Health workforce sustainability in mental health services: A qualitative analysis of factors affecting psychologist retention in Aotearoa New Zealand

Health workforce sustainability in mental health services: A qualitative analysis of factors affecting psychologist retention in Aotearoa New Zealand | 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 Health workforce sustainability in mental health services: A qualitative analysis of factors affecting psychologist retention in Aotearoa New Zealand Kobus Du Plooy, Malcolm Stewart, Amy Kercher, Chei-Wei Hsu, Valerie Tan This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6753953/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 Background Mental health workforce shortages threaten health service capacity globally, with Aotearoa New Zealand experiencing an estimated deficit of 1,000 psychologists and public service waiting times extending to 9 months. Understanding factors influencing healthcare professional retention is critical for health workforce planning and service sustainability. This study investigated professional quality of life and retention intentions among registered psychologists to inform evidence-based health workforce strategies and improve mental health service capacity. Methods A cross-sectional, mixed-methods study collected qualitative data from 380 registered psychologists (9.8% of the national workforce) via online survey between May and September 2024. Participants responded to five open-ended questions exploring professional quality of life, burnout causes, turnover intentions, and career satisfaction. Data were analysed using inductive content analysis following established health services research methodologies. The study received University of Otago Human Ethics Committee approval (reference 23/151). Results Analysis revealed complex health workforce dynamics affecting service capacity and accessibility. Retention-promoting factors included supportive team environments, professional autonomy, manageable workloads, and adequate organizational resources. Conversely, excessive caseloads, inadequate resources, professional devaluation within healthcare hierarchies, and systemic constraints threatened workforce stability. Participants reported widespread ambivalence—maintaining commitment to mental health service delivery while simultaneously considering departure from public health services. Workforce migration from public to private practice emerged as a critical threat to service accessibility, creating significant gaps in publicly funded mental health care for vulnerable populations. Conclusions Health service organizations require evidence-based workforce retention strategies that address systemic barriers, enhance professional autonomy, provide adequate resources, and implement sustainable workload management models. These findings offer actionable insights for health service administrators and policymakers to strengthen mental health workforce capacity, improve service sustainability, and maintain accessible mental health care delivery. The research contributes to health workforce planning literature and supports the development of targeted interventions to enhance healthcare professional retention in publicly funded services. Health workforce Healthcare personnel retention Mental health services Professional burnout Health services administration Workforce planning Qualitative research Health policy Background Effective health service delivery relies fundamentally on a stable, well-supported healthcare workforce. In mental health services globally, workforce shortages threaten service capacity and accessibility, with implications for population health outcomes and health system sustainability [ 1 , 2 ]. Health workforce research emphasizes the critical importance of understanding factors that influence healthcare professional retention, particularly in publicly funded services that serve vulnerable populations [ 3 , 4 ]. The demand for mental health services in Aotearoa New Zealand has steadily increased in recent years, placing mental health professionals, including psychologists, under growing pressure and threatening service capacity. In 2017, a Psychology Workforce Task Group investigated factors contributing to healthcare professional turnover in mental health services and identified strategies to improve workforce retention [ 5 , 6 , 7 ]. This investigation revealed varying levels of job satisfaction depending on work sectors and career stages, with implications for health service planning and delivery. Healthcare professionals who left their roles in mental health services reported feeling undervalued, seeking better remuneration, and desiring improved work-life balance as primary reasons for departure. Those working in public health and social services particularly cited demand-driven stress from high workloads and burnout risk as common reasons for leaving, directly impacting service capacity. They also reported feeling undervalued and receiving poor remuneration. The top six reasons identified were: demand-driven stress; insufficient salary and career progression opportunities; ineffective work processes; ineffective clinical service delivery approaches; devaluation of healthcare professionals and their roles; and unhelpful leadership/management [ 5 , 6 , 7 ]. These workforce challenges were exacerbated by the COVID-19 pandemic, which significantly impacted population mental health needs and strained health service capacity. The global health crisis introduced unprecedented levels of stress, anxiety, and uncertainty, leading to increased mental health concerns across demographics while simultaneously challenging healthcare workforce wellbeing. Lockdowns, social isolation, economic instability, and health concerns all contributed to rises in depression, anxiety disorders, and other mental health conditions, increasing demand for services while compromising workforce stability [ 8 , 9 ]. Research by Chambers and Frampton [ 10 ] revealed that during the COVID-19 pandemic's peak, approximately 33% of psychiatrists in Aotearoa New Zealand experienced severe burnout, directly threatening service delivery capacity. Studies with other health professionals showed high burnout levels among general practitioners, attributed to increased patient complexity, limited appointment times, and excessive paperwork [ 11 ], and among nurses, citing lack of supervision [ 12 ]. Although burnout risk was identified among medical consultants and counsellors, these risks appeared mitigated by perceptions of supportive work environments [ 13 ] and compassion satisfaction [ 14 ], respectively. Concurrently, international health workforce research documented declining mental wellbeing among healthcare professionals. The British Psychological Society [ 15 ] documented declining mental wellbeing among UK mental health professionals, primarily attributed to rapid transitions to remote work, increased ethical challenges, and heavier workloads. In Australia, mental health professionals reported heightened anxiety, depression, and professional burnout [ 16 ]. Similarly, research observed elevated professional exhaustion among Belgian healthcare professionals during this period [ 17 ]. In Aotearoa New Zealand, studies exploring mental health professionals' experiences examined professional quality of life, including Compassion Fatigue, considering factors such as burnout, secondary traumatic stress, and psychological distress [ 18 , 19 ]. Research during the pandemic revealed New Zealand mental health professionals exhibited notably higher burnout and secondary traumatic stress compared to similar healthcare professional groups, threatening service sustainability. During this period, significantly reduced resilience rates and higher stress rates were observed [ 19 , 20 ] compared to earlier measurements among New Zealand healthcare professionals [ 21 ] and professionals in other countries [ 22 ]. Aotearoa New Zealand, like many countries, has experienced exponential increases in demand for mental health services, with widening disparity between access and demand, creating critical health service capacity challenges. Before the COVID-19 pandemic, New Zealand had approximately 3,713 registered psychologists [ 23 ], with 1,639 registered under the clinical scope of practice. This translated to approximately one clinical psychologist for every 145 individuals experiencing mental disorders. Since then, this gap has widened further due to COVID-19 impacts on both healthcare professionals and society, severely compromising service accessibility [ 24 ]. A 2021 report highlighted the critical shortage of mental health professionals, citing 6–9 month waitlists and estimating need for approximately 1,000 additional psychologists to address current demand [ 25 ]. Examining a comprehensive array of factors related to healthcare professional wellbeing is essential for health workforce planning and service sustainability. Considering elements such as purpose, meaning, effort, emotional state, exhaustion, burnout, career intentions, and daily job analysis provides valuable insights into risk and protective factors for health workforce retention. This multifaceted approach elucidates the interplay between components affecting job satisfaction, resilience, and mental health among healthcare professionals. Investigating these factors can identify profession-specific stressors and satisfaction sources, informing targeted interventions and support systems for mental health professionals and contributing to health workforce sustainability. The current project aims to investigate mental health professionals' experiences, exploring professional quality of life, causes of burnout and compassion fatigue, intention to leave the profession, and ideas to improve professional experiences within a health services research framework. This qualitative approach facilitates identification of emerging trends and potential challenges, enabling development of proactive strategies to support the mental health workforce and enhance mental health service quality and accessibility. In addition to studying the overall mental health workforce in New Zealand, this research analyses findings across various practice areas including clinical, counselling, neuropsychology, education, general, trainee, and intern psychologists [ 26 ]. This comparison is crucial for health workforce planning because responsibilities and experiences vary across different practice scopes, requiring tailored retention strategies. Additionally, comparisons will be made between healthcare professionals who identify as Māori and those who do not, recognizing the critical importance of cultural diversity in health workforce planning. Indigenous approaches to mental health care, such as Māori psychology, have historically been sidelined within broader healthcare delivery in New Zealand [ 27 ]. Although recent efforts have promoted equity and bicultural practices in health services, many Māori healthcare professionals still encounter obstacles including racism, disadvantage, and lack of culturally appropriate support throughout training and practice [ 28 ]. These challenges persist as Māori healthcare professionals strive to integrate indigenous approaches into mainstream health service delivery [ 29 ]. Qualitative data in this study offers a valuable approach for gaining deeper insights into healthcare professionals' experiences and informing health service improvements. Qualitative methods allow exploration of nuanced and complex aspects of healthcare professionals' work lives, capturing rich, detailed narratives that quantitative data alone might miss. Through open-ended questions, we can explore subjective experiences, emotions, and perspectives as healthcare professionals navigate challenges of increased demand, potential burnout, and pandemic impacts on their practice. This approach enables more comprehensive understanding of factors contributing to job satisfaction, stress, and resilience within health service contexts. Qualitative data can reveal personal coping strategies, workplace culture impacts, and subtle ways professional experiences shape healthcare professionals' wellbeing and career intentions. Additionally, this method allows exploration of context-specific issues unique to the New Zealand health system, providing culturally relevant insights that can inform targeted interventions and policy decisions to effectively support the mental health workforce and improve service delivery. Aim To investigate the current professional quality of life and intentions to leave the profession among mental health professionals in Aotearoa New Zealand, providing evidence to inform health workforce planning and service sustainability strategies. Methods Design This investigation adopted a cross-sectional, mixed-methods approach using an online survey platform (Qualtrics), designed to inform health workforce research and policy. The present paper reports the qualitative findings, while quantitative analyses were still being undertaken at submission and will be published separately. Procedure The study was approved by the University of Otago Human Ethics Committee (reference 23/151). Research information and participation invitations were distributed via email through professional organizations and groups for mental health professionals in New Zealand, including the New Zealand Psychological Society, New Zealand College of Clinical Psychologists, Te Whatu Ora/Health New Zealand, Department of Corrections, High-Performance Sport New Zealand, New Zealand Defence Force, Ministry of Education, He Paiaka Tōtara (Māori psychologists' organization), Le Va (organization including Pasifika psychologists), and through researchers' professional networks. Participants were encouraged to forward the invitation to colleagues who might not have received it, particularly those working solely in private practice. An invitation was also placed at the registration desk of the 2024 New Zealand Psychological Society's Annual Conference with a QR code for survey completion. Participation was voluntary and anonymous. Participants could register to win one of five NZ $ 50 gift vouchers in recognition of their contribution. To preserve confidentiality, contact details for the prize draw were collected separately from survey responses. Participants agreed to participate by clicking a survey link after reviewing the participant information sheet; data was collected between May and September 2024. Participants This study targeted psychologists registered to practice in New Zealand, representing a significant portion of the mental health workforce. As invitations were distributed only to registered healthcare professionals through professional organizations, all recipients were eligible to participate. Data cleaning revealed that 27 respondents began but did not complete sufficient questions (discontinuing after demographic questions) and were excluded from final analyses. Online Survey The survey collected demographic data including age, gender, ethnicity, and professional details such as registration scope, country of training, and workplace type. Participants completed psychometric questionnaires (results reported elsewhere) and answered five open-ended questions designed to inform health workforce research: How would you describe your current professional quality of life as a psychologist working in Aotearoa New Zealand? What do you believe could be the main causes of burnout and compassion fatigue amongst psychologists in Aotearoa New Zealand? How would you describe your current turnover intentions? (i.e., your feelings about leaving or staying in the profession of psychology) What do you believe are some of the main reasons some psychologists could be considering when thinking about leaving the profession in Aotearoa New Zealand? If you could go back in time, would you pursue a different career instead of psychology based on what you know now? Data Analysis Inductive content analysis was used to analyse the data, following established health services research methodologies. This approach focuses on analysing responses without preconceived categories, allowing the data to guide analysis and identify categories within the data relevant to health workforce planning [ 30 ]. Following the process outlined by Elo and Kyngäs [ 31 ], analysis involved three phases: preparation, organizing, and reporting. All responses were downloaded into an Excel spreadsheet. During the preparation phase, the first author (KDP) read and re-read all responses for full immersion in the data. During the inductive analysis phase, he used open coding to write notes and headings on coding sheets while reading participants' responses. Categories emerged organically and were grouped under higher-order headings to reduce initial headings by collapsing similar ones. These were re-categorized to clearly describe the data, increase understanding of the research topic, and generate new knowledge relevant to health workforce sustainability. During the final abstraction phase, categories were named using content-characteristic words to produce a general description of the overall research topic. This produced a list of main and sub-categories for each question, which were sent to the other authors (CWH, AK), who individually examined the responses and categories generated by the first author before agreeing on final sub- and main categories. There were few differences of opinion between authors following their analyses, and after discussion, agreement was reached about the categories that best represented the data for health workforce research purposes. Results Sample The study sample consisted of 380 participants (approximately 9.8% of registered psychologists in New Zealand during February 2024; New Zealand Psychologists Board, 2024), representing a substantial portion of the mental health workforce. In some instances, participants could select multiple options or opt not to answer certain questions, so totals do not always equal 100%. Regarding gender, 80% identified as female, 19% as male, one as a trans man, and one participant did not answer. Age distribution was: 8% between 20–29 years, 26% between 30–39 years, 30% between 40–49 years, 22% between 50–59 years, 11% between 60–69 years, and 3% were 70 years or older. For ethnicity, 74% identified as New Zealand European, 9% as Māori, 0.4% as Pasifika, 3% as Asian, 27% as other, while 29% did not answer. 