be interpreted as the parties not being self-critical or empathic and having tendency to blame the other party, or as the subordinates and managers having different perspectives. Participants were found to highlight various factors related to QQ, including their subordinates' age, length of experience, and the importance of the job to the employee. Accordingly, participants associated older employees with work boredom and avoiding responsibility, and younger employees with disliking their jobs. Although there is no significant difference in the studies in the literature, the meaning of the job, age [ 33 ] and length of experience have been found to have an effect on QQ [ 22 , 43 , 44 ]. However, the results of these studies differ. Some studies report a higher prevalence of QQ in younger individuals and those with less experience [ 22 ], while others report a higher prevalence in those with more experience [ 43 , 44 ]. This suggests the need for further research examining QQ among healthcare professionals based on age and length of experience. Furthermore, it is understood that the meaning of work and the reasons for QQ differ across age groups [ 36 ]. Therefore, the causes of QQ among healthcare professionals across age groups should be further investigated. On the other hand, it is necessary to create an environment that will increase employees' interest in their work, to examine the importance of the work for the employee at the individual level, and to investigate how employees can be made to take more responsibility. According to the perspective of the managers who participated in the study, unnecessary use of emergency health services increases the workload in emergency health units. This situation results in staff burnout and QQ. This problem suggests that some policies regarding the use of emergency medical services in Turkey need to be reviewed. Statistics on the use of emergency medical services in Turkey reveal a false report rate of 10.26%. In addition, despite the decrease in the population per emergency health station in the last 20 years, the increase in the number of cases [ 45 ] can be considered as unnecessary use. Therefore, it can be stated that health policy makers should take measures to prevent unnecessary use of emergency health services. It has been determined that the fact that emergency health care workers are forced to work more hours due to various reasons (others' QQ, unnecessary use of emergency health units by patients, managers assigning extra tasks to people with whom they have good relationships, etc.) and not being paid in return causes a loss of motivation in the workers, and the lack of sanctions for those who QQ creates a perception of injustice. Furthermore, it has been found that other employees take QQ as an example and consequently engage in QQ themselves. It has also been found that QQers cause increased workload on other employees and create unrest in the work environment. It has been determined that one of the reasons for this situation is the uncertainty of the job descriptions of the employees. Various studies conducted in healthcare institutions have found a negative relationship between the perception of organizational justice and QQ [ 24 , 46 ] and a positive relationship between role ambiguity and fatigue [ 24 ]. In a study conducted by Güler with participants from different sectors, it was found that managers' behavior, unclear job descriptions, organizational injustice, and lack of communication cause QQ [ 33 ]. Additionally, various studies in the literature have found that QQ increases the workload of other employees and decreases their motivation, making it undesirable to work with those who engage in QQ [ 36 ]. On the other hand, it has been found that people with high workload [ 44 , 47 ] and low motivation [ 22 ] tend towards QQ. In this context, the results of this research and those of other studies in the literature support each other. These results can be interpreted as suggesting that QQ influences other employees, creating a vicious cycle in professional life. This is because QQ not only increases the workload of other employees and decreases their motivation, but increased workload and loss of motivation also cause QQ. Participants in this study noted that they exhibit various attitudes and behaviors to prevent employees from engaging in QQ. Participants stated that they prioritize fairness when assigning extra tasks to their subordinates, assigning them sequentially and favoring employees who volunteer. It was determined that the participants primarily tried to motivate their subordinates. It has been determined that some subordinates accept extra work depending on the approach of their managers. However, it has been determined that some employees react negatively to all approaches of managers and refuse to do extra work. It has been understood that in such a case, managers report the situation to the next higher manager. In addition, it was determined that some of the managers who participated in the study preferred employees who volunteered for additional duties, while others preferred to punish employees who did not accept extra duties. The research results indicate that participants are unable to develop effective strategies to prevent QQ among emergency healthcare workers. This is because, despite the strategies employed by managers, some employees' QQ cannot be prevented. In addition, participants' assignment of some employees by exploiting their relationship and favoring volunteers may cause negative experiences such as boredom, burnout, feelings of being used, and perception of injustice in these employees. Therefore, managers should closely monitor employees' QQ processes and implement more systematic strategies to prevent QQ. On the other hand, there are not enough studies in the literature on how managers can prevent QQ. Further research should be conducted on managers' actions to prevent QQ to evaluate their effectiveness. Several studies on employees' QQ processes are noteworthy [ 48 , 49 ]. Managers' awareness of these processes should be increased, QQ actions should be identified early, and interventions should be initiated before employees experience organizational disengagement. It has been found that the negative effects of QQ on employees and the work environment sometimes extend to patients. This suggests that employees' attitudes toward patients are worse. Participants noted that QQ disrupts workflow and that some employees want to change institutions or departments as a result. Güler's study determined that QQ reduces service quality and leads to productivity loss [ 36 ]. Lestari et al., in their study evaluating QQ among hotel employees in Indonesia, found that employee performance decreases as QQ behavior increases [ 38 ]. It is clear that QQ has negative effects on organizational productivity and customer satisfaction. However, in this study, it is observed that the participants touched upon variables related to institutional effects to a limited extent. This may be due to the low awareness of the participants regarding institutional outputs since they were lower-level managers. Since lower-level managers directly manage processes related to service delivery, their awareness of corporate outputs should be increased. The study also investigated the pandemic's role in QQ. Based on the participants' opinions, it was understood that emergency health stations and emergency room workers were affected differently by the pandemic. Accordingly, it was stated that the workload and intensity of emergency health station workers increased during the pandemic, causing professional burnout, and that employees lacked time and were unwilling to take on extra work. It has been determined that employees working in emergency services stated that QQ decreased during the pandemic period due to reasons such as the decrease in unnecessary use of emergency services and the number of patients, work being more standardized during this period, and working hours being shortened to reduce the risk of infection. According to these results, it can be said that the pandemic had different effects on the QQ of employees in emergency health units. Conducting research on healthcare workers regarding the effects of the pandemic on QQ by taking unit differences into account will contribute to obtaining more meaningful results. Conclusion This study on QQ among emergency healthcare workers found that economic, work-related, and employee-related factors inhibit actual resignation. Lower-level managers participating in the study believed that individual factors (age, years of experience, the meaning of the job, avoidance of responsibility, fatigue, etc.) were more likely to cause QQ. Accordingly, it was determined that older people are tired of their jobs and avoid responsibility, while younger people tend to engage in QQ because they dislike their jobs. Furthermore, some managerial factors were found to be associated with QQ. While participants attributed individual reasons to the causes of QQ, the study found that managerial factors were more closely related to the consequences of QQ. Furthermore, it was found that those who practice