Reasons for the Intention to Leave among Nurses Working in Internal Medicine and Surgery Departments of Slovenian Hospitals – A Cross Sectional Study

A systematic study of evidence looking at intentions to leave and the determinants of retention among nurses found that job satisfaction, career development and work-life balance were the most important determinants of retention (3). Job satisfaction is an important pull factor, while lack of job satisfaction is a push factor (4, 5). Furthermore, emotional exhaustion and depersonalisation have been found to be negative factors for nurse retention (6,7,8,9). Advancement opportunities and decision-making authority in patient care were also rated as important in retaining nurses (3, 5, 10,11,12,13), as were training opportunities (14), the opportunity for renewal (15), and positive professional experiences (16). Nurses want to feel empowered, to have autonomy and control over their work, and to feel that their work aligns with their personal and professional standards (17, 18). De Vries et al. (9) investigated the intention to leave the workplace during the COVID-19 epidemic and found six themes of determinants affecting the intention to leave the workplace: personal characteristics, job demands, employment services, working conditions, working relationships and organisational culture. The meta-analysis found that the most important determinants of intention to leave the workplace were fear of COVID-19, age, experience, burnout symptoms and support. French et al. (19) have shown that nurses in hospitals and nursing homes reported poor working conditions, high burnout and poor patient safety and quality of care even before the COVID-19 pandemic.

Williamson et al. (20) noted the importance of leadership and staff support, continuing professional development, recognition of nurses’ work, a positive work environment, and flexible work schedule. Effective local leaders who promote relationship building, professional autonomy and a positive workplace culture can positively influence nurse retention (21). In a study that looked at nurses who terminated their employment in healthcare between 2018 and 2021, Muir et al. (22) found that the factors that could improve nurse retention are reducing and preventing burnout, improving nurse staffing, and supporting nurse work-life balance, as these fall under the purview of employers.

Griffiths et al. (23) found in the pre-COVID era that European nurses working more than 12 hours and those working overtime in a shift were more likely to rate the quality of patient care on their ward as mediocre or poor, to rate patient safety as mediocre or poor, and to report more unfinished nursing tasks on their last shift than nurses working eight hours and no more than the contracted hours. Azzellino et al. (24) found that unfinished nursing tasks or missed care are closely associated with increased job dissatisfaction, which in turn significantly increases the likelihood that nurses will consider leaving their job. A meta-analysis on the prevalence of intention to leave among nurses during the COVID-19 pandemic found that 38% of nurses expressed the intention of leaving their current job (9). In Italy, Sasso et al. (8) found in the pre-COVID era that 35.5% of nurses intended to leave their current job due to job dissatisfaction and 33.1% of them intended to leave the nursing profession. Push factors included understaffing, emotional exhaustion, lack of patient safety, performing non-nursing tasks and being female. Pull factors included positive perceptions of quality and safety of care, and performing core nursing activities.

Demographic data is also important when it comes to the intention of leaving nursing. Length of experience in nursing is directly related to higher job satisfaction; nurses who have been in the profession longer have a higher level of intrinsic or learned ability to handle pressure, which enables them to cope better with working conditions (25). Younger and inexperienced nurses have been found to have limited personal resilience to cope with complex and stressful working conditions (26), which consequently negatively affects job satisfaction and increases the intention to quit. Park et al. (27) found in Korean nurses that satisfaction with salary level was the most visible and enduring predictor of turnover intention. Among other listed factors, satisfaction with salary was also found to be an important factor for intention to leave the hospital in less developed countries (28, 29). Wang et al. (30) found that both compensation and psychological rewards can influence turnover intention.

The Registered Nurse Forecasting (RN4CAST) study (31) was conducted in Slovenia in 2020. The variance in the working environment of nurses in the study can be explained by the following factors: promotion opportunities, educational opportunities, satisfaction with current job, professional status and educational leave. The average value determined for the work environment index in nursing was one of the lowest among the studies conducted to date (32).

The aim was to analyse the self-reported intentions and reasons for leaving a hospital due to job dissatisfaction by nurses in Slovenian hospitals. We included a range of reasons previously identified in meta-analyses of the evidence, covering demographic data as well as self-reported satisfaction with current job and career choice in nursing, job characteristics, workload and evaluation of hospital management performance.

A cross-sectional study was conducted. We followed the RN4CAST research protocol (31).

