Experienced Nurses’ Motivation, Intention to Leave, and Reasons for Turnover: A Qualitative Survey Study

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Introduction
Nursing is defned by autonomous as well as collaborative care with the aim of preventing illness and nursing sick, injured, disabled, or dying people of all ages.Moreover, nursing encompasses caring and advocating for families and loved ones, shaping healthcare policy, management, education, and research [1,2].Since the start of the COVID-19 pandemic in 2020, the vital role nurses play in society and healthcare systems worldwide has become more evident than ever before [3].Today, nurses make up over half of all healthcare professionals and are often the frst, and sometimes the only healthcare professional a patient will meet, which further highlights the signifcance of nurses in the healthcare sector [4][5][6].
Nurses perform a plethora of tasks and care for people in a multitude of healthcare settings, often shouldering a high workload and working long hours [7].During the last decade, increased staf turnover among nurses has led to a global needs-based shortage of nurses [6,8].Global eforts have been made to increase the number of nurses, including various local retention strategies [9,10] and increasing the number of places in nursing programmes.Despite these eforts, the World Health Organization (WHO) forecasts a shortfall of almost 6 million nurses by the year of 2030 and emphasises the importance of retaining experienced nurses in the workforce [6].For some time now, researchers have made great eforts to try to understand the reasons why nurses leave the profession.
Studies looking at why nurses leave the profession often focus on intention to leave (ITL) or the underlying reasons for staf turnover [8,11].ITL is clearly a complex issue triggered by organisational factors, such as the work environment, leadership, stafng levels, and the state of working relationships [12,13], as well as individual factors such as stress, burnout, and a sense that the work nurses perform is not valued [13,14].Earlier studies have revealed that turnover is driven by management style, highlighting a lack of good visible leaders, high workload, stress, disempowerment, and/or lack of autonomy [8,15].Previous research has shown that the fnal decision of nurses to leave the profession (turnover) is often proceeded by a lengthy period of consideration, or ITL [16].It therefore seems unviable to study these variables independently.
One way to understand retention and/or turnover is Herzberg's two-factor theory, which relates job satisfaction/ dissatisfaction to motivation [17].According to the theory, there are two dimensions to job satisfaction: hygiene and motivation.Hygiene factors are essential to maintain a pleasant workplace, and their absence will lead to dissatisfaction; meanwhile, motivation factors can create satisfaction by fulflling the employee's needs for personal growth and a sense of meaning [18].In the context of nursing, hygiene factors include a manageable workload, sufcient stafng levels, and reasonable salary and benefts, while motivators include a diversity of tasks, stimulating responsibilities, and seeing patients recover [19,20].Although the two-factor theory has proved useful in exploring job satisfaction and retention in nursing, it has also been found that, when describing their motivators, nurses contradict the basic tenets of the theory [19].Tis suggests that further research on motivation may be benefcial in terms of understanding retention.
Given the global shortage of nurses and the general high level of work-life stress in the nursing profession, there is every reason to increase our understanding of all aspects that infuence nurses to remain in or leave the profession.Rather than seeking to understand motivation, ITL, or turnover as isolated phenomena, this study aims to simultaneously explore what factors motivate experienced nurses in the workplace and the underlying reasons for strong ITL and high staf turnover within the profession.Tis approach may help further understand both the turnover and retention of nurses.

Materials and Methods
Te data used here originate from the longitudinal analysis of nursing education (LANE) study [21].Te LANE study is a prospective national study in which three Swedish national cohorts (2002, 2004, and 2006) of nurses were repeatedly surveyed early in their career, with a follow-up 11-15 years after graduation.Te qualitative data analyzed in this study were collected through open-ended questions in a survey distributed between October 2017 and January 2018 to all nurses in the three cohorts, i.e., 11, 13, and 15 years after graduation.

Sample.
Of the 2,474 nurses answering the survey, 1,146 (46%) responded to one or more open-ended questions and thus constituted the sample for this study.

