In a time of global nursing shortages an alarming number of young registered nurses have expressed a willingness to leave the profession. In this qualitative case study we investigate in depth why young nurses leave nursing profession and reeducate themselves for a new career. The study is based on longitudinal interviews of three young registered nurses in Finland. These nurses were first interviewed between December 2006 and May 2007, when they were 29–32 years old and having an intention to leave the profession. The second interview took place four years later, from January 2011 to March 2011 when all of them had made the transition to a new career. Data were analyzed in two stages. In the first stage, comprehensive career story narratives were formed on the basis of the interviews. In the second stage, emerging themes in these stories were compared, contrasted, and interpreted in the context of the overall career histories. Nursing as a second career choice and demanding work content as well as poor practice environment and the inability to identify with the stereotypical images of nurses were main themes that emerged from these career stories. The results of this interpretative qualitative study reflect a shift toward insights into understanding professional turnover as a complex and long-lasting process.
Nurses are the largest group of professionals within the global health care system, with a total of 19.3 million nursing and midwifery personnel in the world [
At the same time of this global nursing shortage, many nurses are considering leaving their job, profession or are out of the nursing workforce. According to Flinkman et al. [
Turnover intention appears to be a multistage process consisting of psychological, cognitive, and behavioral components [
From the society’s and healthcare’s points of view, professional turnover is a more significant form of work transitions than organizational turnover [
The youngest generation of nurses are the most willing to leave the job and the nursing profession [
Several factors are related to young RNs’ intentions to leave the profession, including an imbalance of effort and reward, high psychological demands, and higher job strain, which all influence young nurses’ intention to resign from their nursing careers [
Experiences of resent graduates have been widely examined in the nursing research [
Most of the earlier turnover research is concerned with nurses leaving the job or the organization [
Knowing that young nurses’ transition from a student to nursing career is a demanding and stressful process and thus could lead to nurse turnover from the profession [
This inquiry has been designed as a longitudinal qualitative case study using interpretive narrative method. A “case” is being defined as a longitudinal career story interpreted by a young registered nurse.
This is a qualitative case study [
According to Sharp [
Both the interview material and data analysis method in this study can be defined as narrative. The underlying assumption of narrative inquiry is the idea that individuals make sense of their world by telling stories [
Events in a narrative are selected, organized, connected, and evaluated in accordance with the audience to which the narrative is told (e.g., the interviewer) [
Cochran [
The selection of participants was purposeful [ be a registered nurse, have work experience in nursing, have an intention to leave a nursing profession that had started before the age of 30, have a willingness to articulate, and reflect upon, their experiences in their nursing career.
We requested that they add their contact information if they wanted participate the interviews concerning the intention of leaving the nursing profession.
Three young female registered nurses were willing to tell their story to the interviewer and met the inclusion criteria. We decided to accomplish longitudinal career story interviews with these three nurses in order to get an in-depth understanding of the phenomenon of interest. We considered that three young nurses was a sufficient number, because in case study method sample sizes are nonrepresentative [
Young nurses were interviewed twice. The first author conducted all of the interviews: a female researcher who was at the time in her 30s, a registered nurse, and a PhD student in nursing science. The process of gathering the initial data was conducted between December 2006 and May 2007. In the beginning of the first interview the interviewees were asked to draw—on A3-sized paper—their pathway as a nurse and put into this drawing the significant events in, and experiences of, their nursing career. Narratives of personal experiences or life stories are often told in response to open-ended questions, which do not limit or specify the type and the form of the narrative [
When the complete story had been obtained, some detailed relevant questions were presented to encourage further elaboration on the narrative (e.g., “
The second interviews took place four years later, between January and March 2011, when all of these young nurses had made the transition to a new career. In the beginning of the second interview, the participants were asked to continue their earlier career-pathway drawing and were asked to continue their story of being a nurse from any point in their life that they chose
The lengths of the interviews varied from 113 minutes (longest first interview) to 25 minutes (shortest second interview). One nurse chose to be interviewed at her workplace, and the other participants were interviewed in their homes. Interviews were recorded on a digital recorder and were transcribed verbatim by the first author, because analysis and interpretation of such data depends on the adequacy of a carefully prepared manuscript [
Narrative data guided the data analysis method we chose for this inquiry. Data were analyzed in two stages. Firstly, we followed the holistic-content method developed by Lieblich et al. [
We found in the preliminary readings that while these narratives were unique, certain main themes also appeared to be reflected both within and between these stories. A thematic approach to narratives is useful when trying to find common thematic elements across research participants and the events they report [
To evaluate the validity of narrative studies, Riessman [
We followed the ethical guidelines described by the Finnish Advisory Board on Research Integrity [
At the time of the first interview, Anna (a pseudonym) was a young woman at a crossroad in her nursing career. She showed a strong intention for a career change, yet at the same time she was tired and distressed because she was not sure how such a career change would be possible. Anna was very analytical and told her story in an animated way. Her narrative was detailed, complex, and often included cynical humor and sarcasm; she also often vocalized direct quotations from other people’s speech to make parts of her narrative more dramatic. Anna used a great amount of time in the first interview analyzing what she wanted for her future career and what she might be capable of doing if she were to leave nursing work. She had talked about this career change with her relatives and friends and had thought deeply about the advantages and disadvantages of leaving the nursing profession.