QQ increase the workload of other employees and disrupt the peace of the work environment. Furthermore, even if patient care duties are not disrupted, unrest in the work environment negatively impacts patient attitudes. Limitations This study was conducted using qualitative research methods, and data were collected from 17 participants. Therefore, the results cannot be generalized. In addition, the research data include the experiences, perceptions and evaluations of healthcare professionals who work as lower-level managers in units providing emergency healthcare services. In this context, another limitation of the research is that it concerns the experiences, perceptions and evaluations of lower-level managers in units providing emergency health services. Declarations Ethics approval and consent to participate The research's compliance with ethical principles was evaluated by the Amasya University Social Sciences Ethics Committee, and the study was approved with decision number 250640, dated 18/03/2025. Written informed consent for participation was obtained from all participants. This study was conducted in accordance with the Declaration of Helsinki. Consent for publication Written consent was obtained for the publication of participants' personal or clinical information and descriptive images. Competing interests The authors declare that they have no competing interests. Funding Not applicable Author Contribution GG, contributed to all processes on her own. Acknowledgements Endless thanks to the academics who contributed to the analysis processes of this research and to the participants who participated in this research. Data Availability The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. References Formica S, Sfodera F. The great resignation and quiet quitting paradigm shifts: An overview of current situation and future research directions. 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4","display":"","copyAsset":false,"role":"figure","size":287885,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eConsequences of the Quiet Quitting of Emergency Health Services Workers\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"floatimage4.png","url":"https://assets-eu.researchsquare.com/files/rs-7786716/v1/53ddaf12a11c1070edf314cb.png"},{"id":96844889,"identity":"21758179-6d29-4abe-8226-17d4408238b9","added_by":"auto","created_at":"2025-11-26 16:30:21","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":164389,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eCode relationship matrix between reasons for quiet quitting, consequences and place of duty\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"floatimage5.png","url":"https://assets-eu.researchsquare.com/files/rs-7786716/v1/53360ff3cda573354208d033.png"},{"id":96844888,"identity":"de27392e-8703-4669-a7ad-93955e26fc2e","added_by":"auto","created_at":"2025-11-26 16:30:21","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":194773,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eCode relationship matrix between reasons for quiet quitting and attitudes and behaviors during the quiet quitting process\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"floatimage6.png","url":"https://assets-eu.researchsquare.com/files/rs-7786716/v1/72c631de6aacab8790d0a83b.png"},{"id":98283047,"identity":"8a55fde0-7a66-41a6-b7f7-a80c64c8d650","added_by":"auto","created_at":"2025-12-16 06:09:10","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2670334,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7786716/v1/aa2490e4-3c75-4e9a-9ab9-4bc07c7005c7.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Quiet Quitting in Emergency Health Services: A Phenomenological Study on the Experiences of Lower-Level Managers","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThe Covid-19 pandemic, which originated in Wuhan, China and impacted the entire world, has impacted our social lives as well as our professional lives in many ways. To prevent the spread of the virus, some businesses adopted changes such as shorter working hours and working from home, while others provided their employees with additional protective equipment and expected them to work harder [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Some professional groups, particularly those forced to work intensively during the pandemic, experienced burnout due to poor work-life balance [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e] and sought ways to re-establish this balance [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Quiet Quitting (QQ), a response to the hectic work lives during the pandemic, went viral on the social media platform TikTok [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe concept of QQ, which has become more prominent with the pandemic, refers to performing only the tasks that are included in the job description and are required to be performed, not exceeding the job requirements, and working only enough to avoid being fired [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Those who engage in QQ are dissatisfied with their workplace and, instead of expressing this dissatisfaction [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e], they seek alternative employment [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. However, employees cannot always find a job they desire. Therefore, many employees tend to stay at their current place of work and fulfill their basic responsibilities without exceeding expectations, rather than resigning [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. In underdeveloped or developing countries, factors such as lower wages than expected and lack of job security lead to QQ [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e], while in developed economies, the abundance of job opportunities results in real resignation [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThose who engage in QQ refuse to voluntarily spend more time at work, sacrifice their social life, take on more work, or dedicate their entire lives to their work, contrary to employer expectations [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. While there are many reasons for this refusal, it is mostly associated with the attitudes and behaviors of their managers. Today, employees seek managers who coach them, value their ideas, focus on their strengths, support their development, and maintain constant communication [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. They want their managers to trust them and empower them [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Managers' failure to establish the necessary balance in task distribution, assigning additional work to employees who perform better than others while being indifferent to those who perform less [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e], can result in QQ. In some cases, employees who perform poorly are rewarded for reasons such as the employee's astuteness for workplace politics [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e], the manager's favoritism towards certain employees [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e], or unfairness and unethical behavior [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. This leads to social learning, which results in other employees exhibiting the same attitudes and behaviors [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. According to Adams's (1963) \"Equity Theory,\" employees compare their own inputs and outputs with those of others. When these comparisons do not yield results to their advantage, they doubt the manager's fairness and experience feelings of anger and tension [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. In such situations, employees try to match their input-output ratios to those of others [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. While those who work more are punished with additional work, less productive employees turn a blind eye and/or are rewarded, which negatively affects the motivation of other employees, reduces productivity, disrupts harmony in the work environment, reduces profitability, and poses an institutional threat [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Furthermore, conflicts between the goals and values ​​of employees and those ​​of organizations cause confusion in employees, reducing the sense of belonging and commitment to the organization [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eEmployees' QQ behavior can sometimes stem solely from the individual. Demographic characteristics, the employee's personality and concerns [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e], feeling unvalued in the organization, not being able to establish a work-life balance, or simply not wanting to work for any reason are cited as individual reasons [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. It has been reported that young people in particular refuse to sacrifice their personal time to spend more time at work. Young people are trying to achieve balance in their lives by moving away from the competitive work environment [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eSome studies indicate that factors related to the work