Causes of Nursing Turnover Intention in the Health Care Sector: A Narrative Review

Causes of Nursing Turnover Intention in the Health Care Sector: A Narrative Review

Chowdhury Abdllah Al Mamun¹, Md. Kamrul Hasan², Daisy Mui Hung Kee³

¹PhD Fellow, School of Management, University of Sains Malaysia, Gelugor, Penang, Malaysia

²Associate Professor, Department of Business Administration, Faculty of Business Studies, BGMEA University of Fashion & Technology, Dhaka, Bangladesh

³Associate Professor, School of Management, University of Sains Malaysia, Gelugor, Penang, Malaysia

DOI: https://dx.doi.org/10.47772/IJRISS.2025.9010048

Received: 12 December 2024; Accepted: 17 December 2024; Published: 30 January 2025

ABSTRACT

Nursing turnover is one of the critical issues that fuel the contemporary challenges in the healthcare sector. This study aims to look into the determinants of nursing turnover intention, its causes, and management implications reported in previous literature. A comprehensive review has been conducted to critically analysis the relevant literature published between 2015 and 2023 in Scopus, Web of Science, APAIS-Health, and Google Scholar databases. Keyword-searching techniques are performed through electro-search terms to find out the key determinants of nursing turnover intention. The summary of the reviewed literature highlights that job stress and workload, workplace incivility, bullying & violence, and career, pay & reward are the key factors leading to high nursing turnover in the healthcare sector. The findings suggest that positive initiatives towards providing education and training for new nurses, improving workplace conditions, maintaining scheduled workload, and creating opportunities for career growth could be the sound strategies that can enhance nurses’ working performance, ensure job satisfaction, and harness turnover reduction.

Keywords:  Nursing turnover, Turnover intention, Healthcare sector, Career, pay, and reward, Workplace bullying and violence

INTRODUCTION

Nowadays, the demand for health care services provided by professional nurses in health care sectors is enormously increasing across the globe.  However, the high rate of nursing turnover has created a continual challenge, leading to increased healthcare problems in many hospitals (Fei et al., 2023). In recent decades, nursing has been one of the occupations that has encountered substantial manpower shortages due to the high turnover rate (Sabei et al., 2020). According to the NSI (2023), the overall hospital turnover rate is 22.7%, where the registered nurses is 22.5%. Researchers conducted various studies to identify the reasons behind nursing turnover in different contexts. However, the findings of the previous research conducted to identify the causes of nursing turnover in the literature are quite inconsistent.

A number of studies (e.g., Ahn et al., 2023; Park et al., 2019) focus on low career development opportunities, less payment, and lack of reward for performance are the key factors causing nursing turnover issues while other studies claim excessive workload and job stress (Lee et al., 2020), and poor working environment (Poku et al., 2022) contributed to high nursing turnover rate in health care sector. Although several studies have been conducted addressing the causes of nursing turnover issues, the findings of these studies don’t have uniformity and consistency. Therefore, these findings cannot be generalized to design and formulate a pragmatic strategy for defending the challenges of nursing turnover as well as developing this sector as a whole. Hence, it has been necessary to find out the most influencing factors causing nurses’ intention to switch their jobs. Considering the above concern into account, the current study intends to look into the key factors that cause nursing turnover issues and can significantly contribute to mitigating the issues in the healthcare sector.

To address the above issues, a narrative review has been done on 100 articles highly relevant to nursing turnover published in different reputed journals. First, a list of key factors from previous studies that might cause nursing turnover is extracted and then presented based on their rank order. The findings claim that job stress and excessive workload are the dominant factors followed by workplace incivility, bullying, and violence, and low career development opportunities, negligible pay and reward that are fueling high nursing turnover in the healthcare sector. This finding will provide precise insight for the managers and policymakers in the healthcare sector to manage nursing resources properly. It would also help to reduce nursing turnover and mitigate the shortages of nurses issues in this sector effectively and efficiently (Chen et al., 2018). Moreover, a precise finding on the nursing turnover issue would make a significant contribution to the body of knowledge in health care literature.

This is a narrative review article which is organized following a prescribed structure. Just after an incisive introduction, conceptual definitions of turnover are presented. Next, a detailed literature review is done to find the key factors affecting nursing turnover intention. Then, a summary of the methodology used in previous literature is reported. After that,  a summary is prepared with the major causing factors of nursing turnover, followed by a rank order of those factors. The final section presents a concluding remark.