Betty (a pseudonym) already had a new university education at the time of her first interview. She told her story in a good-humored way, often laughing. During her story, Betty mentioned frequently that her nursing job had mostly been “nice” and the patients were also mostly “nice”. There were some more dramatic stories—for example, an unsuccessful resuscitation of a small baby—but mainly her nursing career story was positive and optimistic. She had, however, stayed in her nursing career for quite a short time.
Cecilia (a pseudonym) was very calm and analytical when telling her story. Her narratives were well structured, and she used a flowing narrative style to tell her stories. Cecilia had mainly enjoyed nursing work and taking care of patients. She had a strong sense of treating other people in a fair and just way. During her time at the nursing school confidential tasks were already being given to Cecilia, and teachers were saying that she would become a good teacher. She had already begun to be interested in management when she was in the nursing school and was willing to develop herself professionally from the beginning of her nursing career.
When Anna was in both grammar school and high school, she had no intention of becoming a nurse. She considered many careers, for example, a veterinarian or journalist, but was not sure, or at least confident, of what she wanted to do in her forthcoming career. After high school she applied to university to read nonnursing discipline but was not accepted. She was at that time in practical training in a hospital and liked the work, despite the fact that it was not exactly the work she was considering as a career choice. Not knowing what else to do, she however applied to a nursing school and was accepted. Anna related that she did not know anything about nursing when she was applying to nursing school, but she was confident that she was never going to work as a bedside nurse. In the admission test she achieved a very high overall score but a low motivation score. In her retrospective analysis she reflected that the test had probably quite accurately measured the reality of the situation: she was not especially eager to get into the nursing school. At that time her mother and friends had said that a career in nursing might not be right for Anna’s personality.
Betty was also not interested in a nursing career when she was in high school. After high school Betty applied to university but, disappointingly for her, was not accepted. She was doing voluntary work during a “gap” year and through this became interested in nursing work. She decided to apply for a nursing education because she thought that nursing could be a stepping stone for working in developing countries or in becoming a physician. At the very beginning of her nursing studies she had already started to hesitate: was she choosing the right career? In the beginning of her story she recalled
Cecilia too believed that she became a nurse through serendipity, and a nursing career had not been a childhood dream for her either. After high school Cecilia decided to move abroad and to start university studies there. Before leaving, Cecilia was working for a few months in a hospital and started to consider what it would be like to be a nurse. Coincidentally she noticed an advertisement for the nursing studies in a newspaper, decided to apply, and was accepted. One of her relatives had worked in a hospital when Cecilia was a small child. She thought that there was a certain attraction to nursing work, although at the same time the hospital was quite a frightening place, with white working clothes and with peculiar smells. She recalled
Even though these young nurses did not have nursing as a first career option, they all graduated from nursing school with good grades. They also all received positive feedback from the school and from clinical practices, and their memories from the nursing school were mainly positive in their narratives.