79% completed their psychology training in New Zealand and 21% in another country. Regarding primary work settings, 47% worked in public health services, 26% in private practice, 14% for other government departments, 4% at universities, 3% for private sector organizations, 1% for iwi organizations, and 17% in other employment places. In terms of scope of practice, 68% were registered as clinical psychologists, 18% under the general scope, 2.5% as counselling psychologists, 2.5% as educational psychologists, 0.5% as trainee psychologists, and 8% as intern psychologists, with 2% also holding the neuropsychologist scope. Health Workforce Sustainability Factors The first two open-ended questions investigated healthcare professionals' experiences related to professional quality of life, providing critical insights for health workforce planning. Content analysis explored factors linked with high and low professional quality of life that directly impact workforce retention and service sustainability. Table 1 summarizes the main categories with their respective sub-categories. Table 1 Professional Quality of Life among Mental Health Professionals Factors Enhancing Workforce Retention Factors Threatening Workforce Stability Individual Engagement in Health Service Delivery Healthcare Professional Burnout - Job satisfaction in patient care - Excessive workload and work stress - Meaningful client work - Increased service user complexity - Healthcare staffing shortages - Excessive work hours Healthcare Team and Organizational Support Health System Challenges - Supportive colleagues and peers - Professional undervaluation - Supportive healthcare teams - Inadequate compensation - High quality clinical supervision - Poor resources and working conditions - Support from professional bodies - Limited professional development opportunities Professional Autonomy in Health Service Delivery Health System Pressures - Ability to manage workload effectively - Public and service user knowledge gaps - Professional autonomy in clinical practice - Unrealistic public and service user expectations Personal Impact of Health Service Work - Difficulty prioritizing personal wellbeing - Life stage transitions - Work-life balance challenges Factors Enhancing Health Workforce Retention Participants reported a variety of factors related to high professional quality of life that directly support workforce retention and service sustainability, such as gaining satisfaction from helping patients, the intellectual challenge of healthcare work, having good team support, and having autonomy and flexibility over their workload. Examples of their engagement in health service delivery were highlighted in the following comments: 'I enjoy being a psychologist, I love helping people.' 'Working with clients, continual learning and development, helping others all contribute to enjoyment in my role.' 'My day-to-day work is very enjoyable despite the pressures of time and limited resources.' Many also reported that peer and team support, including support from professional bodies, was an important source of professional quality of life and workforce retention: 'I work with amazing caring teams which come together to support each other. This is so important.' 'The key to this I think is that I only work 2 days per week in private practice and have very good supervision and pretty good collegial support.' 'My professional quality of life is enormously impacted by working within a supportive team. I do not think I would be able to cope with the demands of the job if this was not the case. I have a competent, supportive, protective manager, and colleagues that look after my well-being as I do theirs. I cannot overstate how much this helps my overall well-being.' Many respondents further mentioned the importance of work-life balance, professional autonomy, and organizational changes to manage their workload effectively: 'It has not always been this satisfying but with a recent change to a leadership role I now have a better balance of activities, less hands-on clinical work, more autonomy. As a consequence of this improved balance, I feel more stimulated and motivated with improved wellbeing.' 'Fulfilling [professional quality of life], particularly since I have now been running my own full time private practice for 7 years. While it was a big step away from organisations/agency working most of career - I have enjoyed to freedom and away from workplace and setting stresses. This has been liberating for me, and I still manage to connect professionally with others being a senior psychologist with intentional professional networks.' 'I enjoy my job in private practice and for the most part have an excellent professional quality of life. Being in control of my own work hours, case load and daily schedule (e.g. balancing sessions so that I don't see more than one or two trauma clients a day) is a major factor in this.' Factors Threatening Health Workforce Stability Participants identified factors linked to lower professional quality of life that directly threaten workforce retention and health service capacity, including the challenging nature of working in mental health services in New Zealand at present, particularly within the public health system. The main factors associated with reduced professional quality of life and increased turnover risk included burnout, systemic health service challenges, societal pressures, and personal impacts of healthcare work. Increased risk of burnout was associated with workload stress, such as high caseloads, pressure to see increasing numbers of service users, feeling overwhelmed by never-ending tasks with insufficient time to complete them, excessive work hours, and increasingly complex, high-acuity patients with severe mental health challenges and trauma histories. This was described as emotionally and mentally draining, directly threatening service quality and workforce sustainability. Participants frequently described how the lack of mental health professionals in services throughout the country places a greater burden on those who are still available and makes it difficult to deliver the desired standard of care: "Burnout and difficulties maintaining a work-life balance." "In one word: Challenging. The overall lack of psychologists, particularly within [the public health system], places a greater burden on psychologists that are available to deliver the same quality and type of service." "At times my professional quality of life is sub-optimal due to the high workload and the complexity of clients. It can be difficult to achieve a sense of satisfaction when working with individuals with such high needs." A sense of helplessness was often described by participants, particularly those working in public health and social services, which may contribute to burnout and threaten service sustainability: "the care we wish to provide to people isn't possible in the current conditions/system which feels very helpless and demotivating." Systemic factors leading to low professional quality of life and threatening workforce retention included feeling undervalued, underpaid, and unappreciated; having insufficient resources to work well and/or safely; a lack of understanding from other healthcare professionals and management, and a perceived lack of support from professional bodies. Feeling undervalued, underpaid, and unappreciated by health service employers/organizations, especially in public health and social services compared to private practice was frequently mentioned as a threat to workforce retention: "I love the work that I get to do with clients, and the teams that I get to work with in [public health system], however, I often feel unappreciated and burnt out by the system. The complexity of clients, lack of resources, high demands and feeling unsupported and unappreciated by the system, organisation and union all contribute to a decrease in my professional quality of life as a psychologist." Healthcare staffing shortages in mental health services were also reported to create challenges in providing adequate care and maintaining service quality: 'The demand for psychological services is high. The number of psychologists available to do the work is limited.' Employment conditions in health service organizations, particularly in public health and social service organisations, including relatively low wages, a lack of professional development opportunities, and limited career progression were seen as lowering professional quality of life and threatening workforce retention: "Burnout, overworked and underpaid. Knowing overseas psychologists earn much more for the same work." These systemic difficulties in public health services were seen as motivating many healthcare professionals to work in private practice, creating service gaps in publicly funded care: "The lack of support and resource in the public sector makes working there extremely challenging. Moreover, interacting with agencies such as ACC and their systems make third party work unattractive. I believe this results in people moving into private practice." However, for healthcare professionals outside of public health and social services, especially those in private practice without collegial support, isolation and difficulty achieving work-life balance and boundaries, was seen as challenging for workforce sustainability: 'This work can be very isolating, the acuity and complexity in private is increasing and private practitioners are unsupported by crisis services. The health system is not functioning well overall in my view, and this makes practice as a psychologist very challenging.' Participants also expressed concerns that regulatory bodies, through some initiatives and their perceived lack of advocacy for the profession, lowered professional quality of life for some healthcare professionals: 'The Board's current project of reviewing scopes of practice is misguided & is harming the profession' Societal factors contributing to poor professional quality of life included perceived lack of understanding of mental health professionals' roles by service users, the public, and other healthcare workers: "[There is] a lack of understanding of what psychologists do [in society]." "[There is] a poor understanding by non-psychologist managers about the pressures of the role." Participants also reported personal factors that contributed to feeling overwhelmed and burnt out, impacting workforce sustainability. This included experiencing poor work-life balance: "It is difficult to maintain a good quality of life, balancing between providing a psychology service and allowing time to acquire and learn the skills outside of work hours, so I can deliver appropriately within hours." "I took on a role that was underfunded but because of my work ethic and desire for the role to succeed, I have given up a lot of personal time to do the tasks required. This has had a significant impact on my personal life, including my physical wellbeing. After 12 months, I realised that my capacity, desire, and interest to explore and learn about psychological concepts and ideas had greatly reduced." Health Workforce Migration and Retention Intentions Three questions addressed participant's intention to stay in or leave mental health service delivery, providing critical insights for health workforce planning and factors that were associated with this decision. To assess orientation towards career change irrespective of career stage, respondents were asked if they could go back in time, based on what they know now, would they pursue a different career . Of 129 respondents who answered this question, 16% answered they would pursue a different career, 32% said they would not pursue a different career, 44% answered 'possibly', and eight percent answered 'uncertain'. Most respondents expressed the intention to continue working in mental health services, at least in the short- to medium term. However, many also expressed mixed feelings about their profession; while they wanted to stay in healthcare due to their passion and commitment to service users, they simultaneously considered leaving due to frustration with systemic issues like lack of organizational support, high workloads, and feeling undervalued within health service hierarchies. Table 2 summarizes the main reasons participants stated for staying in or leaving mental health service delivery, providing important insights for health workforce planning. Table 2 Factors Related to Health Workforce Retention and Migration Reasons for Workforce Retention Reasons for Workforce Migration Individual Commitment to Health Service Delivery Healthcare Professional Burnout - Enjoying work with service users - High case loads - Learning and intellectual challenge of healthcare work - Increased complexity of service users - Passion for mental health service delivery Financial Considerations in Health Workforce Health Service Compensation Issues - Need to make a living - Inadequate compensation in public services - Investment in professional training - Opportunities to earn more elsewhere/different types of work - Unable to afford career retraining - Better pay-to-living-cost ratio in other countries (e.g., Australia) Career Stage in Health Services Health System Factors - Close to retirement from health services - Healthcare understaffing - Poor support from management, leaders, colleagues - Poor leadership in health services - Systemic difficulties outweighing job satisfaction - Feeling undervalued and unsupported in health services - Frustration with health system constraints - Regulatory concerns affecting professional practice Personal Factors Affecting Health Service Work - Exploring new interests and careers outside healthcare - Life stage transitions - Difficulties achieving desired work-life balance in health services Reasons for Health Workforce Retention Enjoyment and engagement with healthcare work was a common reason provided for staying in mental health services. Participants reported enjoying their work with service users, feeling passionate about healthcare delivery, and viewing it as meaningful work: 'I am very happy with the work that I do.' '[I intend to] stay in [psychology] for the long run as I feel very passionate about this work, especially working with youth and under resourced communities.' 'I enjoy my profession. I enjoy my role. I intend to remain in this profession until I retire.' 'I believe in the profession and believe I hold a position of skill and provide good services to people who need it. I have worked in the profession for over 3 decades' Financial reasons were also stated for staying in mental health services, like having invested significant time and money into their qualifications, and being unable to afford or unwilling to retrain in another profession: 'I feel trapped because I have invested so much into my qualification. I don't have the option to retrain, nor can I afford to increase my student loan anymore. I had no idea how much I would feel that psychologists are severely underpaid for the level of risk they manage.' 'I regularly think about leaving psychology. However, I feel trapped as financially I cannot afford to retrain for a different career. I often wonder how I will sustain 30 plus years in this career' Some participants were approaching retirement age and were therefore not interested in changing careers but interested in reducing their hours within health services: And as I am heading to retirement age, I am thinking about working less hours and at some point, not working in the profession anymore. Reasons for Health Workforce Migration Despite many healthcare professionals still feeling committed to remaining in mental health services, many were seriously considering or had already decided to leave, creating significant concerns for health service capacity. Burnout, compassion fatigue, and difficulties maintaining work-life balance due to high workloads and caseloads with increasingly complex service user presentations were key concerns that influenced orientation towards leaving health service delivery: 'I do think this role has a shelf life for me, in that at some stage the emotional weight of the work will no longer be sustainable for the relative gains.' 'Acuity and high workloads.' ; '...the increase of acuity and complexity [of cases] without associated time/energy/space/capacity to handle said cases effectively.' 'Feelings of frustration, burnout, and being fed up with high caseloads and an apparent lack of hope that this situation will improve anytime soon.' 'Burnout, compassion fatigue, and just general fatigue. A desire for my lifestyle balance. I think it's also a big reason behind psychologists moving into private practice and/ or part time work.' Insufficient compensation was also frequently mentioned as a reason why healthcare professionals were considering leaving mental health services, especially given the level of responsibility and years of training required: 'Insufficient pay given the level of responsibility provided to psychologists...' 'I think about whether this is the profession for me but feel stuck because it cost me so much to enter the profession (money, years of my life, opportunity costs). I see roles that require no degrees that pay more, and I wonder what on earth I'm doing here?!' 