environment also lead to QQ. These studies indicate that emotional or physical fatigue resulting from work [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e], workplace stress, relationships with managers, other employees, and customers, workplace culture, and workplace policies have an impact on QQ [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. The QQ of healthcare workers has come to the fore with the Covid-19 pandemic. However, research on this topic is limited [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. The pandemic has caused a sudden and rapid increase in demand for healthcare services [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Employee absence due to illness, increase in the number of patients, and implementation of additional preventative measures have further increased the workload of staff in the field, leading to fatigue [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e] and burnout [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. This has led many employees to question their expectations from work and life, and to believing that staying in a job for traditional gains such as salary, title, and promotion opportunities is meaningless [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Healthcare workers who cannot establish a work-life balance have exhibited QQ [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe labor-intensive nature of healthcare services, coupled with the impact of both the quantity and quality of care on patient outcomes, makes QQ important in the healthcare sector [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. This study evaluated the pandemic-related QQ of emergency healthcare workers, who had to work much longer hours than those in other sectors during the pandemic. Studies in the literature have linked QQ to the attitudes and behaviors of managers [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. Therefore, this study aimed to identify the opinions of managers of emergency healthcare workers responsible for daily activities and to uncover what they do to prevent QQ. We aimed to examine the studies in the literature from a different perspective. We aimed to determine how the pandemic affected QQ among employees working in different emergency healthcare units. Furthermore, based on the managers' experiences, we aimed to determine the causes of QQ in emergency healthcare workers working in emergency healthcare units, the managers' approach to those who engage in QQ, the consequences of QQ, and the circumstances associated with QQ. The study sought to answer the following questions:\u003c/p\u003e\u003cp\u003eWhat do low-level managers in emergency healthcare units think of quiet quitting?\u003c/p\u003e\u003cp\u003eWhat attitude to low-level managers in emergency healthcare units have towards their employees\u0026rsquo; quiet quitting?\u003c/p\u003e\u003cp\u003eWhy do emergency healthcare workers not make a real resignation?\u003c/p\u003e\u003cp\u003eIs there a link between emergency healthcare workers; quiet quitting and the pandemic?\u003c/p\u003e\u003cp\u003eWhat are the consequences of emergency healthcare workers\u0026rsquo; quiet quitting?\u003c/p\u003e\u003cp\u003eWhat circumstances are associated with emergency healthcare workers\u0026rsquo; quiet quitting?\u003c/p\u003e"},{"header":"METHODOLOGY","content":"\u003cp\u003eThe study was designed using a qualitative approach, which helps understand the reasons behind individuals\u0026rsquo; behavior, determine how they attribute meaning to events, and explore their perspectives on events [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. There are different designs in the qualitative approach. Since this research focuses on participants\u0026rsquo; experiences, a phenomenological design was used. Phenomenology is the process of revealing meanings by describing events, situations, and objects in a multifaceted and holistic manner [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. In this design, the data source is composed of individuals or groups that can express the phenomenon [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. The researcher examines the participant's experiences, perceptions, and how they make sense of events [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e].\u003c/p\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStudy Group\u003c/h2\u003e\u003cp\u003eFor the purpose of the study, individuals who had experienced the pandemic and were low-level managers in an emergency healthcare unit were selected as the study group. To investigate different characteristics related to the phenomenon under investigation, participants with varying experience levels were selected from different hospitals and stations. This approach aimed to maximize diversity. In this context, maximum diversity sampling was used [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. The study group was selected on a voluntary basis. Furthermore, considering that relevant environmental factors would also influence the research topic, participants from different provinces and regions were selected. Descriptive information about the participants is provided in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eParticipant Descriptive Information\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"8\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eParticipants\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAge\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eGender\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eEducation Level\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eDuration of Experience\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eDuty\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003ePosition\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c8\"\u003e\u003cp\u003eWorking During the Pandemic\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eP1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e42\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eBachelor's Degree.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e21 Years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e112 Emergency Health Station\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eStation Manager\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eWorked\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eP2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e30\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eBachelor's Degree.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e7 Years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003ePublic Hospital\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eEmergency Service Manager\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eWorked\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eP3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e30\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eAssociate's Degree\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e6 Years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e112 Emergency Health Station\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eStation Manager\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eWorked\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eP4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e30\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd 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Years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003ePrivate Hospital\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eEmergency Service Manager\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eWorked\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eP6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e32\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eAssociate's Degree\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e15 Years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eTraining and Research Hospital\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eEmergency Service Manager\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eWorked\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eP7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e32\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eBachelor's Degree.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e13 Years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003ePublic Hospital\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eEmergency Service Manager\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eWorked\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eP8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e44\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMaster's Degree\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e24 Years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003ePublic Hospital\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eEmergency Service Manager\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eWorked\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eP9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e32\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eBachelor's Degree.