Since the beginning of her nursing career, Anna had been working in a ward where many patient were alcoholic, drug abusers, or elderly patients with no hope of recovery. She said that she did not like the routine tasks related to patient hygiene and housekeeping within the ward. Anna did not like working close to the patients; she highlighted nursing tasks that were menial, unpleasant, and intimate. Perhaps because of the work-related burnout, she recalled
Betty also had to take on a great deal of responsibility as a graduate nurse: in some wards she was the only RN during a shift, as all the others were nursing aids. There was insufficient staffing level, and patient care was demanding. When she was employed in her last summer job as a nurse she thought that the nurses where she was working had an increased workload, and that they were extremely busy. She was no longer enjoying nursing work, and she felt that being productive was seen as more important than taking good care of the patients. She told a story about one nightshift when the workload was almost overwhelming
Cecilia liked nursing work related to the patients and their care and enjoyed both the atmosphere of the workplace and her coworkers. The nursing job was demanding but also rewarding. At the same time as relating how much she liked her job, Cecilia also verbalized feelings of guilt and of being burdened because she thought that she was unable to provide the level of care that she considered adequate. She told a story of her last summer in the hospital when there were many inexperienced doctors on the ward. She had subsequently thought that she had to supervise and look after those doctors. She recalls
There was a strong hierarchy in the hospitals, and the lowest in the hierarchy were nursing students—in some workplaces they were not even permitted to go into the coffee room—yet graduate nurses and new nurses in the ward were also low down. Betty noticed during her nursing education that medical students were even lower in the hierarchy than nursing students; after this realisation she decided against pursuing a medical career. Strong hierarchy was a disappointment for these young nurses; however, they felt that they could not change the situation.
During her interviews, Cecilia often recounted her experiences of poor management in the hospital. For example, she had supervised students, often using her own leisure time to do so, but these efforts were not compensated; furthermore, she had lacked feedback about what she was good at, and what she needed to do in order to develop. She had wanted to participate in further education, but as a temporary worker she was not offered this possibility. Cecilia felt that managers in the hospital did not actually understand how demanding the nurses’ work was, and that they had very unrealistic proposals about how to develop patient care. She also confronted ethical problems in the ward; she felt that nurses in the ward were not able to provide humane and proper care. She recalled
Anna felt that nursing would not provide her with intellectual challenges after a few years of work, and that nurses had no career development possibilities. Similarly, Betty had sought career development opportunities but was not able to see the potential for pursuing them in her nursing career; she had hoped that nurses would have some kind of career ladder, to allow for such progress. Thus, this lack of professional development was a common concern, as expressed by Betty
All of these nurses were dissatisfied with their salaries. Anna thought that even a much higher salary would not compensate for work that was otherwise unsatisfactory. Betty said that the salary was too low when compared to the responsibilities of nursing work; she was getting a better salary in her new job outside nursing, even though there she was not able to “kill anyone.” She also thought that higher salaries would improve the image of nursing.
Anna, Betty, and Cecilia all did shift work during their nursing career. Combining private life with shift work was demanding for them, because they found planning their lives around it challenging. Recovering from night shifts was also difficult, because it was hard to be awake at nights and sleep during the day. Betty, furthermore, said that if she did not get enough sleep, she was prone to suffer from migraines.
All of these nurses were working under fixed-term contracts at the beginning of their career, because during the economic depression, graduate nurses were mainly offered only fixed-term employments. Anna felt that the charge-nurse in the ward was using fixed-term contracts as a way to exert power. This power relation changed when there started to be a shortage of nurses in the ward, which provided Anna with a bargaining opportunity. After telling the ward sister that she was looking for a new job, she was offered longer fixed-term contracts. Anna finally secured a permanent work contract after a few years. She thought that getting a permanent job was a good thing for gaining control over one’s own life, although at the same time she also thought that she was then somewhat “trapped.”
Betty did not work in nursing for long and only with temporary work contracts. While studying for a new career she worked for short periods in numerous hospitals. In some places there was no proper orientation for the job, and there was no support for a recently graduated, inexperienced nurse. Cecilia also started with temporary work contracts, working in many different hospitals. She had the possibility to apply for a permanent contract but never did so; she did not want a permanent job because she was sure that she was not going to work for the next forty years as a nurse.