'It is probably a job I would leave or cut down significantly if I had an alternative income steam that allowed me a similar sense of fulfilment without the comparative cost to self. Or if I had a windfall that allowed me to do something completely unrelated and more passion driven.' Many respondents were considering opportunities in other countries, particularly Australia, where it was perceived they would earn better wages while simultaneously be able to maintain a more optimal work-life balance, representing significant health workforce migration: 'I would be more likely to leave NZ but remain in psychology [the profession], for example in Australia - better pay and more development opportunities.' 'One of my interns went to Australia when she graduated and started on a salary of $NZ120k. It's depressing.' ; ' I am planning to go private in the future for financial reasons, once I feel I have enough experience to be comfortable to do so.' 'I don't see myself working in the public sector long term for those financial reasons which I think is a shame for our people who already struggle to access psychology support. However, I am not here for charity, I am here to work and make money to support my own life and whānau. I have also considered moving to Australia with my partner as we could both earn significantly more money. It is whānau and the NZ lifestyle that keeps us here, certainly not our jobs.' A lack of support or recognition and feeling undervalued by health service employers/organizations were also indicated as common reasons for many deciding to leave healthcare. Many also did not feel that their expertise was being respected, especially within existing medical model hierarchies in health services: 'I'm pushed towards [intending to leave] by inflexibility, managers that only care about SMOs.... Plus, I could earn a lot more doing other things and have more time with my whānau.' Poor working conditions in public health and social services, including healthcare understaffing, lack of resources, and unsupportive management was also reported as threatening workforce retention. Frustration with these types of systemic issues in mental health care and feeling unable to effectively help service users due to these constraints prompted many to leave or cut down their involvement in health service delivery, especially those employed in public health and social services: 'Poor quality of offices and equipment, psychologists often working in prefabs, underground offices without windows, no wall art or shared office decorations or comfortable seating, location not near cafes/park or places to be able to leave the office for a break during the day, psychologists often underappreciated and not recognised the amount of necessary but often unbillable time required e.g. often ethical obligations to follow-up are required but not funded so come out of personal time. Compared to professionals in other industry/business with equivalent training there are few perks, low pay, poor work conditions and high responsibility.' 'I also think that there is a huge disconnect between the psychologists on the ground level [in the public health and social services] and the management who only see numbers/systems. When staff don't feel heard, prioritised, and supported, that has a huge impact on feelings of burnout.' 'Understaffing. Medical model equals disrespect for psychology, from upper management, and from other disciplines. Space issues like sharing offices, moving offices around, and thus instability.' Recent regulatory actions around proposed scope of practice changes were also cited by many as a reason for leaving or considering leaving health service delivery, as it has led to distrust and fear around their future professional practice: 'One of the most stressful issues at the moment is the potential for the scopes of practice to seriously impact my ability to do my job. I am unsure what my career will look like in future or what prospects it holds.' 'I intend to leave, mainly due to the NZ Psychologists Board's review of scopes.' 'I am concerned about the impact that the board is having by the scopes of practice review. I feel that it is very invalidating for a general psych and if I was ringfenced off doing therapy or working with clients I currently am, I would leave the profession as I am working with populations which are my passion.' A desire for better career progression, professional development opportunities, and the ability to specialize also led some healthcare professionals to consider leaving mental health services: 'Seeing little prospect for [career] progression.' 'I think we tend to take on more than is ideal for our own well-being due to systemic issues such as needing to work a certain number of hours to meet personal financial commitments which offers little scope for us to be able to attend to our own personal development and growth (alongside professional development and growth).' 'I work in a rural area and there are not the opportunities to specialise [here] as there are in cities.' Finally, certain personal factors like prioritizing personal well-being, exploring new interests, or life changes like retirement were mentioned by some as reasons for deciding to leave health service delivery: 'I love the work that I do, but am definitely putting thought into what I want the remaining years of my career to include. If the demand continued as it is right now, I would think about pulling back from certain work commitments to prioritise my own self-care and personal well-being.' 'Possibly considering continuing with the profession but outside of Aotearoa New Zealand where pay could be better. Or possibly leaving the profession altogether to pursue other career interests that might not require as much demand or carrying of risk.' 'Moving towards retirement age and planning a gradual reduction in hours over the next 3–5 years.' Discussion While many mental health professionals currently appear to remain committed to health service delivery, dissatisfaction with working conditions, lack of organizational support, and poor compensation have led many to consider alternative career paths, working outside Aotearoa New Zealand, or ceasing working in publicly funded health and social services, with significant implications for service capacity and accessibility. Overall, the data highlighted that excessive workload, a lack of support and resources, and working within an under-resourced mental health system seemed to be significantly lowering professional quality of life and increasing intentions to leave health service delivery among many healthcare professionals at present. This is of critical concern for health service planning given that Aotearoa New Zealand already has a clearly identified shortfall in its ability to provide access to mental health services for people who need them, either in general [ 23 ] or through the publicly funded health and social services [ 7 ]. Aotearoa New Zealand also has a limited ability to expand the mental health workforce to meet the gap, with approximately 150 interns and trainees across the training programmes for all scopes of practice annually, plus approximately 40 overseas-trained psychologists joining the workforce each year, and approximately 90 psychologists leaving the profession each year [ 5 ]. This gives a net annual growth of around 100 practising psychologists across all sectors (e.g. health, Corrections, education, Oranga Tamariki, private practice, ACC, non-government organisations, private firms, etc; [ 5 ]). In a situation in which workforce growth is urgently needed for health service sustainability, but there are relatively few new entrants into the workforce, staff retention becomes particularly important for maintaining service capacity. This paper has explored barriers to retention of healthcare staff, particularly related to factors that contribute to healthcare professionals leaving and those that may contribute to them staying in the health service workforce. Health Service Capacity Implications The two primary variables explored in the current analyses are professional quality of life and intention to stay in or leave the Aotearoa New Zealand mental health workforce, both critical factors for health service planning. Many factors that were identified as determinants of higher or lower professional quality of life were also identified as key drivers of intention to stay in or leave mental health service delivery in Aotearoa New Zealand. This suggests that positively modifying the factors related to professional quality of life for healthcare professionals is likely to reduce intention to leave health services and thereby improve workforce retention and service capacity. Many healthcare professionals reported experiencing low professional quality of life at present, especially those working in the public health and social services sector, directly threatening service sustainability. This was expressed as ambivalence about wanting to stay in health service delivery, but also considering leaving due to the frustration with the issues associated with low professional quality of life. While some healthcare professionals considered leaving health services entirely, many saw the solution to this ambivalence as being either to go into private practice or to go overseas, creating significant implications for publicly funded service accessibility. Health Workforce Migration Patterns Respondents widely associated private practice with higher professional quality of life, particularly in relation to better remuneration and more autonomy and flexibility, and with less stress and workload problems, and fewer systemic difficulties that were associated with intentions to leave public health services. Going overseas was associated with better remuneration and some other advantages, representing health workforce migration that threatens service capacity. There is also considerable demand for private practice mental health professionals in Aotearoa New Zealand, with many service users having trouble finding accessible services or waiting on long waitlists, so moving to private practice is a realistic option for many healthcare professionals but creates gaps in publicly funded services. Comparison with Previous Health Workforce Research The results of the current study echo closely and expand on the study by the Psychology Work Force Task Group [ 6 ] completed prior to the COVID-19 pandemic which identified demand driven stress; insufficient salary and career progression opportunities; ineffective work processes; ineffective clinical service delivery approaches; devaluation of healthcare professionals' work and contribution; unhelpful leadership and management performance; stress due to inadequate staff numbers; ineffective organisational structure and function; lack of necessary physical resources; and inadequate working conditions as the top ten most common reasons (in decreasing order of frequency) why health staff considered leaving, or had left, employment in the health and social services. Identical analyses as part of the same study [ 6 ] for two other large government employers of healthcare professionals showed similar reasons for considering leaving or having left employment with them. This appeared consistent with the findings of Kercher et al [ 19 , 20 ] during the COVID 19 pandemic who found elevated levels of Compassion Fatigue (burnout and secondary traumatic stress), stress symptoms, depressive symptoms and low resilience, along with good Compassion Satisfaction (the pleasure derived from being able to do one's work well) among Aotearoa New Zealand healthcare professionals during that time. As we currently transition out of the pandemic, participants in the current study described similar factors to the aforementioned studies as limiting their professional quality of life and discouraging them from staying employed in health and social services. This confluence of results using somewhat different methodologies prior, during, and following the pandemic suggests that the results are robust and represent persistent challenges in health workforce retention. That these studies yield similar results suggests minimal change in conditions for healthcare professionals over this time, indicating ongoing threats to service sustainability. Health Services Research Framework for Workforce Retention The current study's focus on professional quality of life gives a useful framework for planning initiatives for improving workforce retention as we look towards the future of mental health service delivery in Aotearoa New Zealand. Several respondents indicated their intentions to leave health services, or the health and social services sectors could change if there were improvements in the factors leading to this intention. Focusing on initiatives that help to increase professional quality of life and addressing factors associated with low professional quality of life would provide a useful pathway for improving retention within health service delivery and particularly within the health and social services sector. In the Psychology Workforce Task Group [ 6 ], respondents identified improved management/leadership approach; strategies to reduce demand-driven stress; establishing more effective work processes; salary and career development; provision of necessary resources and working conditions to do the job well; explicitly valuing healthcare professionals' contribution; improving effectiveness of clinical practice; sufficient workforce numbers to meet demand; improving overall clinical team function; and developing a positive organisational culture as being the top ten strategies (in decreasing order of frequency) for improving staff retention. These initiatives are consistent with what would be expected to improve professional quality of life as explored in this study and support health service sustainability. Policy Recommendations for Health Service Organizations Based on these findings, health service organizations should consider implementing evidence-based workforce retention strategies that address: Workload Management : Implementing sustainable caseload models and adequate staffing ratios to prevent burnout and maintain service quality. Organizational Support : Developing comprehensive support systems including supervision, peer support, and professional development opportunities. Professional Recognition : Ensuring appropriate compensation, career progression opportunities, and recognition of healthcare professionals' expertise and contributions. Resource Adequacy : Providing sufficient physical resources, equipment, and working conditions to support effective service delivery. Leadership Development : Training healthcare managers in supportive leadership practices that value healthcare professionals and promote positive organizational culture. Work-Life Balance : Implementing policies that support healthcare professionals' wellbeing and prevent burnout through flexible working arrangements and wellness programs. Limitations There were several limitations in the present study and areas that could be improved in future health workforce research. The sample comprised 9.8% of all registered psychologists in Aotearoa New Zealand, recruited via invitations through professional groups. This means that there may be a sampling bias towards participants who had a particular interest in the subject matter of this study and that our sample may not be reflective of thoughts from all New Zealand mental health professionals. Given the qualitative nature of the data, however, our aim was not to generalise to the entire mental health workforce but to glean a richer understanding of professional quality of life and intentions to leave health service delivery among Aotearoa New Zealand healthcare professionals. To this effect, we have achieved our aim of the study. Furthermore, a comparison of the demographics of our sample to participants in the Psychology Workforce Task Group [ 5 ] survey indicated close consistency on gender, age, ethnicity, primary place of work, and scope of practice, suggesting that the demographic mix for the current sample is likely a strong representation of the New Zealand mental health workforce. The use of open questions with free-text written responses and an inductive analytic method do not constrain responses in pre-determined categories so emergent categories can be discovered, but it can lead to variability in responses as different respondents may write about different issues. This was managed in the current study by focusing on the emergent themes without attempting to assess their frequency. Future exploration of this area with different qualitative and quantitative health workforce research approaches would strengthen our understanding of the research topic. This may include strategies such as individual interviews or focus groups for gathering further in-depth information about health service experiences. All healthcare professionals were asked the same questions and to date no analysis of sub-groups has been completed (e.g., groups defined by ethnicity, age, work setting, or scope of practice). This may lead to nuances between the experience of different groups of healthcare professionals being missed, for instance, a Māori clinical psychologist working in a Department of Corrections facility may have a very different experience than a Chinese Educational Psychologist working in a school setting. This is one of the aims of the quantitative data analysis that will be published separately, however, additional future health workforce research exploring these variations in experience may be valuable for health service planning. For example, understanding determinants of professional quality of life for Māori healthcare professionals, and factors promoting their intention to stay within health services may be of relevance to meeting the health needs of the Māori population. Māori comprise approximately 16.5% of the total New Zealand population and are