CONCEPTUAL DEFINITION OF TURNOVER

Since its inception, the concept of turnover has been used in various government, non-government, and private sectors.  It is a commonly-used notion in the field of health care and yet it is a concept difficult to define precisely. It implies that turnover is frequently applied in the literature but the lack of a clear and confined definition regarding turnover is still evident in the literature (Halter et al., 2017). Table 01 presents the conceptual definitions of turnover developed by different researchers.

Table 01: Conceptual definitions of turnover

The above table shows the different types of definition that indicates a need to be explicit about exactly what is meant by the word ‘Turnover’. Based on the above definitions, therefore, this study defines turnover as planned or intended to leave the jobs.

MATERIALS AND METHODS: KEY METHODOLOGIES USED IN PREVIOUS STUDIES ON NURSING TURNOVER

A function extracting related articles as well as reference lists from previous research, reviews, and editorials has been used during the search process. At the outset, 300 article titles and abstracts were scanned. Among these, 100 articles from recently published journals were considered to be potentially relevant for full-text review based on the following criteria: (1) the study limited the search to articles published between 2015 and 2023; (2) language written in English; (3) population in registered or practical/enrolled or assistant nurses employed in the hospital, long term or community care areas also examined. A summary is reported in Table 02.  

Table 02:  A summary of methodology used in nursing turnover literature

A systematic process of retrieving data from reliable sources has been followed for this research. Relevant searches were performed by applying electro-search terms CINAHL, MEDLINE, Health Internetwork Access to Research Initiative (HINARI), PubMed, APAIS-Health and Google Scholar databases. Besides, this study gathered data from ISI Web of Science and Scopus which have been considered reliable sources of databases with high-quality content by scholars. These databases contain journals that are covered by almost all the top publishers (e.g. Elsevier, Emerald, Taylor and Francis, Springer, Willey, Sage, PLOS, and other reputed journals) for providing better understandings and impending guidelines. The sample size of most of the studies was between 200 to 1000 and few studies cover a sample size between 1100 and above. To analyze the data, a large portion of studies used multivariate analysis with SPSS software while some studies also performed SEM with AMOS and PLS software.

LITERATURE REVIEW: FACTORS AFFECTING NURSING TURNOVER IN PREVIOUS STUDIES

A myriad of interrelated factors have an adverse effect on the intention of nursing turnover that negatively influences the overall healthcare sector. As evidence relating to the review of previous literature, this paper looks into the influential factors of nursing turnover. Moreover, this study has found and presented the leading influential factors and predictors based on the indication and argument of the narrative literature for future studies.

Working environment

The findings of recent studies show that nursing turnover intention is directly impacted by the condition of the working environment (Gong et al., 2022; Alenazy et al., 2023).  If nurses are dissatisfied with their working environment, they are more likely to leave their positions (Sheng et al., 2023; Poku et al. (2022) revealed that nearly half of the registered nurses have expressed a desire to leave the profession due to burnout resulting from an unsafe working environment, indicating that they perceive general well-being (i.e. Quality of Work-Life) as low.

Workplace incivility, bullying, and violence

The positive association between workplace incivility and workplace bullying with nurses’ turnover intention has been justified in many studies, indicating that negative behaviors can probably escalate their turnover intention (Faheem et al., 2022; Al Muharraq et al., 2022). Workplace bullying is significantly correlated with turnover intention (Kim et al., 2019; Malik et al., 2017). In contemporary research, nursing turnover has been significantly and positively correlated with workplace violence in the emergency department (Jiang et al., 2023; Zhao et al., 2018).

Table 03: Findings on the effect of Working environment, workplace incivility, bullying, and violence on Nursing turnover intention

Career, pay, and reward

Nurse turnover can probably increase due to career barriers (perceived discrimination and lack of advancement) and basic rewards among nurses in the hospital  (Chang et al., 2019; Park et al., 2019). However, a perception of the career ladder system has a positive association with increased job satisfaction and lower turnover intention (Ahn et al., 2023). As unveiled that there is a considerable correlation between financial satisfaction (i.e. low pay) and turnover intention (Yan et al., 2021; Sharma & Xu, 2022). Prior studies also found that factors such as job satisfaction and effort-reward imbalance (ERI) have a considerable impact on turnover intention (Fei et al., 2022; Kim et al., 2022).