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e12 Years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e112 Emergency Health Station\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eStation Manager\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eWorked\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eP10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e31\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eBachelor's Degree.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e6 Years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e112 Emergency Health Station\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eStation Manager\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eWorked\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eP11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e38\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eBachelor's Degree.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e18 Years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e112 Emergency Health Station\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eStation Manager\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eWorked\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eP12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e37\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eAssociate's Degree\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e15 Years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e112 Emergency Health Station\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eStation Manager\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eWorked\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eP13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e30\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMaster's Degree\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e10 Years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e112 Emergency Health Station\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eStation Manager\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eWorked\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eP14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e32\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eAssociate's Degree\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e14 Years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e112 Emergency Health Station\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eStation Manager\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eWorked\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eP15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e42\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eDoctoral Degree\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e19 Years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003ePublic Hospital\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eEmergency Service Manager\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eWorked\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eP16\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e35\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eHigh\u0026rsquo;s Degree\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e16 Years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003ePrivate Hospital\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eEmergency Service Manager\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eWorked\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eP17\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e29\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eDoctoral Degree\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e4 Years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003ePublic Hospital\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eEmergency Service Manager\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eWorked\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eAll of the participants in the study group were working during the pandemic. Eight of them worked in emergency medical stations and nine worked in hospital emergency services. The gender distribution of the participants was nine male and eight female, and the age range was 29\u0026ndash;44.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eData Collection Tools\u003c/h3\u003e\n\u003cp\u003eThe researcher created an interview form appropriate for the purpose of the study. The questions in the interview form were determined through a literature review. The suitability of the interview questions for the purpose of the study was evaluated by two academics. Following this evaluation, the interview form was finalized. The interview form consisted of two parts. The first part addressed demographic characteristics (age, gender, education level, duration of experience, unit, and position). The second part included seven open-ended questions. These questions are as follows:\u003c/p\u003e\u003cp\u003eHow do your subordinates handle your requests for matters outside their job descriptions, calls outside of work hours, and requests to work overtime? How do they react?\u003c/p\u003e\u003cp\u003eWhat do you do when your subordinates reject your requests for matters outside their job descriptions? What strategies do you follow?\u003c/p\u003e\u003cp\u003eWhat do you think are the reasons why your subordinates reject your requests for matters that are outside their job descriptions?\u003c/p\u003e\u003cp\u003eHow do you think that your subordinates\u0026rsquo; refusal of requests for work that falls outside their job descriptions can be prevented? How can employees be encouraged to take on more responsibility?\u003c/p\u003e\u003cp\u003eWhat are your thoughts on the impact of your subordinates' refusal to accept requests for work outside their job descriptions? Who is affected by this situation and how?\u003c/p\u003e\u003cp\u003eWhat do you think about the relationship between your subordinates' rejection of your requests for matters outside their job descriptions and the pandemic?\u003c/p\u003e\n\u003ch3\u003eData Collection\u003c/h3\u003e\n\u003cp\u003eResearch data were collected using a semi-structured interview technique. In this technique, respondents have the right to partially correct the questions prepared by the researcher and to make changes together with the researcher. However, additional questions can be asked of the study group to obtain more detailed information [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. Participants were asked seven open-ended questions and additional questions if needed. The data collection process was terminated when the data started to become repetitive [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. Before the interviews began, participants were informed about the research, the interview questions were shared, and verbal consent was obtained. Participants' consent and the interviews were recorded using a voice recorder.\u003c/p\u003e\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\u003ch2\u003eData Analysis\u003c/h2\u003e\u003cp\u003eThe interviews, recorded with a voice recorder, were transferred to the MAXQDA program. The total interview duration was determined to be 409 minutes and 8 seconds. The transcripts of the interviews are 104 pages. Different analysis techniques can be used in data analysis. Content analysis is a common analysis technique in qualitative studies. In content analysis, the researcher can both use existing materials and generate their own data [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. In this study, thematic-constructive content analysis, a type of content analysis, was used. In this type of analysis, superordinate themes are often derived from the research question. Subthemes of each superordinate theme are created based on the research data. Sometimes, new themes can be added to the superordinate theme list based on the data [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. In this study, the interview transcripts were read several times to ensure familiarity with the data and identify important sections. Thematic superordinate categories were then created. Codes associated with these themes were identified. These codes were combined to create subthemes. To prevent data loss, the interview transcripts were re-examined according to the identified themes and codes.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eReliability and Validity\u003c/h3\u003e\n\u003cp\u003eIn qualitative research, different strategies such as triangulation, participant verification, appropriate and sufficient participation in the data collection process, and expert review are used to ensure research validity. In this study, Merriam's \"triangulation,\" \"participant verification,\" \"appropriate and sufficient participation in the data collection phase,\" \"maximum diversity,\" and \"expert review\" strategies were followed [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. In line with these strategies, the data obtained from the interview transcripts were first checked by comparing them with concepts in the literature and the participants' statements. Participants' statements were reflected back and confirmed during the interviews. The study group included people from different hospitals and stations. The research codes and the generated themes were evaluated with two experts. As a result of the evaluations, the names of one theme and three codes were changed. A new code was also added. Two codes that could not be reconciled were removed from the research data.