disproportionately represented as service users in many health and social services. Māori mental health professionals are recognised as having a particularly important role in especially assisting Māori service users but currently comprise only 7.5% of the mental health workforce [ 32 ]. Some initiatives are in place to build the number of Māori healthcare professionals, but the need to ensure that conditions supporting high professional quality of life and intention to stay within health services are particularly important for Māori healthcare professionals and service accessibility. These limitations mean that this research should be interpreted with appropriate consideration for health workforce research methodology. Conclusions This study investigated the current professional quality of life and intentions to leave mental health service delivery among Aotearoa New Zealand healthcare professionals, providing vital information for health workforce planning and developing strategies to improve workforce retention and service sustainability. Findings highlighted processes that may lead many healthcare professionals to be suffering from burnout and low professional quality of life and to consider leaving mental health service delivery, particularly in the public health and social services throughout Aotearoa New Zealand. Given the importance of mental health services to the health and wellbeing of the population [ 33 , 34 ], this is concerning and requires urgent preventative action from health service administrators and policymakers. From a health equity perspective, improving access to mental health services through public health and social services is particularly important for vulnerable populations. This study indicates that initiatives that would improve professional quality of life and counteract intentions to leave are urgently required as they would improve the retention of healthcare professionals in public health and social services and more broadly in New Zealand's health system. Some remedial initiatives suggested by the Psychology Workforce Task Group [ 7 ] appear to still be highly relevant to addressing the findings of this study and future health workforce research should ideally focus on tailored interventions to enhance workforce retention, especially among underrepresented groups like Māori healthcare professionals, to ensure sustainable and equitable mental health service delivery. Declarations Ethics Approval and Consent to Participate This study was approved by the University of Otago Human Ethics Committee (reference 23/151). All participants provided informed consent by agreeing to participate after reviewing the participant information sheet. Consent for Publication Not applicable - no individual participant data, images, or videos are included. Competing Interests The authors declare that they have no competing interests. Funding Not applicable - no specific funding was received for this study. Author Contribution KDP designed the study, collected data, conducted the analysis, and drafted the manuscript. CWH and AK contributed to the study design, data analysis, and manuscript revision. All authors read and approved the final manuscript. Acknowledgement The authors thank all psychologists who participated in this study and the professional organizations that facilitated recruitment, including the New Zealand Psychological Society, New Zealand College of Clinical Psychologists, and other healthcare organizations that supported data collection. Data Availability The qualitative datasets generated and analysed during the current study are not publicly available due to the confidential nature of participant responses, but anonymized data summaries are available from the corresponding author on reasonable request and with appropriate ethical approval. References World Health Organization. Global strategy on human resources for health: Workforce 2030. Geneva: WHO; 2016. Scheffler RM, Bruckner TA, Spetz J. The labor market for human resources for health in low- and middle-income countries. Washington, DC: World Bank; 2013. Buchan J, Dhillon IS, Campbell J. Health employment and economic growth: an evidence base. Geneva: World Health Organization; 2017. Liu JX, Goryakin Y, Maeda A, Bruckner T, Scheffler R. Global Health workforce labor market projections for 2030. Hum Resour Health. 2017;15:11. Psychology Workforce Task Group. The Aotearoa NZ Psychology Workforce Survey. New Zealand College of Clinical Psychologists; 2016. Psychology Workforce Task Group. Retaining the psychological workforce. New Zealand College of Clinical Psychologists; 2017. Psychology Workforce Task Group. How many psychologists? A discussion paper about the number of psychologists needed in the health services in NZ. New Zealand College of Clinical Psychologists; 2017. Ministry of Health. Annual Data Explorer 2021/22: New Zealand Health Survey. Wellington: Ministry of Health; 2022. Chambers CN, Frampton CM. Burnout, stress, and intentions to leave work in NZ psychiatrists: A mixed methods cross-sectional study. BMC Psychiatry. 2022;22:380. Chambers CN, Frampton CM. Burnout, stress, and intentions to leave work in NZ psychiatrists: A mixed methods cross-sectional study. BMC Psychiatry. 2022;22:380. Royal New Zealand College of General Practitioners. Survey results raise concern for the health and sustainability of general practice. 2021. Available from: https://www.rnzcgp.org.nz/RNZCGP/News/College_news/2021/Survey_results_raise_concern_for_the_health_and_sustainability_of_general_practice.aspx Kalliath TJ, Beck A. Is the path to burnout and turnover paved by a lack of supervisory support? A structural equations test. N Z J Psychol. 2001;30:72–80. Surgenor LJ, Spearing RL, Horn J, Beautrais AL, Mulder RT, Chen P. Burnout in hospital-based medical consultants in the New Zealand public health system. N Z Med J. 2009;122:1300. Temitope K. Secondary traumatic stress, burnout and the role of resilience in New Zealand counsellors: A thesis presented in partial fulfilment of the requirements for the degree of Master of Arts in Psychology at Massey University, New Zealand. 2014. British Psychological Society. The impact of Covid-19 on the wellbeing of psychologists. London: BPS; 2020. Northwood K, Siskind D, Suetani S, McArdle PA. An assessment of psychological distress and professional burnout in mental health professionals in Australia during the COVID-19 pandemic. Australas Psychiatry. 2021;29:628–34. Glowacz F, Schmits E, Kinard A. The impact of the COVID-19 crisis on the practices and mental health of psychologists in Belgium: Between exhaustion and resilience. Int J Environ Res Public Health. 2022;19:14410. Blayney M, Kercher A. Psychologists' experiences of burnout in Aotearoa NZ: A nationwide qualitative survey. N Z J Psychol. 2023;57:57–65. Kercher A, Gossage L. Identifying risk factors for compassion fatigue in psychologists in Aotearoa, New Zealand, during the COVID-19 pandemic. Prof Psychol Res Pract. 2024;55:28–38. Kercher A, Rahman J, Pedersen M. The COVID-19 pandemic, psychologists' professional quality of life and mental health. Front Psychol. 2024;15:1339869. McCormack HM, MacIntyre TE, O'Shea D, Herring MP, Campbell MJ. The Prevalence and Cause(s) of Burnout Among Applied Psychologists: A Systematic Review. Front Psychol. 2018;9:1897. Campbell-Sills L, Forde D, Stein MB. Demographic and childhood environmental predictors of resilience in a community sample. J Psychiatr Res. 2009;43:1007–12. Rucklidge JJ, Darling KA, Mulder RT. Addressing the treatment gap in NZ with more therapists – Is it practical and will it work? N Z Med J. 2018;131:8–15. Ministry of Health. Annual Data Explorer 2021/22: New Zealand Health Survey. Wellington: Ministry of Health; 2022. Cardwell H. Shortage of psychologists leaving patients on waitlist for 9 to 12 months. Radio New Zealand; 2021. New Zealand Psychologists Board. Scopes of Practice. 2022. Available from: https://psychologistsboard.org.nz/looking-to-register/scopes-of-practice/ Groot S, Rua M, Awatere-Masters B, Dudgeon P, Garvey D. Special issue: Ignored no longer: Emerging Indigenous researchers on Indigenous psychologies. Aust Community Psychol. 2012;24:5–11. Waitoki W, Rucklidge JJ, Feather JS. Indigenous perspectives in psychology. In: Waitoki W, Rucklidge JJ, Feather JS, Robertson NR, editors. Professional Practice of Psychology in Aotearoa New Zealand. 4th ed. Wellington: New Zealand Psychological Society; 2024. Nikora LW. Māori and psychology: Indigenous psychology in NZ. Psychol Aotearoa. 2007;1:22–30. Vears DF, Gillam L. Inductive content analysis: A guide for beginning qualitative researchers. Focus Health Prof Educ. 2022;23:111–27. Elo S, Kyngäs H. The qualitative content analysis process. J Adv Nurs. 2008;62:107–15. Theodore R, Bowden N, Kokaua J, Ruhe T, Hobbs M, Hetrick S, et al. Mental health inequities for Māori youth: A population-level study of mental health service data. N Z Med J. 2022;135:79–90. Prince M, Patel V, Saxena S, Maj M, Phillips MR, Rahman A. Global mental health 1: No health without mental health. Lancet. 2007;370:859–77. Stewart MW, Bushnell J, Hauraki J, Roberts M. Evidence and wisdom: The role and value of psychologists in healthcare. J N Z Coll Clin Psychol. 2014;24:3–14. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6753953","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":464666787,"identity":"e96055bf-be74-4fa5-828b-5bd45821f81f","order_by":0,"name":"Kobus Du Plooy","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABFklEQVRIiWNgGAWjYBACgwM8IIqZgYEdRFcQocWwAaaFGUSfYZAgqMWYAVkLYxsRWszYe49J/mCwTtzOzHzwMe88mzr+/sUHGH7UMOTJN2DXYsNzLk2ahyE9cWczW7Ix77Y0CYkbzxIYe44xFDPi0iKRYybNwHA4ccNhHjNp3m2HJRhunDFg4G1gSGzG5TCgFqDDYFrmHJaQB2ph/AvU0obL+0AtEjxwLQ2HJQzO9xgwg2zpwaHFsOdcsjWPQboxyC+Gc46lSW68wZZwWOaYROIMHFoMjvcevPmjwlp2O3vzwQdvamz45c4fPvgQyEicj8P7UI1gxMAEjiOJBIYDDETED1gL4w8Qi/8AYdWjYBSMglEwogAABRdU8Fxi+cMAAAAASUVORK5CYII=","orcid":"","institution":"University of Otago","correspondingAuthor":true,"prefix":"","firstName":"Kobus","middleName":"","lastName":"Du Plooy","suffix":""},{"id":464666788,"identity":"5633353b-7abb-4700-bcb4-f1daf6a67dad","order_by":1,"name":"Malcolm Stewart","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Malcolm","middleName":"","lastName":"Stewart","suffix":""},{"id":464666789,"identity":"6cffa368-1386-48f4-b1f0-176deff05146","order_by":2,"name":"Amy Kercher","email":"","orcid":"","institution":"Auckland University of Technology","correspondingAuthor":false,"prefix":"","firstName":"Amy","middleName":"","lastName":"Kercher","suffix":""},{"id":464666790,"identity":"8feee6ad-6e1d-4ab4-92c4-4aba277dfe1c","order_by":3,"name":"Chei-Wei Hsu","email":"","orcid":"","institution":"University of Otago","correspondingAuthor":false,"prefix":"","firstName":"Chei-Wei","middleName":"","lastName":"Hsu","suffix":""},{"id":464666791,"identity":"1130f20f-e46e-4b7e-9af3-5c14391d72ad","order_by":4,"name":"Valerie Tan","email":"","orcid":"","institution":"University of Otago","correspondingAuthor":false,"prefix":"","firstName":"Valerie","middleName":"","lastName":"Tan","suffix":""}],"badges":[],"createdAt":"2025-05-26 23:08:10","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6753953/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6753953/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":94064848,"identity":"c2ed2ada-9eec-4bc4-94fa-1b7104ee5680","added_by":"auto","created_at":"2025-10-22 07:46:53","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1122429,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6753953/v1/9b56f05a-275b-448f-a3e7-ed7de9381cd5.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Health workforce sustainability in mental health services: A qualitative analysis of factors affecting psychologist retention in Aotearoa New Zealand","fulltext":[{"header":"Background","content":"\u003cp\u003eEffective health service delivery relies fundamentally on a stable, well-supported healthcare workforce. In mental health services globally, workforce shortages threaten service capacity and accessibility, with implications for population health outcomes and health system sustainability [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Health workforce research emphasizes the critical importance of understanding factors that influence healthcare professional retention, particularly in publicly funded services that serve vulnerable populations [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe demand for mental health services in Aotearoa New Zealand has steadily increased in recent years, placing mental health professionals, including psychologists, under growing pressure and threatening service capacity. In 2017, a Psychology Workforce Task Group investigated factors contributing to healthcare professional turnover in mental health services and identified strategies to improve workforce retention [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. This investigation revealed varying levels of job satisfaction depending on work sectors and career stages, with implications for health service planning and delivery.\u003c/p\u003e \u003cp\u003eHealthcare professionals who left their roles in mental health services reported feeling undervalued, seeking better remuneration, and desiring improved work-life balance as primary reasons for departure. Those working in public health and social services particularly cited demand-driven stress from high workloads and burnout risk as common reasons for leaving, directly impacting service capacity. They also reported feeling undervalued and receiving poor remuneration. The top six reasons identified were: demand-driven stress; insufficient salary and career progression opportunities; ineffective work processes; ineffective clinical service delivery approaches; devaluation of healthcare professionals and their roles; and unhelpful leadership/management [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThese workforce challenges were exacerbated by the COVID-19 pandemic, which significantly impacted population mental health needs and strained health service capacity. The global health crisis introduced unprecedented levels of stress, anxiety, and uncertainty, leading to increased mental health concerns across demographics while simultaneously challenging healthcare workforce wellbeing. Lockdowns, social isolation, economic instability, and health concerns all contributed to rises in depression, anxiety disorders, and other mental health conditions, increasing demand for services while compromising workforce stability [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eResearch by Chambers and Frampton [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] revealed that during the COVID-19 pandemic's peak, approximately 33% of psychiatrists in Aotearoa New Zealand experienced severe burnout, directly threatening service delivery capacity. Studies with other health professionals showed high burnout levels among general practitioners, attributed to increased patient complexity, limited appointment times, and excessive paperwork [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e], and among nurses, citing lack of supervision [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Although burnout risk was identified among medical consultants and counsellors, these risks appeared mitigated by perceptions of supportive work environments [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] and compassion satisfaction [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e], respectively.\u003c/p\u003e \u003cp\u003eConcurrently, international health workforce research documented declining mental wellbeing among healthcare professionals. The British Psychological Society [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] documented declining mental wellbeing among UK mental health professionals, primarily attributed to rapid transitions to remote work, increased ethical challenges, and heavier workloads. In Australia, mental health professionals reported heightened anxiety, depression, and professional burnout [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Similarly, research observed elevated professional exhaustion among Belgian healthcare professionals during this period [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn Aotearoa New Zealand, studies exploring mental health professionals' experiences examined professional quality of life, including Compassion Fatigue, considering factors such as burnout, secondary traumatic stress, and psychological distress [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Research during the pandemic revealed New Zealand mental health professionals exhibited notably higher burnout and secondary traumatic stress compared to similar healthcare professional groups, threatening service sustainability. During this period, significantly reduced resilience rates and higher stress rates were observed [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e] compared to earlier measurements among New Zealand healthcare professionals [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e] and professionals in other countries [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAotearoa New Zealand, like many countries, has experienced exponential increases in demand for mental health services, with widening disparity between access and demand, creating critical health service capacity challenges. Before the COVID-19 pandemic, New Zealand had approximately 3,713 registered psychologists [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e], with 1,639 registered under the clinical scope of practice. This translated to approximately one clinical psychologist for every 145 individuals experiencing mental disorders. Since then, this gap has widened further due to COVID-19 impacts on both healthcare professionals and society, severely compromising service accessibility [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. A 2021 report highlighted the critical shortage of mental health professionals, citing 6\u0026ndash;9 month waitlists and estimating need for approximately 1,000 additional psychologists to address current demand [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eExamining a comprehensive array of factors related to healthcare professional wellbeing is essential for health workforce planning and service sustainability. Considering elements such as purpose, meaning, effort, emotional state, exhaustion, burnout, career intentions, and daily job analysis provides valuable insights into risk and protective factors for health workforce retention. This multifaceted approach elucidates the interplay between components affecting job satisfaction, resilience, and mental health among healthcare professionals. Investigating these factors can identify profession-specific stressors and satisfaction sources, informing targeted interventions and support systems for mental health professionals and contributing to health workforce sustainability.