Work-family conflict

Recent studies reported that work-family conflict has both direct and indirect impacts on turnover intent (Fei et al., 2023). Filipino nurses have experienced moderate levels of work-family conflict (WFC) which are significantly correlated with job satisfaction, work stress, and turnover intention (Cao et al., 2021; Choi, 2015; Hatam, 2016). Family work conflict has an indirect effect on nursing turnover through higher burnout levels (Van der Heijden et al., 2019).

Table 04: Findings on the effect of Career, pay, and reward, work-family conflict, role & goal perceptions on Nursing turnover intention

Role and goal perceptions

Role stress has a significant positive relationship with the inclination of turnover (Boudrias et al., 2020; Hoseini et al., 2021). Contrariwise, lower turnover intentions are observed among nurses with satisfactory work demands, and those who experienced less role conflict (Nelson et al., 2021). Also, due to role overload and work constraints, newly licensed nurses have more probability of turnover intention (Andrews et al., 2023). Role conflict and role ambiguity have indirect effects on turnover intention through burnout (Han et al., 2015).

Excessive workload and job stress

Employee job stress and work related anxiey havr statistically considerable direct, indirect, and total effects on nursing turnover intention (Choi et al., 2017;  Han et al., 2015; Ma et al., 2021). Frequent work stress due to perceived workload (Yang et al., 2017; Holland et al., 2019), subjective workload and psychological workloads (demands) (Hwang et al., 2022; Daouda et al., 2021), longer work hours or days (Sato et al., 2022) could have an adverse effect on personal wellbeing (e.g., life satisfaction and health), thereby probably reporting higher turnover intention.

Table 05: Findings on the effect of Job stress & excessive workload and role of leadership style on Nursing turnover intention

The role of leadership style

As observed, abusive leadership practices are likely to have a higher turnover intention (Lavoie‐Tremblay et al., 2016; Perkins et al., 2023). Laissez-faire leadership role is positively associated with ever-increasing turnover intent (Pishgooie et al., 2019). Moreover, transformational leadership and authentic leadership are negatively correlated to turnover intention among registered nurses in Jordanian public hospitals (Alkarabsheh et al., 2022). Finally, empathetic leadership is not fairly likely to diminish turnover intent while mindful leadership can probably lower turnover intention (Wibowo & Paramita, 2022).

Health issues

Prevailing an unhealthy lifestyle has a higher inclination of nursing turnover (Han et al., 2020). Consesequence of this, shift work disorder (SWD) has multiple negative health-related effects, and leading to highly correlated with turnover intention (Jiang et al., 2023; Blytt et al., 2022). As found, there was a significant correlation between neuropsychological cluster (e.g. including, sleep disturbance, depression, and fatigue) and turnover intention (Asakura et al., 2020; Ki & Choi-Kwon, 2022; Djupedal et al., 2022).

Table 06: Findings on the effect of Health issues, patient mistreatment, and individual factors on Nursing turnover intention

Individual factors

Individual factors such as age, academic qualification, gender, marital status, working status, being childless, and work experiences are attributed to turnover intent (Chen et al., 2018; Al Mamun & Hasan, 2017). Personal reasons are generally shown for the resignation of nurses which differ from following their spouse or family, getting married, having a baby, adopting a maternity plan and continuing their education (Dewanto & Wardhani, 2018;  Bae et al., 2021). Considering experience and education, less experienced nurses had a higher intention to leave, and nurses with higher education showed a low intention to leave their jobs (Kim & Moon, 2021). In terms of gender and age, turnover intentions are highly influenced by factors such as young age, and lack of interest in nursing among males in comparison with older nurses, which is due to their lower ability problem-solving and lack of work skills (Chen et al., 2023).

Patient mistreatment

Patient-initiated misbehavior and violence have led to feeling disappointed with one’s job due to morally wrong and negative word-of-mouth communication which is in turn positively associated with occupational turnover intention (Zhan et al., 2019; Jiang et al., 2019). In a contemporary study, verbal and physical abuse by patients and their relatives have led to psychological problems and consequently, they are likely to leave their jobs (Yosep et al., 2023; Jeong & Kim, 2017). When a nurse experiences more mistreatment by patients, they perceive their work to be less meaningful, which in turn lead to higher levels of career withdrawal intention (Cai et al., 2022).