All Slovenian general hospitals (N = 10) and university hospitals (N=2) were invited to participate in the study. Of these, eight from the former group and two from the latter decided to participate. All employed nurses and healthcare assistants working in direct patient care and in adult surgery and internal medicine departments were included (31) (N=2813). The response rate was 35.91% (n=1010); 848 (83.96%) of respondents were female and 160 were male (15.84%). The sample included 403 nurses (40%) and 605 (60%) healthcare assistants (HCAs). On average, they had been employed for 21.42 years (SD=3.40). In nursing, the average length of employment was 15.34 years (SD=11.12). Respondents’ average age was 37.02 years (SD=10.65).

We employed the Emotional Exhaustion subscale of the Maslach Burnout Inventory for Human Services Survey (MBIHSS) (33). The scale has seven response options (0–never, 1–a few times a year or less, 2–once a month or less, 3–a few times a month, 4–once a week, 5–a few times a week, 6–every day). A higher score implies a higher degree of emotional exhaustion. The use of the emotional exhaustion subscale is conceptually and empirically well justified, as it is considered a core element of burnout (34, 35). Good scale reliability was achieved (n=9; α=0.883).

Regarding the respondents’ work characteristics, data was collected using the RN4CAST survey methodology (31): satisfaction with current work and professional aspects of work (1–very dissatisfied, 2–somewhat dissatisfied, 3–moderately satisfied, 4–very satisfied) (n=10; α=0.891). Various scales with one question were used to describe the conditions in the working environment (1–bad, 2–fair, 3–good, 4–excellent), intention to leave the hospital (1–yes, 2–no), and satisfaction with the decision to work in nursing (1–very dissatisfied, 2–somewhat dissatisfied, 3–fairly satisfied, 4–very satisfied). Various scales with one question were used to review the confidence of hospital management in resolving patient care issues, and patient readiness for discharge (1–not at all confident, 2–somewhat confident, 3–reliably confident, 4–very confident), the overall score for patient safety (1–failing, 2–poor, 3–acceptable, 4–very good, 5–excellent) and the overall quality of patient care on the ward/department (1–poor, 2–adequate, 3–good, 4–excellent) (31). Data on overtime in the last month was collected. We used the previously developed recommendations for the translation process (36).

The Slovenian National Medical Ethics Committee approved the study (No. 0120-488/2019/6, January 7, 2020). The study was conducted in accordance with the Helsinki declaration (37). The participants gave their written consent to participate in the study and gave permission to publish the results of the study in scientific journals (online, open-access). The data was collected before the outbreak of the epidemic in Slovenia from 10 February to 7 March 2020. The period of data collection was two weeks for each hospital. The management appointed research coordinators who administered questionnaires printed on paper. The respondents returned them at the agreed collection point in a sealed envelope.

The statistical package SPSS 22 was used for data analysis. Univariate, bivariate statistical analyses and multivariate analyses were performed. Statistical significance was defined at p<0.05.

Aiken et al. (44) pointed out that most hospitals have not made significant improvements in staffing or the working environment in the last decade; policy makers should require hospitals to meet safe minimum standards for nurse staffing. Continuing chronic understaffing and unacceptable working conditions in hospitals will not restore public and nurses’ confidence in hospitals. The importance of the number of nurses employed for patient health outcomes appears to be an explanatory factor in the Slovenian study (46).

One of the most important tasks of managers and leaders is to create a favourable working environment for nurses with effective and qualified leaders. Managers need to understand that a salary increase for nurses is not enough to retain these workers; salary and adequate working conditions are important, their absence leads to dissatisfaction, while achievements and recognition increase job satisfaction and performance. Policies aimed at increasing nurse autonomy, allowing post-graduate specialisations, recognising Master of Nursing degrees in clinical settings, providing recognition and improving communication are effective in increasing job satisfaction and decreasing turnover.

First, the results reflect the views and experiences of the nurses who participated in the survey. The response rate was relatively modest and may have led to response bias—especially if those with stronger opinions were more likely to respond. Secondly, the study focused exclusively on internal medicine and surgical departments and excluded other hospital areas that may have different organisational cultures and working conditions. Thirdly, the use of self-report data raises the possibility that certain responses may be both over- and under-reported because work environment and job satisfaction perceptions are inherently subjective and may vary over time and between individuals. Finally, the study is cross-sectional and thus narrows our capacity for drawing causal conclusions. While the regression models show significant relationships, they do not allow conclusions to be drawn on the direction or time course of these relationships.