\u003c/p\u003e \u003cp\u003eThe current project aims to investigate mental health professionals' experiences, exploring professional quality of life, causes of burnout and compassion fatigue, intention to leave the profession, and ideas to improve professional experiences within a health services research framework. This qualitative approach facilitates identification of emerging trends and potential challenges, enabling development of proactive strategies to support the mental health workforce and enhance mental health service quality and accessibility.\u003c/p\u003e \u003cp\u003eIn addition to studying the overall mental health workforce in New Zealand, this research analyses findings across various practice areas including clinical, counselling, neuropsychology, education, general, trainee, and intern psychologists [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. This comparison is crucial for health workforce planning because responsibilities and experiences vary across different practice scopes, requiring tailored retention strategies. Additionally, comparisons will be made between healthcare professionals who identify as Māori and those who do not, recognizing the critical importance of cultural diversity in health workforce planning.\u003c/p\u003e \u003cp\u003eIndigenous approaches to mental health care, such as Māori psychology, have historically been sidelined within broader healthcare delivery in New Zealand [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Although recent efforts have promoted equity and bicultural practices in health services, many Māori healthcare professionals still encounter obstacles including racism, disadvantage, and lack of culturally appropriate support throughout training and practice [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. These challenges persist as Māori healthcare professionals strive to integrate indigenous approaches into mainstream health service delivery [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eQualitative data in this study offers a valuable approach for gaining deeper insights into healthcare professionals' experiences and informing health service improvements. Qualitative methods allow exploration of nuanced and complex aspects of healthcare professionals' work lives, capturing rich, detailed narratives that quantitative data alone might miss. Through open-ended questions, we can explore subjective experiences, emotions, and perspectives as healthcare professionals navigate challenges of increased demand, potential burnout, and pandemic impacts on their practice. This approach enables more comprehensive understanding of factors contributing to job satisfaction, stress, and resilience within health service contexts. Qualitative data can reveal personal coping strategies, workplace culture impacts, and subtle ways professional experiences shape healthcare professionals' wellbeing and career intentions. Additionally, this method allows exploration of context-specific issues unique to the New Zealand health system, providing culturally relevant insights that can inform targeted interventions and policy decisions to effectively support the mental health workforce and improve service delivery.\u003c/p\u003e"},{"header":"Aim","content":"\u003cp\u003eTo investigate the current professional quality of life and intentions to leave the profession among mental health professionals in Aotearoa New Zealand, providing evidence to inform health workforce planning and service sustainability strategies.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003cdiv id=\"Sec4\" class=\"Section3\"\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Methods","content":"\u003ch2\u003eDesign\u003c/h2\u003e\u003cp\u003eThis investigation adopted a cross-sectional, mixed-methods approach using an online survey platform (Qualtrics), designed to inform health workforce research and policy. The present paper reports the qualitative findings, while quantitative analyses were still being undertaken at submission and will be published separately.\u003c/p\u003e\n\u003ch3\u003eProcedure\u003c/h3\u003e\n\u003cp\u003e The study was approved by the University of Otago Human Ethics Committee (reference 23/151). Research information and participation invitations were distributed via email through professional organizations and groups for mental health professionals in New Zealand, including the New Zealand Psychological Society, New Zealand College of Clinical Psychologists, Te Whatu Ora/Health New Zealand, Department of Corrections, High-Performance Sport New Zealand, New Zealand Defence Force, Ministry of Education, He Paiaka Tōtara (Māori psychologists' organization), Le Va (organization including Pasifika psychologists), and through researchers' professional networks. Participants were encouraged to forward the invitation to colleagues who might not have received it, particularly those working solely in private practice. An invitation was also placed at the registration desk of the 2024 New Zealand Psychological Society's Annual Conference with a QR code for survey completion.\u003c/p\u003e \u003cp\u003eParticipation was voluntary and anonymous. Participants could register to win one of five NZ\u003cspan\u003e$\u003c/span\u003e50 gift vouchers in recognition of their contribution. To preserve confidentiality, contact details for the prize draw were collected separately from survey responses. Participants agreed to participate by clicking a survey link after reviewing the participant information sheet; data was collected between May and September 2024.\u003c/p\u003e\n\u003ch3\u003eParticipants\u003c/h3\u003e\n\u003cp\u003eThis study targeted psychologists registered to practice in New Zealand, representing a significant portion of the mental health workforce. As invitations were distributed only to registered healthcare professionals through professional organizations, all recipients were eligible to participate. Data cleaning revealed that 27 respondents began but did not complete sufficient questions (discontinuing after demographic questions) and were excluded from final analyses.\u003c/p\u003e\n\u003ch3\u003eOnline Survey\u003c/h3\u003e\n\u003cp\u003eThe survey collected demographic data including age, gender, ethnicity, and professional details such as registration scope, country of training, and workplace type. Participants completed psychometric questionnaires (results reported elsewhere) and answered five open-ended questions designed to inform health workforce research:\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eHow would you describe your current professional quality of life as a psychologist working in Aotearoa New Zealand?\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eWhat do you believe could be the main causes of burnout and compassion fatigue amongst psychologists in Aotearoa New Zealand?\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eHow would you describe your current turnover intentions? (i.e., your feelings about leaving or staying in the profession of psychology)\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eWhat do you believe are some of the main reasons some psychologists could be considering when thinking about leaving the profession in Aotearoa New Zealand?\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eIf you could go back in time, would you pursue a different career instead of psychology based on what you know now?\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eData Analysis\u003c/h2\u003e \u003cp\u003eInductive content analysis was used to analyse the data, following established health services research methodologies. This approach focuses on analysing responses without preconceived categories, allowing the data to guide analysis and identify categories within the data relevant to health workforce planning [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. Following the process outlined by Elo and Kyng\u0026auml;s [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e], analysis involved three phases: preparation, organizing, and reporting.\u003c/p\u003e \u003cp\u003eAll responses were downloaded into an Excel spreadsheet. During the preparation phase, the first author (KDP) read and re-read all responses for full immersion in the data. During the inductive analysis phase, he used open coding to write notes and headings on coding sheets while reading participants' responses. Categories emerged organically and were grouped under higher-order headings to reduce initial headings by collapsing similar ones. These were re-categorized to clearly describe the data, increase understanding of the research topic, and generate new knowledge relevant to health workforce sustainability. During the final abstraction phase, categories were named using content-characteristic words to produce a general description of the overall research topic.\u003c/p\u003e \u003cp\u003eThis produced a list of main and sub-categories for each question, which were sent to the other authors (CWH, AK), who individually examined the responses and categories generated by the first author before agreeing on final sub- and main categories. There were few differences of opinion between authors following their analyses, and after discussion, agreement was reached about the categories that best represented the data for health workforce research purposes.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eSample\u003c/h2\u003e \u003cp\u003eThe study sample consisted of 380 participants (approximately 9.8% of registered psychologists in New Zealand during February 2024; New Zealand Psychologists Board, 2024), representing a substantial portion of the mental health workforce. In some instances, participants could select multiple options or opt not to answer certain questions, so totals do not always equal 100%.\u003c/p\u003e \u003cp\u003eRegarding gender, 80% identified as female, 19% as male, one as a trans man, and one participant did not answer. Age distribution was: 8% between 20\u0026ndash;29 years, 26% between 30\u0026ndash;39 years, 30% between 40\u0026ndash;49 years, 22% between 50\u0026ndash;59 years, 11% between 60\u0026ndash;69 years, and 3% were 70 years or older. For ethnicity, 74% identified as New Zealand European, 9% as Māori, 0.4% as Pasifika, 3% as Asian, 27% as other, while 29% did not answer. 79% completed their psychology training in New Zealand and 21% in another country.\u003c/p\u003e \u003cp\u003eRegarding primary work settings, 47% worked in public health services, 26% in private practice, 14% for other government departments, 4% at universities, 3% for private sector organizations, 1% for iwi organizations, and 17% in other employment places. In terms of scope of practice, 68% were registered as clinical psychologists, 18% under the general scope, 2.5% as counselling psychologists, 2.5% as educational psychologists, 0.5% as trainee psychologists, and 8% as intern psychologists, with 2% also holding the neuropsychologist scope.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eHealth Workforce Sustainability Factors\u003c/h2\u003e \u003cp\u003eThe first two open-ended questions investigated healthcare professionals' experiences related to professional quality of life, providing critical insights for health workforce planning. Content analysis explored factors linked with high and low professional quality of life that directly impact workforce retention and service sustainability. Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e summarizes the main categories with their respective sub-categories.\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\u003eProfessional Quality of Life among Mental Health Professionals\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\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 \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFactors Enhancing Workforce Retention\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFactors Threatening Workforce Stability\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIndividual Engagement in Health Service Delivery\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHealthcare Professional Burnout\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e- Job satisfaction in patient care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e- Excessive workload and work stress\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e- Meaningful client work\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e- Increased service user complexity\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e- Healthcare staffing shortages\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e- Excessive work hours\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHealthcare Team and Organizational Support\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eHealth System Challenges\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e- Supportive colleagues and peers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e- Professional undervaluation\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e- Supportive healthcare teams\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e- Inadequate compensation\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e- High quality clinical supervision\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e- Poor resources and working conditions\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e- Support from professional bodies\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e- Limited professional development opportunities\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eProfessional Autonomy in Health Service Delivery\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eHealth System Pressures\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e- Ability to manage workload effectively\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e- Public and service user knowledge gaps\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e- Professional autonomy in clinical practice\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e- Unrealistic public and service user expectations\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003ePersonal Impact of Health Service Work\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e- Difficulty prioritizing personal wellbeing\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e- Life stage transitions\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e- Work-life balance challenges\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eFactors Enhancing Health Workforce Retention\u003c/h2\u003e \u003cp\u003eParticipants reported a variety of factors related to high professional quality of life that directly support workforce retention and service sustainability, such as gaining satisfaction from helping patients, the intellectual challenge of healthcare work, having good team support, and having autonomy and flexibility over their workload. Examples of their engagement in health service delivery were highlighted in the following comments:\u003c/p\u003e \u003cp\u003e \u003cem\u003e'I enjoy being a psychologist, I love helping people.'\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e'Working with clients, continual learning and development, helping others all contribute to enjoyment in my role.'\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e'My day-to-day work is very enjoyable despite the pressures of time and limited resources.'\u003c/em\u003e \u003c/p\u003e \u003cp\u003eMany also reported that peer and team support, including support from professional bodies, was an important source of professional quality of life and workforce retention:\u003c/p\u003e \u003cp\u003e \u003cem\u003e'I work with amazing caring teams which come together to support each other. This is so important.'\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e'The key to this I think is that I only work 2 days per week in private practice and have very good supervision and pretty good collegial support.'\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e'My professional quality of life is enormously impacted by working within a supportive team. I do not think I would be able to cope with the demands of the job if this was not the case. I have a competent, supportive, protective manager, and colleagues that look after my well-being as I do theirs. I cannot overstate how much this helps my overall well-being.'\u003c/em\u003e \u003c/p\u003e \u003cp\u003eMany respondents further mentioned the importance of work-life balance, professional autonomy, and organizational changes to manage their workload effectively:\u003c/p\u003e \u003cp\u003e \u003cem\u003e'It has not always been this satisfying but with a recent change to a leadership role I now have a better balance of activities, less hands-on clinical work, more autonomy. As a consequence of this improved balance, I feel more stimulated and motivated with improved wellbeing.'