Within the narratives, all these young nurses described what kind of people nurses are: nurturing, altruistic, and willing to serve. They did not, however, place themselves within these expected images of nurses. In their stories, these young nurses narrate nursing as a profession, not as a vocational calling. They construct themselves as talented and ambitious and striving for career advancement. Throughout Anna’ story, she described herself as intellectual, creative, and systematic, but that she was not able to use any of these qualities in nursing. She thought that many other nurses were hoping to change career but found it impossible because of the demands of their families. Her boyfriend concurred, as he had said that she was too bright and talented for a nursing work
Betty also related that she had not been a nurturer when she was a child. When Betty applied to the nursing school, her parents said that she was too ambitious for a nursing career, and that she would not stay in nursing for long. However, Betty was a strong-minded woman and decided at that time to continue, despite her parents’ worries. After graduation, Cecilia worked on a ward taking care of elderly patients. She was afraid that she was going to be “stuck” in that ward, where she was not capable of using her knowledge and talents as a nurse. Cecilia also produced stereotypical images of nurses in her stories: she described that nurses had a role within the hospital of the physicians’ handmaids. She thought that nurses had a lower professional status in the hospital than physicians and that a nurse’s role was not autonomous.
Anna also said that people did not know what the nursing profession requires. She also thought that the average person did not know how demanding the nursing job is or how many skills nursing work requires, and that she did not like the stereotypical picture of nurses given in the media and on television
In her search for a new career Anna tried to discover one that would better suit her personality as an intellectual, creative, and systematic person. Her decision for changing careers had started as a “sinking” feeling, although the interviews did not reveal a single instance where this intention would have started. This transition process had lasted for many years and was difficult for Anna; indeed a number of times during the interview she remembered that she had often cried and had occasionally felt very tired. However, she presented herself as an active actor who had the power to change a situation that was not satisfactory to her. After the first interview Anna applied to university for a nonnursing discipline, and was accepted. She graduated, and she found a new workplace outside nursing, and also resigned from her permanent nursing job. Anna was the only one of these three nurses who thought that she would never work as a registered nurse again. As Anna shared
According to Betty’s story, how she ended up in a different career was as serendipitous as her initial choice to become a nurse. A friend had given her an extra application form for the entrance exam to study nonnursing discipline in the university; after sending in the application she decided to prepare carefully for the exam, studied hard, and was accepted. She managed her financial problems while studying by working as a nurse and by living frugally, which required both self-discipline and sacrificing her own comfort. After graduating from a university, she received a demanding work outside the nursing field. At the time of the second interview Betty had some thoughts of continuing her education in university to doctoral level and also doing some nursing work occasionally under temporary contracts. In Finland reregistration is not required, so Betty would have the possibility to return to nursing.
During the transition process many changes were happening in Cecilia’s private life. Her family was very supportive of her career change, because they saw that she was not satisfied with nursing. Cecilia applied to the university to study nonnursing discipline and was accepted. She graduated, and because she was having a university degree, she got a new demanding job in human resource management in a large organization. She enjoyed her new work, even though it was demanding and the workdays were long.
In this inquiry, we used a qualitative case-study approach to form an in-depth investigation into the reasons why young registered nurses may leave nursing profession. This study produced three rich, detailed accounts of career transition from a perspective of a young generation. The results of this exploratory qualitative study reflect a shift toward insights into understanding professional turnover as a complex and long-lasting process. These transition processes cannot be simply captured with questionnaires. This could be one reason why earlier quantitative studies do not provide a clear picture of the reasons why nurses leave nursing.
All of these career stories are unique but also have similarities (see Figure
Framework enlightening themes associated with young registered nurse career transition.