Data Collection.
Initially, all nursing students enrolled at the 26 Swedish universities ofering nursing programmes graduating in the autumn of 2002, 2004, and 2006 were invited to participate in the LANE study.A total of 4,316 graduates consented to participate when invited, and 4,002 were still eligible for participation when the long-term follow-up (11-15 years after graduation) was conducted in 2017.Te response rate at the long-term follow-up was 62% (2,474).Data used in this study were collected from three open-ended questions included in the long-term follow-up questionnaire.Te three questions addressed (a) engagement and motivation, (b) ITL, and (c) reasons for leaving the profession.Te open-ended questions and the number of answers in the form of written comments to each question are presented in Table 1.In total, 1,146 participants gave 1,542 answers to the questions (29 participants answered all three questions, 338 answered two questions, and 779 answered one question).

Data
Analysis.Te analysis process followed the inductive qualitative content analysis framework presented by Graneheim and Lundman [22].Te written comments to the three questions (Table 1) constituted the unit of analysis and were initially treated as three subject areas: professional work motivation, why nurses intend to leave, and why nurses have left the profession/turnover.All the written comments were scanned and digitally transferred to the data analysis program NVivo [23].Te primary responsibility for analysing diferent subject areas was shared among the researchers.CG and MSN analysed the text about motivation, while AH and AR analysed the text related to ITL and turnover, all following the analytical steps outlined below.In the frst step, the written comments were read and meaning units-the relevant text for the purpose of the study-were identifed.In the second step, the meaning units were coded.Coding involved labelling the meaning units with a descriptive word close to the original text [24].In the third step, the codes were abstracted and sorted into subcategories.Tese three steps were followed by a comparison of the two research groups' preliminary results.Te purpose of this comparison was to identify similarities and diferences related to the three subject areas.During this process, the labelling and defnition of fve categories could be completed (Table 2).Finally, each category could be described based on what emerged in all three subject areas.

Results and Discussion
Among the respondents, 1,035 (90%) were female, and the age distribution was as follows: 504 (44%) were younger than 39 years, 391 (34%) were aged 40-49 years, and 251 (22%) were older than 50 years.It had been between 11 and 15 years since they graduated from nursing education.In addition, 57% of the respondents had received specialist nurse education, and they worked across various sectors of the healthcare system, including inpatient care, outpatient care, home care, prehospital ambulance care, research, and management.
Te result showed that what motivates experienced nurses, what sparks their ITL, and reasons for high turnover could be divided into fve broad categories: organisational characteristics, work characteristics, relationships at work, work recognition, and health issues (Figure 1).Te three subject areas motivation, ITL, and turnover are illustrated horizontally, and descriptions of the categories and subcategories within each of the three subject areas are illustrated vertically.
It was rare for a single motivator or underlying cause for ITL or turnover to be stated.Motivation often seemed to be linked to several accumulating factors.Similarly, a combination of reasons was often stated by nurses who either intended to leave or had already left the profession.Although the content of the categories interacts in the interests of clarity, the categories will be described separately.Verbatim quotes related to each subcategory can be found in Table 2.

Organisational characteristics
3.1.1.Motivation.Nurses were motivated when the organisation clearly defned roles, goals, and tasks.Another motivator was when management ofered employees opportunities to infuence routines and work schedules.Tis was particularly true of scheduling working hours, which enabled nurses to better plan their personal lives and achieve work-life balance, both between shifts and when not scheduled to work.A manager's ability to translate overarching organisational objectives into tangible and specifc daily goals was also an important motivator.Tose who could do this and reorganise work when workloads became excessive and ensure adequate stafng were described as responsible managers.

ITL.
Organisational characteristics could also be found in data regarding why nurses often thought about leaving the profession.Tese included working hours, the difculty of combining work with family or personal life, lack of time for recovery, and frustration with management and the organisation of work.Te nurses also described a lack of organisational resources, including inadequate stafng levels.Te results of the analysis also revealed that nurses who felt unable to infuence their work often considered leaving the profession.
3.1.3.Turnover.Among the organisational characteristics referred to by the nurses who had left the profession were poor leadership, lack of infuence, and inadequate stafng levels.Tese nurses described a lack of leadership and a lack of trust in their immediate manager, as well as discontent with constant reorganisation.Excessive administrative demands and a high nurse-to-patient ratio were described as draining.Te decision to leave was also made due to demanding working hours that precluded a healthy work-life balance.More specifcally, a schedule with too many short turnarounds with inadequate rest, too many shifts in a month, or excessive overtime were stated as the reasons for high staf turnover, as was a lack of foresight regarding holidays and scheduling that made it impossible to combine work with family life.