\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e'Fulfilling [professional quality of life], particularly since I have now been running my own full time private practice for 7 years. While it was a big step away from organisations/agency working most of career - I have enjoyed to freedom and away from workplace and setting stresses. This has been liberating for me, and I still manage to connect professionally with others being a senior psychologist with intentional professional networks.'\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e'I enjoy my job in private practice and for the most part have an excellent professional quality of life. Being in control of my own work hours, case load and daily schedule (e.g. balancing sessions so that I don't see more than one or two trauma clients a day) is a major factor in this.'\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eFactors Threatening Health Workforce Stability\u003c/h2\u003e \u003cp\u003eParticipants identified factors linked to lower professional quality of life that directly threaten workforce retention and health service capacity, including the challenging nature of working in mental health services in New Zealand at present, particularly within the public health system. The main factors associated with reduced professional quality of life and increased turnover risk included burnout, systemic health service challenges, societal pressures, and personal impacts of healthcare work.\u003c/p\u003e \u003cp\u003eIncreased risk of burnout was associated with workload stress, such as high caseloads, pressure to see increasing numbers of service users, feeling overwhelmed by never-ending tasks with insufficient time to complete them, excessive work hours, and increasingly complex, high-acuity patients with severe mental health challenges and trauma histories. This was described as emotionally and mentally draining, directly threatening service quality and workforce sustainability. Participants frequently described how the lack of mental health professionals in services throughout the country places a greater burden on those who are still available and makes it difficult to deliver the desired standard of care:\u003c/p\u003e \u003cp\u003e \u003cem\u003e\"Burnout and difficulties maintaining a work-life balance.\"\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\"In one word: Challenging. The overall lack of psychologists, particularly within [the public health system], places a greater burden on psychologists that are available to deliver the same quality and type of service.\"\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\"At times my professional quality of life is sub-optimal due to the high workload and the complexity of clients. It can be difficult to achieve a sense of satisfaction when working with individuals with such high needs.\"\u003c/em\u003e \u003c/p\u003e \u003cp\u003eA sense of helplessness was often described by participants, particularly those working in public health and social services, which may contribute to burnout and threaten service sustainability:\u003c/p\u003e \u003cp\u003e \u003cem\u003e\"the care we wish to provide to people isn't possible in the current conditions/system which feels very helpless and demotivating.\"\u003c/em\u003e \u003c/p\u003e \u003cp\u003eSystemic factors leading to low professional quality of life and threatening workforce retention included feeling undervalued, underpaid, and unappreciated; having insufficient resources to work well and/or safely; a lack of understanding from other healthcare professionals and management, and a perceived lack of support from professional bodies.\u003c/p\u003e \u003cp\u003eFeeling undervalued, underpaid, and unappreciated by health service employers/organizations, especially in public health and social services compared to private practice was frequently mentioned as a threat to workforce retention:\u003c/p\u003e \u003cp\u003e \u003cem\u003e\"I love the work that I get to do with clients, and the teams that I get to work with in [public health system], however, I often feel unappreciated and burnt out by the system. The complexity of clients, lack of resources, high demands and feeling unsupported and unappreciated by the system, organisation and union all contribute to a decrease in my professional quality of life as a psychologist.\"\u003c/em\u003e \u003c/p\u003e \u003cp\u003eHealthcare staffing shortages in mental health services were also reported to create challenges in providing adequate care and maintaining service quality:\u003c/p\u003e \u003cp\u003e \u003cem\u003e'The demand for psychological services is high. The number of psychologists available to do the work is limited.'\u003c/em\u003e \u003c/p\u003e \u003cp\u003eEmployment conditions in health service organizations, particularly in public health and social service organisations, including relatively low wages, a lack of professional development opportunities, and limited career progression were seen as lowering professional quality of life and threatening workforce retention:\u003c/p\u003e \u003cp\u003e \u003cem\u003e\"Burnout, overworked and underpaid. Knowing overseas psychologists earn much more for the same work.\"\u003c/em\u003e \u003c/p\u003e \u003cp\u003eThese systemic difficulties in public health services were seen as motivating many healthcare professionals to work in private practice, creating service gaps in publicly funded care:\u003c/p\u003e \u003cp\u003e \u003cem\u003e\"The lack of support and resource in the public sector makes working there extremely challenging. Moreover, interacting with agencies such as ACC and their systems make third party work unattractive. I believe this results in people moving into private practice.\"\u003c/em\u003e \u003c/p\u003e \u003cp\u003eHowever, for healthcare professionals outside of public health and social services, especially those in private practice without collegial support, isolation and difficulty achieving work-life balance and boundaries, was seen as challenging for workforce sustainability:\u003c/p\u003e \u003cp\u003e \u003cem\u003e'This work can be very isolating, the acuity and complexity in private is increasing and private practitioners are unsupported by crisis services. The health system is not functioning well overall in my view, and this makes practice as a psychologist very challenging.'\u003c/em\u003e \u003c/p\u003e \u003cp\u003eParticipants also expressed concerns that regulatory bodies, through some initiatives and their perceived lack of advocacy for the profession, lowered professional quality of life for some healthcare professionals:\u003c/p\u003e \u003cp\u003e\u003cem\u003e'The Board's current project of reviewing scopes of practice is misguided \u0026amp; is harming the profession'\u003c/em\u003e\u003c/p\u003e \u003cp\u003eSocietal factors contributing to poor professional quality of life included perceived lack of understanding of mental health professionals' roles by service users, the public, and other healthcare workers:\u003c/p\u003e \u003cp\u003e \u003cem\u003e\"[There is] a lack of understanding of what psychologists do [in society].\"\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\"[There is] a poor understanding by non-psychologist managers about the pressures of the role.\"\u003c/em\u003e \u003c/p\u003e \u003cp\u003eParticipants also reported personal factors that contributed to feeling overwhelmed and burnt out, impacting workforce sustainability. This included experiencing poor work-life balance:\u003c/p\u003e \u003cp\u003e \u003cem\u003e\"It is difficult to maintain a good quality of life, balancing between providing a psychology service and allowing time to acquire and learn the skills outside of work hours, so I can deliver appropriately within hours.\"\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\"I took on a role that was underfunded but because of my work ethic and desire for the role to succeed, I have given up a lot of personal time to do the tasks required. This has had a significant impact on my personal life, including my physical wellbeing. After 12 months, I realised that my capacity, desire, and interest to explore and learn about psychological concepts and ideas had greatly reduced.\"\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eHealth Workforce Migration and Retention Intentions\u003c/h2\u003e \u003cp\u003eThree questions addressed participant's intention to stay in or leave mental health service delivery, providing critical insights for health workforce planning and factors that were associated with this decision. To assess orientation towards career change irrespective of career stage, respondents were asked \u003cem\u003eif they could go back in time, based on what they know now, would they pursue a different career\u003c/em\u003e. Of 129 respondents who answered this question, 16% answered they would pursue a different career, 32% said they would not pursue a different career, 44% answered 'possibly', and eight percent answered 'uncertain'.\u003c/p\u003e \u003cp\u003eMost respondents expressed the intention to continue working in mental health services, at least in the short- to medium term. However, many also expressed mixed feelings about their profession; while they wanted to stay in healthcare due to their passion and commitment to service users, they simultaneously considered leaving due to frustration with systemic issues like lack of organizational support, high workloads, and feeling undervalued within health service hierarchies.\u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e summarizes the main reasons participants stated for staying in or leaving mental health service delivery, providing important insights for health workforce planning.\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\u003eFactors Related to Health Workforce Retention and Migration\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\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 \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReasons for Workforce Retention\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eReasons for Workforce Migration\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIndividual Commitment to Health Service Delivery\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHealthcare Professional Burnout\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e- Enjoying work with service users\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e- High case loads\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e- Learning and intellectual challenge of healthcare work\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e- Increased complexity of service users\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e- Passion for mental health service delivery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFinancial Considerations in Health Workforce\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eHealth Service Compensation Issues\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e- Need to make a living\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e- Inadequate compensation in public services\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e- Investment in professional training\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e- Opportunities to earn more elsewhere/different types of work\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e- Unable to afford career retraining\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e- Better pay-to-living-cost ratio in other countries (e.g., Australia)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCareer Stage in Health Services\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eHealth System Factors\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e- Close to retirement from health services\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e- Healthcare understaffing\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e- Poor support from management, leaders, colleagues\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e- Poor leadership in health services\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e- Systemic difficulties outweighing job satisfaction\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e- Feeling undervalued and unsupported in health services\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e- Frustration with health system constraints\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e- Regulatory concerns affecting professional practice\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003ePersonal Factors Affecting Health Service Work\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e- Exploring new interests and careers outside healthcare\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e- Life stage transitions\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e- Difficulties achieving desired work-life balance in health services\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eReasons for Health Workforce Retention\u003c/h2\u003e \u003cp\u003eEnjoyment and engagement with healthcare work was a common reason provided for staying in mental health services. Participants reported enjoying their work with service users, feeling passionate about healthcare delivery, and viewing it as meaningful work:\u003c/p\u003e \u003cp\u003e \u003cem\u003e'I am very happy with the work that I do.'\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e'[I intend to] stay in [psychology] for the long run as I feel very passionate about this work, especially working with youth and under resourced communities.'\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e'I enjoy my profession. I enjoy my role. I intend to remain in this profession until I retire.'\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e'I believe in the profession and believe I hold a position of skill and provide good services to people who need it. I have worked in the profession for over 3 decades'\u003c/em\u003e \u003c/p\u003e \u003cp\u003eFinancial reasons were also stated for staying in mental health services, like having invested significant time and money into their qualifications, and being unable to afford or unwilling to retrain in another profession:\u003c/p\u003e \u003cp\u003e \u003cem\u003e'I feel trapped because I have invested so much into my qualification. I don't have the option to retrain, nor can I afford to increase my student loan anymore. I had no idea how much I would feel that psychologists are severely underpaid for the level of risk they manage.'\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e'I regularly think about leaving psychology. However, I feel trapped as financially I cannot afford to retrain for a different career. I often wonder how I will sustain 30 plus years in this career'\u003c/em\u003e \u003c/p\u003e \u003cp\u003eSome participants were approaching retirement age and were therefore not interested in changing careers but interested in reducing their hours within health services:\u003c/p\u003e \u003cp\u003e \u003cem\u003eAnd as I am heading to retirement age, I am thinking about working less hours and at some point, not working in the profession anymore.\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eReasons for Health Workforce Migration\u003c/h2\u003e \u003cp\u003eDespite many healthcare professionals still feeling committed to remaining in mental health services, many were seriously considering or had already decided to leave, creating significant concerns for health service capacity. Burnout, compassion fatigue, and difficulties maintaining work-life balance due to high workloads and caseloads with increasingly complex service user presentations were key concerns that influenced orientation towards leaving health service delivery:\u003c/p\u003e \u003cp\u003e \u003cem\u003e'I do think this role has a shelf life for me, in that at some stage the emotional weight of the work will no longer be sustainable for the relative gains.'\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e'Acuity and high workloads.' ; '...the increase of acuity and complexity [of cases] without associated time/energy/space/capacity to handle said cases effectively.'\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e'Feelings of frustration, burnout, and being fed up with high caseloads and an apparent lack of hope that this situation will improve anytime soon.'\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e'Burnout, compassion fatigue, and just general fatigue. A desire for my lifestyle balance. I think it's also a big reason behind psychologists moving into private practice and/ or part time work.'\u003c/em\u003e \u003c/p\u003e \u003cp\u003eInsufficient compensation was also frequently mentioned as a reason why healthcare professionals were considering leaving mental health services, especially given the level of responsibility and years of training required:\u003c/p\u003e \u003cp\u003e \u003cem\u003e'Insufficient pay given the level of responsibility provided to psychologists...'\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e'I think about whether this is the profession for me but feel stuck because it cost me so much to enter the profession (money, years of my life, opportunity costs). I see roles that require no degrees that pay more, and I wonder what on earth I'm doing here?!'\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e'It is probably a job I would leave or cut down significantly if I had an alternative income steam that allowed me a similar sense of fulfilment without the comparative cost to self. Or if I had a windfall that allowed me to do something completely unrelated and more passion driven.'\u003c/em\u003e \u003c/p\u003e \u003cp\u003eMany respondents were considering opportunities in other countries, particularly Australia, where it was perceived they would earn better wages while simultaneously be able to maintain a more optimal work-life balance, representing significant health workforce migration:\u003c/p\u003e \u003cp\u003e \u003cem\u003e'I would be more likely to leave NZ but remain in psychology [the profession], for example in Australia - better pay and more development opportunities.'