Findings of this inquiry support the work of others; for example, in Takase’s [
As seen in this inquiry, the long-lasting process of career transition can actually start even before young nurses enter the nursing education. None of these nurses who shared their stories held nursing as a childhood dream; they described their career choices as a “second career choice,” or that they had “drifted” into nursing, rather than as a purposefully selected occupation. After being a while in a nursing career all of these nurses applied to their primary educational choice, to study at the university. This finding resonates with previous research. Nursing career chosen as a “default choice” [
According to these young nurses stories, the work content of nursing was demanding, and the nursing practice environment was not ideal in terms of nurse-patient ratios, rush, shift hours, and general appreciation. Nurses felt tired because they could not provide as adequate nursing care as they were willing. Nurses’ narratives bought up ethical dilemmas associated with not being able to provide humane and proper care. Not being able to do one’s best and not being able to influence working conditions were in contradiction with the talent and ambitions of these young women. Similar themes came up in McGillis Hall and Kiesners [
Young nurses reproduced cultural images and stereotypes of a nurse’s role and behaviour. They described what kind of people nurses are supposed to be: nurturing, altruistic, and willing to serve. Similar traditional stereotypes of “good women” have been presented on media and in public when nursing has been presented as a “virtue script” [
As seen in this inquiry, public stereotypes can have negative impact on nurses’ self-esteem [
In these stories, young nurses described themselves as talented and determined to go ahead in their career, attributes not historically attached to nurses [
Most of this earlier literature was focused on turnover from the perspectives of organizations or professions, with the researchers viewing it as a preventable or negative result [
What kind of new knowledge of nurses’ professional turnover can we expect to get based on qualitative case-study approach? The purpose of this inquiry was not to seek universal explanations of why young nurses leave nursing profession. The results are not meant to be generalized to a certain population [
The findings of this study are significant for three reasons. First, nurses were given an opportunity to tell their own story of why they had initially intended to leave, and why they eventually left, nursing. The voices of nurses who have intended to leave nursing have rarely been studied from their own perspective. Second, in contrast to the majority of previous studies that have mainly focused on turnover intentions and not actual turnover, a unique feature of this study is its longitudinal nature, which allows the reader to follow nurses through the process of their career transition. Third, nurses here provided stories of negative images and stereotypes in relation to their intention to leave nursing; in earlier studies of professional turnover, nurses’ own negative stereotypes and images have not been significant factors in causing an intention to leave. Furthermore, it provides unique real-life contextual knowledge of young nurses’ experiences of leaving a nursing career. This knowledge can be used as a basis for further studies and in discussions concerning nurses’ intentions to leave nursing from a generational perspective. More in-depth research is needed in order to better understand why nurses leave, and even more significantly, what could motive the younger generation of nurses to stay in nursing. In addition, there is also a need for longitudinal research that tracks nurses throughout the career change processes.
The findings should be viewed in light of the study’s limitations. The findings reported in this study may be limited due to the sampling methods which were used. It is possible that the nurses who volunteered, and thus were prepared to tell their career stories, were different from other nurses who had also considered leaving the profession. These nurses were interested in the subject under investigation, they had all thought about the motives for why they had an intention to leave and were willing to narrate their experiences. All of the nurses who participated were open to the experience, sociable, and talkative. These are all also characteristics that are associated with persons who are more likely to change their career [
All of these nurses had the personal and financial opportunities to gain a new education at university, something that is not possible for all nurses with an intention to leave. Furthermore, the participants were all aware of the interviewer’s occupation as a registered nurse; thus it is possible that this knowledge may have influenced the way in which they recounted their career stories. They were also aware that the topic of the research was the intention to leave nursing; this in turn might have brought up more negative issues from their career, in order to justify their reasons for leaving it.
The use of the qualitative case study method made it possible to examine nurses’ career turnover as an ongoing and multidimensional process, in which several causes consequently impacted on the final decision to leave the nursing profession. We demonstrated that narrative career interviews are a feasible way of collecting data regarding career transition processes. We also claim that in-depth narrative stories can provide unique real-life contextual knowledge of nurses’ experiences when living through these kinds of career transitions. We conclude that the qualitative case-study approach is a potential and novel way of doing turnover research in nursing science. Given the complex nature of nurse turnover, such a qualitative, in-depth approach is essential, alongside with quantitative studies, for a sound development of the nurse turnover research.
The authors are deeply grateful to all nurses who participated in the interviews and shared their experiences. University of Turku, the Finnish Association of Nursing Research, and the Finnish Foundation of Nursing Education provided financial support for this research.