Work Characteristics
3.2.1.Motivation.Work characteristics described as motivational included being able to nurse based on a humanistic approach and in line with the nurse's own personal values.Tis was described as a matter of considering and protecting the patient's dignity and integrity throughout the care situation.Another motivational factor was being aforded a large measure of professional autonomy.Autonomy was described as the opposite of when tasks were controlled in detail by others.Nursing was also considered motivational when the nurse was able to take responsibility, both individually and as a member of a team, for achieving operational goals, developing nursing, and providing high-quality, evidence-based care.Continuing professional and personal development was also a motivator.

ITL.
Nurses with intention to leave the profession also highlighted specifc work characteristics.Several nurses described their duties as not being in line with nursing ethics and values.Te issue of patient safety was raised, such as when managers and nurses had diferent thresholds for when patient care could be considered safe.Tey highlighted moral distress experienced when unable to meet the personal needs of patients and their loved ones by providing high-quality care.Work factors were described as emotionally and physically demanding; caring for the sick had begun to drain them.Tey also noted that the nature of their work left no opportunity for desired personal and professional development.Nurses described changing job or profession as one way of acquiring this sought-after development.

Turnover.
Nurses who had left the profession described the job as unsustainable by nature due to the weight of emotional and ethical distress.Tey also stated that there was too little focus on patient safety and providing highquality nursing care.One major reason for turnover was the perception that caring had "disappeared" from nursing, their competence as nurses was not being utilised, and they were therefore unable to provide patients with high-quality care.Nurses who had left the profession also stated that there was little opportunity for professional development and that they wanted to develop both personally and professionally.

Relationships at Work
3.3.1.Motivation.Good relationships and well-functioning teamwork among competent, qualifed, and supportive colleagues were stated as important motivational factors.A supportive, collegial climate was also described as facilitating continuous learning and development and thus as particularly motivational.Te important qualities in a relationship included being able to express one's thoughts, feelings, and opinions freely and to share laughter with colleagues even when work was stressful or emotionally taxing.A safe, tolerant, inclusive that provided a sense of belonging was also a motivation.It was also considered important that equality should be an accepted part of the work community.

ITL.
Frustration with collegial relationships was mentioned as one reason why nurses often thought about leaving the nursing profession.Tat said, these comments consisted of short statements that lacked further detailed information.Although brief, many comments concerned a lack of teamwork and a lack of trust and collaboration with the colleagues closest to the respondents.

Turnover.
Nurses who had left the profession mentioned the professional hierarchy as a reason.One cause of hierarchical tension was when the nurse believed that they were considered to be doing no more than following orders given by doctors.

Motivation.
Recognition is clearly important for sustaining motivation at work, including in terms of being paid a reasonable living wage.Te factors that nurses included in the defnition of a reasonable wage included individual salary setting, as well as the profession's salary level.It was considered motivating when the salary was set fairly  6 Journal of Nursing Management taking into account individual performance and hard work, unsociable working hours, competence, and training.Remuneration for additional responsibilities or developing work on the ward was perceived as having a motivational efect.Moreover, a salary commensurate with the important societal function of the nursing profession was seen as important to sustaining motivation.It was also considered motivational when, in addition to any personal recognition nurses might receive, the signifcance of nursing as a profession was acknowledged at governmental and societal levels.For example, nurses described themselves as motivated when political decisions concerning the organisation of healthcare including the nursing perspective, or when the mass media covered the work of nurses in an insightful way.Recognition at a personal level was described in terms of nurses being treated with respect, receiving positive feedback, and feeling appreciated by patients, colleagues, or management.