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eThis section presents findings regarding the reasons for QQ, its consequences, and the reasons for not resigning based on the experiences of lower-level managers involved in the provision of emergency health services. The study identified three categories, four themes, 14 subthemes, 38 codes, and five subcodes. The categories for the themes of the research are in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eQuiet Quitting Category, Theme, Sub-Theme Grouping\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCategories\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eThemes\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSub-Themes\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"7\" rowspan=\"8\"\u003e\u003cp\u003ePredisposing Factors\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eReasons for Not Resigning\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eEconomic Factors\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eWork-Related Factors\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eIndividual Factors\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\" morerows=\"4\" rowspan=\"5\"\u003e\u003cp\u003eReasons for Quiet Quitting\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eIndividual Factors\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eManagerial Factors\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eWork-Related Factors\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePandemic-Related Factors\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePolitical Factors\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eProcess\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eAttitudes and Behaviors Regarding Extra Requests\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eManagerial Attitudes and Behaviors\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eEmployee Attitudes and Behaviors\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003eConsequences\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003eConsequences of Quiet Quitting\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eReflected on Employees\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eReflected in the Work Environment\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eReflected on the Patient\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eReflected on the Institution\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\n\u003ch3\u003eTheme 1: Reasons for Not Resigning\u003c/h3\u003e\n\u003cp\u003eThis theme was created to identify why participants' subordinates chose QQ instead of a real resignation. This theme consists of 10 codes and 3 subthemes (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eSome of the participant expressions that were effective in creating the codes are given below.\u003c/p\u003e\n\u003ch3\u003eEconomic Factors\u003c/h3\u003e\n\u003cp\u003eP4: \u0026ldquo;Currently, very few people can survive on a single salary.\u0026rdquo;\u003c/p\u003e\u003cp\u003eP14:\u0026rdquo; She/He has to work; she/he needs money. She/He has no chance of retirement.\u0026rdquo;\u003c/p\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eWork-Related Factors\u003c/h2\u003e\u003cp\u003eP8: \u0026rdquo;I don't like inpatients... In the wards, they're always busy with secretarial work, document recording. But we have a secretary in the emergency room. All they do is nursing.\u0026rdquo;\u003c/p\u003e\u003cp\u003eP9: \u0026ldquo;Also, since it is a shift system, the personnel working 24 hours a day have the opportunity to rest for 72 hours.\u0026rdquo;\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003eIndividual Factors\u003c/h2\u003e\u003cp\u003eP11: \u0026ldquo;No one wants to give up a steady income, even if they don't enjoy their profession. And then what happens? It becomes a habit. \u0026ldquo;\u003c/p\u003e\u003cp\u003eP15: \u0026ldquo;It's not a profession you can do without love. After a while, that love becomes a habit.\u0026rdquo;\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003eTheme 2. Reasons for Quiet Quitting\u003c/h2\u003e\u003cp\u003eIn this theme, which determined the factors that influence the QQ of healthcare workers providing emergency healthcare services, 5 subcodes, 16 codes and 5 subthemes were determined by analyzing the participants' responses to the questions (Fig.\u0026nbsp;2).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003e*\u003c/b\u003e This code was created to draw attention to some positive developments during the pandemic process.\u003c/p\u003e\u003cp\u003e\u003cb\u003eFigure 2. Reasons for Quiet Quitting of Emergency Health Services Workers\u003c/b\u003e\u003c/p\u003e\u003cp\u003eSome of the participant expressions that were influential in creating the codes are given below.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003eIndividual Factors\u003c/h2\u003e\u003cp\u003eP1: \u0026ldquo;Everyone has their own choice... It's a passion. If you have the passion and desire, you can do the extra tasks.\u0026rdquo;\u003c/p\u003e\u003cp\u003eP16: \u0026ldquo;People who have been on duty a little longer, that is, those who are close to retirement, are already fatigued.\u0026rdquo;\u003c/p\u003e\u003cp\u003eP17: \u0026ldquo;No one who doesn't love their job can do it. People who are not responsible cannot do this job.\u0026rdquo;\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\u003ch2\u003eWork-Related Factors\u003c/h2\u003e\u003cp\u003eP4: \u0026ldquo;We cannot do it ourselves because our workload is high, so we ask our staff to do it. They don't do it because it's outside their job description.\u0026rdquo;\u003c/p\u003e\u003cp\u003eP10: \u0026ldquo;Even if they make the staff do different jobs, they should give them what they deserve. They should give them what they're entitled to in terms of wages and leave.\u0026rdquo;\u003c/p\u003e\u003cp\u003eP15: \u0026ldquo;You know, everyone is trying to make sure that there is no work left and that patients do not suffer.\u0026rdquo;\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\u003ch2\u003eManagerial Factors\u003c/h2\u003e\u003cp\u003eP2: \u0026ldquo;I go and tell their manager. Sometimes some problems are solved. After all, it's on a personal level... Some problems may not be solved..\u0026rdquo;\u003c/p\u003e\u003cp\u003eP7: \u0026ldquo;It's not our job to enter documents, let the medical secretary do it...\u0026rdquo;\u003c/p\u003e\u003cp\u003eP8: \u0026ldquo;He/she doesn't work. He/she thinks, \"Nothing will happen to him/her, so I won't work either.\u0026rdquo;\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\u003ch2\u003ePandemic-Related Factors\u003c/h2\u003e\u003cp\u003eP3: \u0026ldquo;During the pandemic, I distributed medicine from village to village by ambulance. I don't think that should be the role of an emergency healthcare vehicle. That wasn't my job. So, I can't claim to have done my job during the pandemic.\u0026rdquo;\u003c/p\u003e\u003cp\u003eP16: \u0026ldquo;During the pandemic, there was a decrease in the number of patients coming to the Emergency Department because they were more need-based. Since patients who really needed it came, the service provided to them became better.\u0026rdquo;\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec18\" class=\"Section2\"\u003e\u003ch2\u003ePolitical Factors\u003c/h2\u003e\u003cp\u003eP2: \u0026ldquo;The increasing wage gap between professional groups or the fact that a nurse working here earns exactly the same money as a medical secretary, that\u0026rsquo;s also something that\u0026rsquo;s questioned.\u0026rdquo;\u003c/p\u003e\u003cp\u003e P13: \u0026ldquo;When they stopped working on cases that provided professional satisfaction and instead started working on empty cases, work started to become a chore. People could not enjoy professional satisfaction either.\u0026rdquo;\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec19\" class=\"Section2\"\u003e\u003ch2\u003eTheme 3. Attitudes and Behaviors Regarding Extra Demands\u003c/h2\u003e\u003cp\u003eThis theme was created to explore how lower-level managers react when their subordinates are asked to perform tasks outside their job descriptions, and what managers do to address these reactions. The theme contains 15 codes and two subthemes (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eSome of the participant expressions that were effective in creating the codes are given below.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec20\" class=\"Section2\"\u003e\u003ch2\u003eManagerial Attitudes and Behaviors\u003c/h2\u003e\u003cp\u003eP1: \u0026ldquo;When there are no volunteers, I assign them by lottery and in turns. Everyone has to do it. There is such a duty, there is no monetary reward, but there is such a duty.