\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e'One of my interns went to Australia when she graduated and started on a salary of $NZ120k. It's depressing.' ; ' I am planning to go private in the future for financial reasons, once I feel I have enough experience to be comfortable to do so.'\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e'I don't see myself working in the public sector long term for those financial reasons which I think is a shame for our people who already struggle to access psychology support. However, I am not here for charity, I am here to work and make money to support my own life and whānau. I have also considered moving to Australia with my partner as we could both earn significantly more money. It is whānau and the NZ lifestyle that keeps us here, certainly not our jobs.'\u003c/em\u003e \u003c/p\u003e \u003cp\u003eA lack of support or recognition and feeling undervalued by health service employers/organizations were also indicated as common reasons for many deciding to leave healthcare. Many also did not feel that their expertise was being respected, especially within existing medical model hierarchies in health services:\u003c/p\u003e \u003cp\u003e \u003cem\u003e'I'm pushed towards [intending to leave] by inflexibility, managers that only care about SMOs.... Plus, I could earn a lot more doing other things and have more time with my whānau.'\u003c/em\u003e \u003c/p\u003e \u003cp\u003ePoor working conditions in public health and social services, including healthcare understaffing, lack of resources, and unsupportive management was also reported as threatening workforce retention. Frustration with these types of systemic issues in mental health care and feeling unable to effectively help service users due to these constraints prompted many to leave or cut down their involvement in health service delivery, especially those employed in public health and social services:\u003c/p\u003e \u003cp\u003e \u003cem\u003e'Poor quality of offices and equipment, psychologists often working in prefabs, underground offices without windows, no wall art or shared office decorations or comfortable seating, location not near cafes/park or places to be able to leave the office for a break during the day, psychologists often underappreciated and not recognised the amount of necessary but often unbillable time required e.g. often ethical obligations to follow-up are required but not funded so come out of personal time. Compared to professionals in other industry/business with equivalent training there are few perks, low pay, poor work conditions and high responsibility.'\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e'I also think that there is a huge disconnect between the psychologists on the ground level [in the public health and social services] and the management who only see numbers/systems. When staff don't feel heard, prioritised, and supported, that has a huge impact on feelings of burnout.'\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e'Understaffing. Medical model equals disrespect for psychology, from upper management, and from other disciplines. Space issues like sharing offices, moving offices around, and thus instability.'\u003c/em\u003e \u003c/p\u003e \u003cp\u003eRecent regulatory actions around proposed scope of practice changes were also cited by many as a reason for leaving or considering leaving health service delivery, as it has led to distrust and fear around their future professional practice:\u003c/p\u003e \u003cp\u003e \u003cem\u003e'One of the most stressful issues at the moment is the potential for the scopes of practice to seriously impact my ability to do my job. I am unsure what my career will look like in future or what prospects it holds.'\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e'I intend to leave, mainly due to the NZ Psychologists Board's review of scopes.'\u003c/em\u003e \u003c/p\u003e \u003cp\u003e\u003cem\u003e 'I am concerned about the impact that the board is having by the scopes of practice review. I feel that it is very invalidating for a general psych and if I was ringfenced off doing therapy or working with clients I currently am, I would leave the profession as I am working with populations which are my passion.'\u003c/em\u003e\u003c/p\u003e \u003cp\u003eA desire for better career progression, professional development opportunities, and the ability to specialize also led some healthcare professionals to consider leaving mental health services:\u003c/p\u003e \u003cp\u003e \u003cem\u003e'Seeing little prospect for [career] progression.'\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e'I think we tend to take on more than is ideal for our own well-being due to systemic issues such as needing to work a certain number of hours to meet personal financial commitments which offers little scope for us to be able to attend to our own personal development and growth (alongside professional development and growth).'\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e'I work in a rural area and there are not the opportunities to specialise [here] as there are in cities.'\u003c/em\u003e \u003c/p\u003e \u003cp\u003eFinally, certain personal factors like prioritizing personal well-being, exploring new interests, or life changes like retirement were mentioned by some as reasons for deciding to leave health service delivery:\u003c/p\u003e \u003cp\u003e \u003cem\u003e'I love the work that I do, but am definitely putting thought into what I want the remaining years of my career to include. If the demand continued as it is right now, I would think about pulling back from certain work commitments to prioritise my own self-care and personal well-being.'\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e'Possibly considering continuing with the profession but outside of Aotearoa New Zealand where pay could be better. Or possibly leaving the profession altogether to pursue other career interests that might not require as much demand or carrying of risk.'\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e'Moving towards retirement age and planning a gradual reduction in hours over the next 3\u0026ndash;5 years.'\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eWhile many mental health professionals currently appear to remain committed to health service delivery, dissatisfaction with working conditions, lack of organizational support, and poor compensation have led many to consider alternative career paths, working outside Aotearoa New Zealand, or ceasing working in publicly funded health and social services, with significant implications for service capacity and accessibility.\u003c/p\u003e \u003cp\u003eOverall, the data highlighted that excessive workload, a lack of support and resources, and working within an under-resourced mental health system seemed to be significantly lowering professional quality of life and increasing intentions to leave health service delivery among many healthcare professionals at present. This is of critical concern for health service planning given that Aotearoa New Zealand already has a clearly identified shortfall in its ability to provide access to mental health services for people who need them, either in general [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e] or through the publicly funded health and social services [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Aotearoa New Zealand also has a limited ability to expand the mental health workforce to meet the gap, with approximately 150 interns and trainees across the training programmes for all scopes of practice annually, plus approximately 40 overseas-trained psychologists joining the workforce each year, and approximately 90 psychologists leaving the profession each year [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. This gives a net annual growth of around 100 practising psychologists across all sectors (e.g. health, Corrections, education, Oranga Tamariki, private practice, ACC, non-government organisations, private firms, etc; [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]). In a situation in which workforce growth is urgently needed for health service sustainability, but there are relatively few new entrants into the workforce, staff retention becomes particularly important for maintaining service capacity. This paper has explored barriers to retention of healthcare staff, particularly related to factors that contribute to healthcare professionals leaving and those that may contribute to them staying in the health service workforce.\u003c/p\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eHealth Service Capacity Implications\u003c/h2\u003e \u003cp\u003eThe two primary variables explored in the current analyses are professional quality of life and intention to stay in or leave the Aotearoa New Zealand mental health workforce, both critical factors for health service planning. Many factors that were identified as determinants of higher or lower professional quality of life were also identified as key drivers of intention to stay in or leave mental health service delivery in Aotearoa New Zealand. This suggests that positively modifying the factors related to professional quality of life for healthcare professionals is likely to reduce intention to leave health services and thereby improve workforce retention and service capacity.\u003c/p\u003e \u003cp\u003eMany healthcare professionals reported experiencing low professional quality of life at present, especially those working in the public health and social services sector, directly threatening service sustainability. This was expressed as ambivalence about wanting to stay in health service delivery, but also considering leaving due to the frustration with the issues associated with low professional quality of life. While some healthcare professionals considered leaving health services entirely, many saw the solution to this ambivalence as being either to go into private practice or to go overseas, creating significant implications for publicly funded service accessibility.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eHealth Workforce Migration Patterns\u003c/h2\u003e \u003cp\u003eRespondents widely associated private practice with higher professional quality of life, particularly in relation to better remuneration and more autonomy and flexibility, and with less stress and workload problems, and fewer systemic difficulties that were associated with intentions to leave public health services. Going overseas was associated with better remuneration and some other advantages, representing health workforce migration that threatens service capacity. There is also considerable demand for private practice mental health professionals in Aotearoa New Zealand, with many service users having trouble finding accessible services or waiting on long waitlists, so moving to private practice is a realistic option for many healthcare professionals but creates gaps in publicly funded services.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eComparison with Previous Health Workforce Research\u003c/h2\u003e \u003cp\u003eThe results of the current study echo closely and expand on the study by the Psychology Work Force Task Group [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e] completed prior to the COVID-19 pandemic which identified demand driven stress; insufficient salary and career progression opportunities; ineffective work processes; ineffective clinical service delivery approaches; devaluation of healthcare professionals' work and contribution; unhelpful leadership and management performance; stress due to inadequate staff numbers; ineffective organisational structure and function; lack of necessary physical resources; and inadequate working conditions as the top ten most common reasons (in decreasing order of frequency) why health staff considered leaving, or had left, employment in the health and social services. Identical analyses as part of the same study [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e] for two other large government employers of healthcare professionals showed similar reasons for considering leaving or having left employment with them. This appeared consistent with the findings of Kercher et al [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e] during the COVID 19 pandemic who found elevated levels of Compassion Fatigue (burnout and secondary traumatic stress), stress symptoms, depressive symptoms and low resilience, along with good Compassion Satisfaction (the pleasure derived from being able to do one's work well) among Aotearoa New Zealand healthcare professionals during that time. As we currently transition out of the pandemic, participants in the current study described similar factors to the aforementioned studies as limiting their professional quality of life and discouraging them from staying employed in health and social services. This confluence of results using somewhat different methodologies prior, during, and following the pandemic suggests that the results are robust and represent persistent challenges in health workforce retention. That these studies yield similar results suggests minimal change in conditions for healthcare professionals over this time, indicating ongoing threats to service sustainability.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003eHealth Services Research Framework for Workforce Retention\u003c/h2\u003e \u003cp\u003eThe current study's focus on professional quality of life gives a useful framework for planning initiatives for improving workforce retention as we look towards the future of mental health service delivery in Aotearoa New Zealand. Several respondents indicated their intentions to leave health services, or the health and social services sectors could change if there were improvements in the factors leading to this intention. Focusing on initiatives that help to increase professional quality of life and addressing factors associated with low professional quality of life would provide a useful pathway for improving retention within health service delivery and particularly within the health and social services sector. In the Psychology Workforce Task Group [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e], respondents identified improved management/leadership approach; strategies to reduce demand-driven stress; establishing more effective work processes; salary and career development; provision of necessary resources and working conditions to do the job well; explicitly valuing healthcare professionals' contribution; improving effectiveness of clinical practice; sufficient workforce numbers to meet demand; improving overall clinical team function; and developing a positive organisational culture as being the top ten strategies (in decreasing order of frequency) for improving staff retention. These initiatives are consistent with what would be expected to improve professional quality of life as explored in this study and support health service sustainability.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec22\" class=\"Section2\"\u003e \u003ch2\u003ePolicy Recommendations for Health Service Organizations\u003c/h2\u003e \u003cp\u003eBased on these findings, health service organizations should consider implementing evidence-based workforce retention strategies that address:\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eWorkload Management\u003c/b\u003e: Implementing sustainable caseload models and adequate staffing ratios to prevent burnout and maintain service quality.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eOrganizational Support\u003c/b\u003e: Developing comprehensive support systems including supervision, peer support, and professional development opportunities.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eProfessional Recognition\u003c/b\u003e: Ensuring appropriate compensation, career progression opportunities, and recognition of healthcare professionals' expertise and contributions.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eResource Adequacy\u003c/b\u003e: Providing sufficient physical resources, equipment, and working conditions to support effective service delivery.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eLeadership Development\u003c/b\u003e: Training healthcare managers in supportive leadership practices that value healthcare professionals and promote positive organizational culture.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eWork-Life Balance\u003c/b\u003e: Implementing policies that support healthcare professionals' wellbeing and prevent burnout through flexible working arrangements and wellness programs.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cdiv id=\"Sec23\" class=\"Section3\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eThere were several limitations in the present study and areas that could be improved in future health workforce research. The sample comprised 9.8% of all registered psychologists in Aotearoa New Zealand, recruited via invitations through professional groups. This means that there may be a sampling bias towards participants who had a particular interest in the subject matter of this study and that our sample may not be reflective of thoughts from all New Zealand mental health professionals. Given the qualitative nature of the data, however, our aim was not to generalise to the entire mental health workforce but to glean a richer understanding of professional quality of life and intentions to leave health service delivery among Aotearoa New Zealand healthcare professionals. To this effect, we have achieved our aim of the study. Furthermore, a comparison of the demographics of our sample to participants in the Psychology Workforce Task Group [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e] survey indicated close consistency on gender, age, ethnicity, primary place of work, and scope of practice, suggesting that the demographic mix for the current sample is likely a strong representation of the New Zealand mental health workforce.