ITL.
One frequently stated reason why nurses often thought about leaving the profession was a lack of recognition, particularly in terms of salary.Salary was described as unfair in relation to the workload, commitment, unsociable working hours, and short shift turnaround.Furthermore, when the salary was not perceived as compensating for the price nurses pay in terms of their family and personal life, they began to consider leaving the profession.Tere were descriptions of salaries not rising despite eforts such as further education, taking on extra assignments, or showing commitment.Aside from salary, lack of recognition from colleagues, patients, managers, and society was also mentioned as the reason to consider leaving the profession.

Turnover.
In terms of recognition, the nurses who had left the profession did name the lack of a fair salary, salary development, or recognition from managers as a reason for leaving the profession.

Health Issues.
Te ffth category, health issues, was represented in two of the subject areas (ITL and turnover).

ITL.
Common reasons behind ITL were deteriorating health, emotional exhaustion, and/or insomnia.Some nurses who often thought about leaving stated that, although their health had not yet been afected, they were afraid that their health would sufer if they continued working in nursing.
3.5.2.Turnover.Stress, insomnia, and fatigue were described as contributing factors to deteriorating health and a reason for leaving.From some of the comments, it was clear that, while the nurses themselves did not want to leave the profession, they felt that this was the only way to take control of their health and sustain a personal life.