\u0026rdquo;\u003c/p\u003e\u003cp\u003eP14: \u0026ldquo;You can't call everyone anyway. You call those you can, depending on your relationship. You call those you won't get a negative reaction from, but they still might not answer. Ultimately, if I can't find anyone, I have to do it myself, whether I'm available or not.\u0026rdquo;\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec21\" class=\"Section2\"\u003e\u003ch2\u003eEmployee Attitudes and Behaviors\u003c/h2\u003e\u003cp\u003eP8: \u0026ldquo;I mean, they generally don't want to come, but there's no one else. Someone has to come. I tell them to decide among themselves or to draw lots, they come inevitably.\u0026rdquo;\u003c/p\u003e\u003cp\u003eP16: \u0026ldquo;We can't get them to do something they doesn't accept as their duty; we're having a hard time. A report is kept, it's reported to upper management, and the process takes a bit longer.\u0026rdquo;\u003c/p\u003e\u003cp\u003eP17: \u0026ldquo;It just remains what I said. If I can get it done that day, it's done. If I don't have it done, it won't be done for 2 or 3 days. Other colleagues don't care much about it either. That's why it takes a little longer, of course, inevitably.\u0026rdquo;\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec22\" class=\"Section2\"\u003e\u003ch2\u003eTheme 3. Consequences of Quiet Quitting\u003c/h2\u003e\u003cp\u003eThe study aimed to determine the results of the QQ of emergency healthcare workers. For this purpose, the responses to the questions were examined, and as a result of the analysis, 12 codes and 4 sub-themes were identified (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eSome of the participant expressions that were effective in creating the codes are given below.\u003c/p\u003e\u003cdiv id=\"Sec23\" class=\"Section3\"\u003e\u003ch2\u003eReflected on Employees\u003c/h2\u003e\u003cp\u003eP7: \u0026ldquo;Colleagues generally refuse extra tasks because they don't want their workload to increase.\u0026rdquo;\u003c/p\u003e\u003cp\u003eP10: \u0026ldquo;While everyone's job description says to work that day, no one works, we're the ones working. We get nothing in return.\u0026rdquo;\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec24\" class=\"Section2\"\u003e\u003ch2\u003eReflected in the Work Environment\u003c/h2\u003e\u003cp\u003eP1: \u0026ldquo;First of all, you explain the situation nicely, but if you can't find a solution, it can turn into an argument.\u0026rdquo;\u003c/p\u003e\u003cp\u003eP4: \u0026ldquo;After a while, we get upset with our colleagues and become antagonistic towards each other. Issues on which we could agree and compromise now seem very distant to us.\u0026rdquo;\u003c/p\u003e\u003cp\u003eP10: \u0026ldquo;If you quit quietly, no one will want to come to you or keep watch with you. In other words, he/she says, \u0026ldquo;I don't want to keep watch with this person.\u0026rdquo;\u003c/p\u003e\u003cdiv id=\"Sec25\" class=\"Section3\"\u003e\u003ch2\u003eReflected on the Patient\u003c/h2\u003e\u003cp\u003eP8: \u0026ldquo;So, of course, he's/she\u0026rsquo;s not behaving openly or eagerly (towards the patient). He's/she\u0026rsquo;s just doing his/her job. In other words, he's/she\u0026rsquo;s only doing what he/she has to.\u0026rdquo;\u003c/p\u003e\u003cp\u003eP16: \u0026ldquo;They don't show a friendly face to the patient, or they raise their voice a bit when they need to say something. Inevitably, patients are affected by this situation (tension in the work environment).\u0026rdquo;\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec26\" class=\"Section3\"\u003e\u003ch2\u003eReflected on the Institution\u003c/h2\u003e\u003cp\u003eP2: \u0026ldquo;Some employees experience lower morale and lower motivation when they work longer hours. They don't want to come to work. They start selecting people. They request a change of location.\u0026rdquo;\u003c/p\u003e\u003cp\u003eP3: \u0026ldquo;Of course, it can disrupt the workflow (rejection of extra tasks).\u0026rdquo;\u003c/p\u003e\u003cp\u003eP7: \u0026ldquo;Of course, when you do things reluctantly, there will inevitably be a problem. I mean, there will definitely be a problem.\u0026rdquo;\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec27\" class=\"Section3\"\u003e\u003ch2\u003eCode-Relationship Matrix Findings\u003c/h2\u003e\u003cp\u003eWithin the scope of the research, a code relationship matrix was created to determine the circumstances related to QQ. To reveal the relationships between codes in this matrix, intersections above two were evaluated as the frequency limit. Related codes are defined by. The findings of the analyses are presented in Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e5\u003c/span\u003e and Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e6\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eAs seen in Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e5\u003c/span\u003e, during the pandemic, there is a relationship between emergency services and congestion and unnecessary use codes, and between stations and increased workload and congestion codes. According to managers' experiences, older employees are associated with work burnout and avoiding responsibility, while younger employees are associated with disliking their job and avoiding responsibility.\u003c/p\u003e\u003cp\u003eThere are relationships between the perceived injustice, increased workload, social learning, workplace unrest, ambiguity in job descriptions, pay inequality, and loss of motivation codes. Social learning is associated with lack of sanctions; nature of the work is associated with ambiguity in job descriptions; and avoidance of responsibility is associated with ambiguity in job descriptions and increased workload.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eAmong the attitudes and behaviors during the QQ process, the code for objecting to/not performing extra duties is related to the codes for advanced age, avoiding responsibility, social learning, workload, reporting to a superior, and ambiguity of job descriptions. The code for ambiguity of job descriptions is related to the codes for reluctance, forced fulfillment (of tasks), nature of work, intensity, and evading responsibility. There are relationships between the code for forced fulfillment (obligation) and the codes for reluctance, ambiguity of job descriptions, sequential assignment, and reporting to a superior (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eEmergency healthcare services address sudden, life-threatening situations that may arise if not addressed within 24 hours. These services are extremely complex, intensive, tiring, and stressful. They sometimes require performance and dedication beyond expectations. However, some team members, for various reasons, perform below expectations and do not go beyond their job descriptions. This situation has numerous negative impacts on patients, other employees, and organizational outcomes. This study has revealed the state of QQ, its causes, process, and results, and why employees choose QQ instead of physical resignation among emergency health service workers.\u003c/p\u003e\u003cp\u003eParticipating managers in the study found that economic factors were the most frequently cited as a contributing factor to their subordinates' refusal to resign. According to participants, employees in emergency healthcare units receive additional benefits, and their wages are higher than those offered in other sectors. However, it has been understood that the limited job opportunities and job security in the country prevent real resignation. It has been determined that factors such as less paperwork, shift work, rapid patient turnover, and peace in the work environment in units providing emergency health services are effective in encouraging employees to continue working in these units.\u003c/p\u003e\u003cp\u003eIn a study conducted on this subject, it was determined that although participants' expectations from their organizations differed among generations X, Y, and Z, wage practices, work environment, and communication were among the common expectations [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. As a result of research conducted by G\u0026uuml;n, it was determined that the effect of economic factors on QQ for the healthcare workers participating in the research was greater than other factors (work-related factors, administrative factors) [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. These factors have been highlighted in many studies on QQ. Reasons such as lack of job security [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e], and lower salaries in different jobs [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e] have been associated with employees choosing QQ rather than a real resignation. \u0026Ccedil;elik and Kaya evaluated the results of 40 studies on QQ written in Turkish and found that the reasons for QQ were, respectively, low wages, going beyond job descriptions, irregular overtime payments, and lack of job security [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]. The results of this study and other studies in the literature indicate that economic factors are an important factor in real resignation. Employee resignations should be prevented due to their various negative impacts on organizations. To achieve this, economic improvements, ensuring the work-pay balance for employees, and ensuring job security are considered crucial. On the other hand, it's understood that employees often resort to QQ rather than real resignation when their economic expectations are not met and job opportunities are limited. Considering the negative impact QQ has on organizations, it's crucial to prevent employee QQ. Therefore, all businesses should identify the causes of QQ and develop solutions.