\u003c/p\u003e \u003cp\u003eThe use of open questions with free-text written responses and an inductive analytic method do not constrain responses in pre-determined categories so emergent categories can be discovered, but it can lead to variability in responses as different respondents may write about different issues. This was managed in the current study by focusing on the emergent themes without attempting to assess their frequency. Future exploration of this area with different qualitative and quantitative health workforce research approaches would strengthen our understanding of the research topic. This may include strategies such as individual interviews or focus groups for gathering further in-depth information about health service experiences.\u003c/p\u003e \u003cp\u003eAll healthcare professionals were asked the same questions and to date no analysis of sub-groups has been completed (e.g., groups defined by ethnicity, age, work setting, or scope of practice). This may lead to nuances between the experience of different groups of healthcare professionals being missed, for instance, a Māori clinical psychologist working in a Department of Corrections facility may have a very different experience than a Chinese Educational Psychologist working in a school setting. This is one of the aims of the quantitative data analysis that will be published separately, however, additional future health workforce research exploring these variations in experience may be valuable for health service planning. For example, understanding determinants of professional quality of life for Māori healthcare professionals, and factors promoting their intention to stay within health services may be of relevance to meeting the health needs of the Māori population. Māori comprise approximately 16.5% of the total New Zealand population and are disproportionately represented as service users in many health and social services. Māori mental health professionals are recognised as having a particularly important role in especially assisting Māori service users but currently comprise only 7.5% of the mental health workforce [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. Some initiatives are in place to build the number of Māori healthcare professionals, but the need to ensure that conditions supporting high professional quality of life and intention to stay within health services are particularly important for Māori healthcare professionals and service accessibility. These limitations mean that this research should be interpreted with appropriate consideration for health workforce research methodology.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThis study investigated the current professional quality of life and intentions to leave mental health service delivery among Aotearoa New Zealand healthcare professionals, providing vital information for health workforce planning and developing strategies to improve workforce retention and service sustainability. Findings highlighted processes that may lead many healthcare professionals to be suffering from burnout and low professional quality of life and to consider leaving mental health service delivery, particularly in the public health and social services throughout Aotearoa New Zealand. Given the importance of mental health services to the health and wellbeing of the population [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e], this is concerning and requires urgent preventative action from health service administrators and policymakers. From a health equity perspective, improving access to mental health services through public health and social services is particularly important for vulnerable populations. This study indicates that initiatives that would improve professional quality of life and counteract intentions to leave are urgently required as they would improve the retention of healthcare professionals in public health and social services and more broadly in New Zealand's health system. Some remedial initiatives suggested by the Psychology Workforce Task Group [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e] appear to still be highly relevant to addressing the findings of this study and future health workforce research should ideally focus on tailored interventions to enhance workforce retention, especially among underrepresented groups like Māori healthcare professionals, to ensure sustainable and equitable mental health service delivery.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003cstrong\u003eEthics Approval and Consent to Participate\u003c/strong\u003e \u003cp\u003e This study was approved by the University of Otago Human Ethics Committee (reference 23/151). All participants provided informed consent by agreeing to participate after reviewing the participant information sheet.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConsent for Publication\u003c/strong\u003e \u003cp\u003eNot applicable - no individual participant data, images, or videos are included.\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 - no specific funding was received for this study.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eKDP designed the study, collected data, conducted the analysis, and drafted the manuscript. CWH and AK contributed to the study design, data analysis, and manuscript revision. All authors read and approved the final manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eThe authors thank all psychologists who participated in this study and the professional organizations that facilitated recruitment, including the New Zealand Psychological Society, New Zealand College of Clinical Psychologists, and other healthcare organizations that supported data collection.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe qualitative datasets generated and analysed during the current study are not publicly available due to the confidential nature of participant responses, but anonymized data summaries are available from the corresponding author on reasonable request and with appropriate ethical approval.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eWorld Health Organization. Global strategy on human resources for health: Workforce 2030. Geneva: WHO; 2016.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eScheffler RM, Bruckner TA, Spetz J. The labor market for human resources for health in low- and middle-income countries. Washington, DC: World Bank; 2013.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBuchan J, Dhillon IS, Campbell J. Health employment and economic growth: an evidence base. Geneva: World Health Organization; 2017.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLiu JX, Goryakin Y, Maeda A, Bruckner T, Scheffler R. Global Health workforce labor market projections for 2030. Hum Resour Health. 2017;15:11.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePsychology Workforce Task Group. The Aotearoa NZ Psychology Workforce Survey. New Zealand College of Clinical Psychologists; 2016.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePsychology Workforce Task Group. Retaining the psychological workforce. New Zealand College of Clinical Psychologists; 2017.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePsychology Workforce Task Group. How many psychologists? A discussion paper about the number of psychologists needed in the health services in NZ. New Zealand College of Clinical Psychologists; 2017.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMinistry of Health. Annual Data Explorer 2021/22: New Zealand Health Survey. Wellington: Ministry of Health; 2022.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChambers CN, Frampton CM. Burnout, stress, and intentions to leave work in NZ psychiatrists: A mixed methods cross-sectional study. BMC Psychiatry. 2022;22:380.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChambers CN, Frampton CM. Burnout, stress, and intentions to leave work in NZ psychiatrists: A mixed methods cross-sectional study. BMC Psychiatry. 2022;22:380.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRoyal New Zealand College of General Practitioners. Survey results raise concern for the health and sustainability of general practice. 2021. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.rnzcgp.org.nz/RNZCGP/News/College_news/2021/Survey_results_raise_concern_for_the_health_and_sustainability_of_general_practice.aspx\u003c/span\u003e\u003cspan address=\"https://www.rnzcgp.org.nz/RNZCGP/News/College_news/2021/Survey_results_raise_concern_for_the_health_and_sustainability_of_general_practice.aspx\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKalliath TJ, Beck A. Is the path to burnout and turnover paved by a lack of supervisory support? A structural equations test. N Z J Psychol. 2001;30:72\u0026ndash;80.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSurgenor LJ, Spearing RL, Horn J, Beautrais AL, Mulder RT, Chen P. Burnout in hospital-based medical consultants in the New Zealand public health system. N Z Med J. 2009;122:1300.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTemitope K. Secondary traumatic stress, burnout and the role of resilience in New Zealand counsellors: A thesis presented in partial fulfilment of the requirements for the degree of Master of Arts in Psychology at Massey University, New Zealand. 2014.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBritish Psychological Society. The impact of Covid-19 on the wellbeing of psychologists. London: BPS; 2020.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNorthwood K, Siskind D, Suetani S, McArdle PA. An assessment of psychological distress and professional burnout in mental health professionals in Australia during the COVID-19 pandemic. Australas Psychiatry. 2021;29:628\u0026ndash;34.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGlowacz F, Schmits E, Kinard A. The impact of the COVID-19 crisis on the practices and mental health of psychologists in Belgium: Between exhaustion and resilience. Int J Environ Res Public Health. 2022;19:14410.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBlayney M, Kercher A. Psychologists' experiences of burnout in Aotearoa NZ: A nationwide qualitative survey. N Z J Psychol. 2023;57:57\u0026ndash;65.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKercher A, Gossage L. Identifying risk factors for compassion fatigue in psychologists in Aotearoa, New Zealand, during the COVID-19 pandemic. Prof Psychol Res Pract. 2024;55:28\u0026ndash;38.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKercher A, Rahman J, Pedersen M. The COVID-19 pandemic, psychologists' professional quality of life and mental health. Front Psychol. 2024;15:1339869.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMcCormack HM, MacIntyre TE, O'Shea D, Herring MP, Campbell MJ. The Prevalence and Cause(s) of Burnout Among Applied Psychologists: A Systematic Review. Front Psychol. 2018;9:1897.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCampbell-Sills L, Forde D, Stein MB. Demographic and childhood environmental predictors of resilience in a community sample. J Psychiatr Res. 2009;43:1007\u0026ndash;12.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRucklidge JJ, Darling KA, Mulder RT. Addressing the treatment gap in NZ with more therapists \u0026ndash; Is it practical and will it work? N Z Med J. 2018;131:8\u0026ndash;15.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMinistry of Health. Annual Data Explorer 2021/22: New Zealand Health Survey. Wellington: Ministry of Health; 2022.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCardwell H. Shortage of psychologists leaving patients on waitlist for 9 to 12 months. Radio New Zealand; 2021.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNew Zealand Psychologists Board. Scopes of Practice. 2022. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://psychologistsboard.org.nz/looking-to-register/scopes-of-practice/\u003c/span\u003e\u003cspan address=\"https://psychologistsboard.org.nz/looking-to-register/scopes-of-practice/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGroot S, Rua M, Awatere-Masters B, Dudgeon P, Garvey D. Special issue: Ignored no longer: Emerging Indigenous researchers on Indigenous psychologies. Aust Community Psychol. 2012;24:5\u0026ndash;11.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWaitoki W, Rucklidge JJ, Feather JS. Indigenous perspectives in psychology. In: Waitoki W, Rucklidge JJ, Feather JS, Robertson NR, editors. Professional Practice of Psychology in Aotearoa New Zealand. 4th ed. Wellington: New Zealand Psychological Society; 2024.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNikora LW. Māori and psychology: Indigenous psychology in NZ. Psychol Aotearoa. 2007;1:22\u0026ndash;30.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVears DF, Gillam L. Inductive content analysis: A guide for beginning qualitative researchers. Focus Health Prof Educ. 2022;23:111\u0026ndash;27.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eElo S, Kyng\u0026auml;s H. The qualitative content analysis process. J Adv Nurs. 2008;62:107\u0026ndash;15.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTheodore R, Bowden N, Kokaua J, Ruhe T, Hobbs M, Hetrick S, et al. Mental health inequities for Māori youth: A population-level study of mental health service data. N Z Med J. 2022;135:79\u0026ndash;90.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePrince M, Patel V, Saxena S, Maj M, Phillips MR, Rahman A. Global mental health 1: No health without mental health. Lancet. 2007;370:859\u0026ndash;77.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eStewart MW, Bushnell J, Hauraki J, Roberts M. Evidence and wisdom: The role and value of psychologists in healthcare. J N Z Coll Clin Psychol. 2014;24:3\u0026ndash;14.\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":"Health workforce, Healthcare personnel retention, Mental health services, Professional burnout, Health services administration, Workforce planning, Qualitative research, Health policy","lastPublishedDoi":"10.21203/rs.3.rs-6753953/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6753953/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003cbr\u003e\nMental health workforce shortages threaten health service capacity globally, with Aotearoa New Zealand experiencing an estimated deficit of 1,000 psychologists and public service waiting times extending to 9 months. Understanding factors influencing healthcare professional retention is critical for health workforce planning and service sustainability. This study investigated professional quality of life and retention intentions among registered psychologists to inform evidence-based health workforce strategies and improve mental health service capacity.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003cbr\u003e\nA cross-sectional, mixed-methods study collected qualitative data from 380 registered psychologists (9.8% of the national workforce) via online survey between May and September 2024. Participants responded to five open-ended questions exploring professional quality of life, burnout causes, turnover intentions, and career satisfaction. Data were analysed using inductive content analysis following established health services research methodologies. The study received University of Otago Human Ethics Committee approval (reference 23/151).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003cbr\u003e\nAnalysis revealed complex health workforce dynamics affecting service capacity and accessibility. Retention-promoting factors included supportive team environments, professional autonomy, manageable workloads, and adequate organizational resources. Conversely, excessive caseloads, inadequate resources, professional devaluation within healthcare hierarchies, and systemic constraints threatened workforce stability. Participants reported widespread ambivalence—maintaining commitment to mental health service delivery while simultaneously considering departure from public health services. Workforce migration from public to private practice emerged as a critical threat to service accessibility, creating significant gaps in publicly funded mental health care for vulnerable populations.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e\u003cbr\u003e\nHealth service organizations require evidence-based workforce retention strategies that address systemic barriers, enhance professional autonomy, provide adequate resources, and implement sustainable workload management models. These findings offer actionable insights for health service administrators and policymakers to strengthen mental health workforce capacity, improve service sustainability, and maintain accessible mental health care delivery. The research contributes to health workforce planning literature and supports the development of targeted interventions to enhance healthcare professional retention in publicly funded services.\u003c/p\u003e","manuscriptTitle":"Health workforce sustainability in mental health services: A qualitative analysis of factors affecting psychologist retention in Aotearoa New Zealand","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-06-02 11:18:31","doi":"10.21203/rs.3.rs-6753953/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":"04db518d-eab7-4004-b5ff-b917fb96af6c","owner":[],"postedDate":"June 2nd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-10-22T07:38:41+00:00","versionOfRecord":[],"versionCreatedAt":"2025-06-02 11:18:31","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6753953","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6753953","identity":"rs-6753953","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}