Nursing empowerment

As demonstrated, nurses who are dissatisfied with their level of job autonomy have a higher probability of turnover as compared to those satisfied (Gebregziabher et al., 2020). A decrease in psychological empowerment has led to a considerably more intensified direct impact on anticipating turnover intention while nurse administrators exploit unmannerly supervision (Ren & Kim, 2023; Favaro et al., 2021).

Table 07: Findings on the effect of Empowerment, the Covid-Effect on Nursing Turnover Intention

 The Covid-19 panic

The fear of getting affected by COVID-19 is linked to nurses’ stress at work and can probably have an impact on their decision to leave their positions (De los Santos & Labrague, 2021). Similarly, fear of COVID-19 has not only a direct effect on organizational and professional turnover intent but also has an indirect effect on it through increased work stress (Ekingen et al., 2023). Nurses have a considerably higher level of turnover intent during COVID-19 in comparison with before COVID-19 (Nashwan et al., 2021; Schug et al., 2022).

RESULTS AND DISCUSSIONS: A SUMMARY OF THE FINDINGS

After thoroughly reviewing the relevant literature, it is found that a significant number of factors are associated with the nursing turnover intention in the healthcare sector. This study has made a summary of the findings of previous studies addressing the nursing turnover issues to find out the driving forces causing nursing turnover intention. The summary report is presented in table 7.

Table 08: Summary of the findings of previous studies on nursing turnover intention

It is seen from the above table that job stress and heavy workload have been reported as the leading cause of nursing turnover followed by workplace incivility, bullying and violence, career pay rewards, and work-family conflict. Contrarily, nursing empowerment and then perceived role and leadership style are found as less influencing factors causing nursing turnover intention in the healthcare sector.  COVID-19 and patient mistreatment have been found less influencing factors as they have also been positioned in seven studies like leadership style.

Table 9: Rank order of the factors causing nursing turnover intention

Out of 100 reviewed articles, 15.2% reported job stress and heavy workload, 11.5% reported workplace incivility, bullying, and violence, and 9.50% reported unhealthy career, pay, and reward are the major causes of nursing turnover intention from their current profession. On the opposite, leadership style, patient misbehavior, empowerment, and perceived role and goal occupied positions between 4.75% and 6.65% of the articles. It implies that these factors are less significant contributors to nursing turnover intention cases. Besides, the Covid 19 panic also plays a vital role in nursing turnover intention although the number of research works on Covid panic in nursing turnover has just started during the COVID-19 pandemic situation.

Figure 1: Proposed framework to examine nursing turnover intention using the key factors

Work-family conflict and individual factors have occupied the third largest position in the nursing turnover intention rate. It has, therefore, been observed that about nine factors have been found causing nursing turnover intention. Among them, three factors are considered to develop a framework from the top order that need special attention to mitigate the nursing turnover issues.

MANAGERIAL IMPLICATIONS

Nursing turnover is one of the critical issues that lead to increased health care problem in health care industry. This study provides a solid insight into regarding the key factors causing nursing turnover intention in the healthcare sector. To sum up, it can be said that these findings provide a more precise feed to the management body, policymakers, and other stakeholders that can help them to take pragmatic policy for reducing the nursing turnover rate in the healthcare sector. By carefully understanding the intent of nursing turnover based on the findings of this study, managers and policymakers can tailor better strategic initiatives to maximize nurse retention in the workplace.

CONCLUSION

This study revealed the different sets of influential factors associated with turnover intention among the nurses working in the healthcare sector. This research has provided further insight into the issue of nursing turnover, suggestions, and implications for nurse retention. Management should closely monitor and evaluate the reasons for nursing turnover intention in their organizations. Performance appraisal systems and flexible job opportunities also require changing the workplace culture to provide evidence that the nursing profession is not a “dead-end job”. Nurses feel empowered if they contribute to the decision-making process, ultimately resulting in delivering quality healthcare in which they are involved. Therefore, hospitals should stress the need to finance the schooling of new nurses and increase job satisfaction by improving proper staff-to-patient ratios, building flexible programming, and generating opportunities for career advancement.

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