\u003c/p\u003e\u003cp\u003eIn this study, data was collected based on the opinions and experiences of lower-level managers, and it was determined that participants most frequently cited factors related to their subordinates (individual factors). While studies in the literature prioritize managerial factors as the causes of QQ [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e], some studies place managerial factors lower [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. In some studies, the key factors influencing QQ vary across generations. Accordingly, the most important factor for Generation X is related to managers' skills while for Generation Y, lack of appreciation is seen as more important, and for Generation Z, working conditions are seen as more important [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. The main reason for the discrepancy in the results of the studies in the literature may be due to differences in study groups. This study aimed to provide a different perspective on the studies in the literature by identifying the causes of QQ from the perspective of managers. The research results demonstrate the necessity of this approach. It can be said that managers and employees have different opinions about the causes of QQ. Employees emphasize manager-related factors, while managers seem to emphasize employee-related factors. This result can be interpreted as the parties not being self-critical or empathic and having tendency to blame the other party, or as the subordinates and managers having different perspectives.\u003c/p\u003e\u003cp\u003eParticipants were found to highlight various factors related to QQ, including their subordinates' age, length of experience, and the importance of the job to the employee. Accordingly, participants associated older employees with work boredom and avoiding responsibility, and younger employees with disliking their jobs. Although there is no significant difference in the studies in the literature, the meaning of the job, age [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e] and length of experience have been found to have an effect on QQ [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e, \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]. However, the results of these studies differ. Some studies report a higher prevalence of QQ in younger individuals and those with less experience [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e], while others report a higher prevalence in those with more experience [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e, \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]. This suggests the need for further research examining QQ among healthcare professionals based on age and length of experience. Furthermore, it is understood that the meaning of work and the reasons for QQ differ across age groups [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. Therefore, the causes of QQ among healthcare professionals across age groups should be further investigated. On the other hand, it is necessary to create an environment that will increase employees' interest in their work, to examine the importance of the work for the employee at the individual level, and to investigate how employees can be made to take more responsibility.\u003c/p\u003e\u003cp\u003eAccording to the perspective of the managers who participated in the study, unnecessary use of emergency health services increases the workload in emergency health units. This situation results in staff burnout and QQ. This problem suggests that some policies regarding the use of emergency medical services in Turkey need to be reviewed. Statistics on the use of emergency medical services in Turkey reveal a false report rate of 10.26%. In addition, despite the decrease in the population per emergency health station in the last 20 years, the increase in the number of cases [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e] can be considered as unnecessary use. Therefore, it can be stated that health policy makers should take measures to prevent unnecessary use of emergency health services.\u003c/p\u003e\u003cp\u003eIt has been determined that the fact that emergency health care workers are forced to work more hours due to various reasons (others' QQ, unnecessary use of emergency health units by patients, managers assigning extra tasks to people with whom they have good relationships, etc.) and not being paid in return causes a loss of motivation in the workers, and the lack of sanctions for those who QQ creates a perception of injustice. Furthermore, it has been found that other employees take QQ as an example and consequently engage in QQ themselves. It has also been found that QQers cause increased workload on other employees and create unrest in the work environment. It has been determined that one of the reasons for this situation is the uncertainty of the job descriptions of the employees. Various studies conducted in healthcare institutions have found a negative relationship between the perception of organizational justice and QQ [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e] and a positive relationship between role ambiguity and fatigue [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. In a study conducted by G\u0026uuml;ler with participants from different sectors, it was found that managers' behavior, unclear job descriptions, organizational injustice, and lack of communication cause QQ [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. Additionally, various studies in the literature have found that QQ increases the workload of other employees and decreases their motivation, making it undesirable to work with those who engage in QQ [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. On the other hand, it has been found that people with high workload [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e, \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e] and low motivation [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e] tend towards QQ. In this context, the results of this research and those of other studies in the literature support each other. These results can be interpreted as suggesting that QQ influences other employees, creating a vicious cycle in professional life. This is because QQ not only increases the workload of other employees and decreases their motivation, but increased workload and loss of motivation also cause QQ.\u003c/p\u003e\u003cp\u003eParticipants in this study noted that they exhibit various attitudes and behaviors to prevent employees from engaging in QQ. Participants stated that they prioritize fairness when assigning extra tasks to their subordinates, assigning them sequentially and favoring employees who volunteer. It was determined that the participants primarily tried to motivate their subordinates. It has been determined that some subordinates accept extra work depending on the approach of their managers. However, it has been determined that some employees react negatively to all approaches of managers and refuse to do extra work. It has been understood that in such a case, managers report the situation to the next higher manager. In addition, it was determined that some of the managers who participated in the study preferred employees who volunteered for additional duties, while others preferred to punish employees who did not accept extra duties.\u003c/p\u003e\u003cp\u003eThe research results indicate that participants are unable to develop effective strategies to prevent QQ among emergency healthcare workers. This is because, despite the strategies employed by managers, some employees' QQ cannot be prevented. In addition, participants' assignment of some employees by exploiting their relationship and favoring volunteers may cause negative experiences such as boredom, burnout, feelings of being used, and perception of injustice in these employees. Therefore, managers should closely monitor employees' QQ processes and implement more systematic strategies to prevent QQ. On the other hand, there are not enough studies in the literature on how managers can prevent QQ. Further research should be conducted on managers' actions to prevent QQ to evaluate their effectiveness. Several studies on employees' QQ processes are noteworthy [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e, \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e]. Managers' awareness of these processes should be increased, QQ actions should be identified early, and interventions should be initiated before employees experience organizational disengagement.\u003c/p\u003e\u003cp\u003eIt has been found that the negative effects of QQ on employees and the work environment sometimes extend to patients. This suggests that employees' attitudes toward patients are worse. Participants noted that QQ disrupts workflow and that some employees want to change institutions or departments as a result. G\u0026uuml;ler's study determined that QQ reduces service quality and leads to productivity loss [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. Lestari et al., in their study evaluating QQ among hotel employees in Indonesia, found that employee performance decreases as QQ behavior increases [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. It is clear that QQ has negative effects on organizational productivity and customer satisfaction. However, in this study, it is observed that the participants touched upon variables related to institutional effects to a limited extent. This may be due to the low awareness of the participants regarding institutional outputs since they were lower-level managers. Since lower-level managers directly manage processes related to service delivery, their awareness of corporate outputs should be increased.\u003c/p\u003e\u003cp\u003eThe study also investigated the pandemic's role in QQ. Based on the participants' opinions, it was understood that emergency health stations and emergency room workers were affected differently by the pandemic. Accordingly, it was stated that the workload and intensity of emergency health station workers increased during the pandemic, causing professional burnout, and that employees lacked time and were unwilling to take on extra work. It has been determined that employees working in emergency services stated that QQ decreased during the pandemic period due to reasons such as the decrease in unnecessary use of emergency services and the number of patients, work being more standardized during this period, and working hours being shortened to reduce the risk of infection. According to these results, it can be said that the pandemic had different effects on the QQ of employees in emergency health units. Conducting research on healthcare workers regarding the effects of the pandemic on QQ by taking unit differences into account will contribute to obtaining more meaningful results.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study on QQ among emergency healthcare workers found that economic, work-related, and employee-related factors inhibit actual resignation. Lower-level managers participating in the study believed that individual factors (age, years of experience, the meaning of the job, avoidance of responsibility, fatigue, etc.) were more likely to cause QQ. Accordingly, it was determined that older people are tired of their jobs and avoid responsibility, while younger people tend to engage in QQ because they dislike their jobs. Furthermore, some managerial factors were found to be associated with QQ.\u003c/p\u003e\u003cp\u003eWhile participants attributed individual reasons to the causes of QQ, the study found that managerial factors were more closely related to the consequences of QQ. Furthermore, it was found that those who practice QQ increase the workload of other employees and disrupt the peace of the work environment. Furthermore, even if patient care duties are not disrupted, unrest in the work environment negatively impacts patient attitudes.\u003c/p\u003e"},{"header":"Limitations","content":"\u003cp\u003eThis study was conducted using qualitative research methods, and data were collected from 17 participants. Therefore, the results cannot be generalized. In addition, the research data include the experiences, perceptions and evaluations of healthcare professionals who work as lower-level managers in units providing emergency healthcare services. In this context, another limitation of the research is that it concerns the experiences, perceptions and evaluations of lower-level managers in units providing emergency health services.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003cp\u003e The research's compliance with ethical principles was evaluated by the Amasya University Social Sciences Ethics Committee, and the study was approved with decision number 250640, dated 18/03/2025. Written informed consent for participation was obtained from all participants. This study was conducted in accordance with the Declaration of Helsinki.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003cp\u003e Written consent was obtained for the publication of participants' personal or clinical information and descriptive images.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003ch2\u003eCompeting interests\u003c/h2\u003e\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e\u003cp\u003eNot applicable\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eGG, contributed to all processes on her own.\u003c/p\u003e\u003ch2\u003eAcknowledgements\u003c/h2\u003e\u003cp\u003eEndless thanks to the academics who contributed to the analysis processes of this research and to the participants who participated in this research.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eFormica S, Sfodera F. 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AIMS Public Health. 2025;12(1):44\u0026ndash;55. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3934/publichealth.2025004\u003c/span\u003e\u003cspan address=\"10.3934/publichealth.2025004\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGupte A, Decoding. quiet quitting. 2022. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.linkedin.com/pulse/decoding-quiet-quitting-ashlesha-gupte/\u003c/span\u003e\u003cspan address=\"https://www.linkedin.com/pulse/decoding-quiet-quitting-ashlesha-gupte/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e Accessed 13 Sept 2025.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eJain P. The pyramid of quiet quitting. 2025. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.linkedin.com/posts/parul-jain-539010255_quietquitting-employeeengagement-leadership-activity-7369383125061132292-LXtL\u003c/span\u003e\u003cspan address=\"https://www.linkedin.com/posts/parul-jain-539010255_quietquitting-employeeengagement-leadership-activity-7369383125061132292-LXtL\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e Accessed 13 Sept 2025.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Quiet Quitting, Emergency Healthcare Workers, Managers, Healthcare Institutions","lastPublishedDoi":"10.21203/rs.3.rs-7786716/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7786716/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eObjective\u003c/h2\u003e\u003cp\u003eThis study identified the reasons, processes, consequences, and associated situations for quiet quitting among emergency healthcare workers. It also revealed why silent resignation is preferred over real resignation.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eThe study employed a phenomenological design, a type of qualitative research design. The study group consisted of low-level managers working in emergency healthcare units. Data were collected through semi-structured interviews conducted face-to-face or by telephone. A total of 17 participants were interviewed. The data were analyzed using thematic constructive content analysis.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eThe analysis identified 5 subcodes, 38 codes, 14 subthemes, and 4 themes. The findings indicated that economic reasons were the most significant factor preventing emergency healthcare workers from resigning. Individual and work-related factors were identified as the primary reasons for quiet quitting. Participants were found to have adopted various practices to prevent quiet quitting, such as being fair, assigning tasks sequentially, and selecting volunteers. It was concluded that silent resignation has various negative effects on other employees, patients, and institutions.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eThe study concluded that the practices adopted by lower-level managers to prevent quiet quitting were inadequate. Some employees resigned silently for various reasons, and this increased the workload of other employees, decreased their motivation, and negatively impacted the atmosphere of the work environment and the quality of patient care. It also revealed that further research is needed on quiet quitting in healthcare.\u003c/p\u003e","manuscriptTitle":"Quiet Quitting in Emergency Health Services: A Phenomenological Study on the Experiences of Lower-Level Managers","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-11-26 16:30:16","doi":"10.21203/rs.3.rs-7786716/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"21efe52e-be26-474c-889f-8ae82f07e60e","owner":[],"postedDate":"November 26th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-12-16T06:08:13+00:00","versionOfRecord":[],"versionCreatedAt":"2025-11-26 16:30:16","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7786716","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7786716","identity":"rs-7786716","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}