Discussion
To the best of our knowledge, this is the frst study to simultaneously explore motivation, ITL, and turnover in the context of nursing.Te current view of staf turnover in nursing is that it is the result of a negative spiral that ultimately ends with nurses abandoning the profession [25], hence Selberg and Mulinari's [25] concept of turnover contagion; one nurse's decision to leave a failing clinic prompts other nurses to follow suit.In other words, "quitting leads to quitting" (p.96).By addressing all four areas in which, according to the result of this study, there seems to be an interrelation between motivation, ITL, and turnover, we may be able to not only halt a negative spiral but also increase motivation and, in the long term, wellbeing in the workplace.Taken together, the fve categories-organisational characteristics, work characteristics, relationships at work, recognition, and health issues-are crucial for sustaining motivation and avoiding staf turnover.Tis study reveals that while organisational characteristics can be highly motivating, they can also be the underlying causes of ITL and staf turnover.Judging by the result of this study, organisational characteristics can motivate nurses even when involving a high level of responsibility and challenge; however, this is highly dependent on management and leadership.Tis is in line with the previous research showing that nursing leadership plays a vital role in creating healthy work environments and manageable workloads [12,26,27].Nurses in leadership positions also play an important role in ensuring that their fellow nurses have control over their work and shifts and have sufcient time for recovery [28,29], as well as authorising work schedules that take account of the individual nurse's life situation [26,30].Te organisational characteristics category clearly showed the underlying problems in terms of afording nurses the possibility to infuence their own work and working hours and to recover between shifts.Furthermore, the result of this study clearly shows that nurses that are unable to achieve a healthy worklife balance fnd it difcult to sustain motivation and remain in the profession.
In the category work characteristics, nurses stated that meeting and caring for patients were highly motivational, thus revealing a true passion for the profession of nursing.Even among those who intended to leave or had left, there was clearly a strong wish to continue nursing; however, according to their accounts, the situation made it impossible to provide care in a manner consistent with their professional values.Also, in the category of work characteristics, nurses who had left the profession gave emotional distress as one of the reasons for doing so.Nursing is clearly demanding work, and the negative impact of emotional stress on the wellbeing of nurses has been thrown into stark relief by the COVID-19 pandemic [3,5].It could be argued that the stress that nurses experience is inherent to the profession, given the highly unpredictable nature of the job and the unsociable working hours nurses must work in order to provide healthcare around the clock.To make such demanding work characteristics motivational, and so that nurses can thrive in their jobs, the emphasis should be on providing adequate resources and individual control over their work [31].Toode et al. [30] underline that even a more intense workload may be motivating when it leads to an Journal of Nursing Management increased sense of professional accomplishment, career opportunities, or professional development.Tis reasoning is in line with the fndings of another Swedish study conducted by Gadolin et al. [32], which showed that when nurses perceived that their contribution was valued and their wellbeing was being safeguarded, they could focus on their main task of providing care.
Furthermore, Gadolin's results [32] reveal the importance of validating nurses' sense of competency and utilising their competence in the role of nurse.Te results of our study also show that when nurses perceived their nursing competence to be valued and appropriately utilised by the organisation, it positively infuenced their working experience.One core characteristic of nursing has been said to be that of "caring about" patients and their loved ones by providing psychosocial support, compassion, and sympathy [33].At the same time, paradoxically and partly contrary to these earlier studies, our study shows that nurses did not feel that their competence was being fully utilised; in other words, there is a discrepancy between what nurses have the ability to do and what they were permitted to do.It has been argued that the lingering and obsolete traditionalist view of nurses as being merely the physician's assistant continues to play down and negatively afect the expertise of nursing practice [34].In the relationships at work category of this study, these views were described in terms of hierarchical collegial relationships and as one reason for turnover.More and more noncaring tasks, such as cleaning and administration, have also been described as stealing valuable time away from caring [33].Incongruity between the nurse's professional values and competence and tasks they are expected to perform may leave them caught in-between and faced with ethical dilemmas [35].
Te category relationships at work also highlight how important relationships in the workplace and being able to rely on the competence of colleagues are to motivation and remaining in the profession.Management in workplaces perceived as healthy organisations is described as creating a culture of openness, respect, fairness, and justice [36].Coomber and Louise Barriball [37] describe poor relationships with colleagues as one of the most signifcant factors behind work-related stress, leading to ITL and turnover.Te social aspects of the workplace, such as being able to share and discuss opinions and concerns about patient care with colleagues, have been found to be associated with empowerment, thus reducing the likelihood of nurses leaving the profession [12].Furthermore, good collaboration, social support, and positive team spirit on a ward where nurses are treated as equally valued healthcare professionals has been highlighted as important motivators [30].Although interpersonal relationships are presented as hygiene factors in Hertzberg's two-factor theory [18], the result of our study, in line with prior research [19,30], concludes that nurses describe good collegial relationships as motivational factors that contribute to job satisfaction and motivation for retention.Gadolin et al. [32] recently demonstrated that sound relationships with colleagues are vital if nurses are to feel supported by the organisation, which in turn is associated with a variety of favourable outcomes such as greater commitment and improved wellbeing [38].It is also a prerequisite if quality improvement work in healthcare is to succeed [39].So, the results of this study support previous studies in underlining the importance of collegiality in healthcare.
Te results of the present study further highlight the importance of recognition to the work of nurses, and this was emphasised in all subject areas.One of the key aspects of recognition is a fair and adequate salary, and the study shows that nurses' salaries are frequently perceived as both unfair and inadequate.According to the fndings in the review by Coomber and Louise Barriball [37], one often-stated concern regarding nurses' salaries was the perceived inequity of pay given the high level of knowledge, responsibility, and workload compared to "less qualifed professions."Experienced nurses also felt that their level of experience was not recognised as important [37].Recognition of such factors, or lack thereof, in a nurse's pay packet can either be a motivator or lead to ITL and staf turnover.Again, the result of this study contrasts Hertzberg's two-factor theory [18] as salary and monetary compensation are hygiene factors.Te result of the present study indicates that recognition in terms of a fair salary can be motivation factors as it signals that nurses are recognized as important.Tat said, it is important to emphasise that, in line with prior research, this study demonstrates that while salary was often stated as one reason for ITL or leaving the profession, it was rarely the sole source of discontent; nurses also demanded other forms of recognition [12].
Although health issues were only raised in two subject areas, they were described as a major obstacle to remain in the profession, prompting ITL and departures.Tis confrms the results of an earlier quantitative study showing that early-career burnout left nurses feeling disengaged and exhausted at work, leading to higher [14] and escalating levels of intention to leave the profession [40].Moreover, there were increasing symptoms of burnout, while undergraduates predicted nurses' ITL and turnover after graduation [41].Interestingly, this qualitative study based on nurses' own words raises similar issues regarding fear of or actual deteriorating health.It is clear that, while health was not considered a motivational factor at work, the deleterious efects of the job on health were considered too high a price to pay for remaining in the profession.Hence, employers taking preventive measures that detect the early signs of burnout in order to reduce staf turnover is important.
4.1.Limitations.Among respondents who stated that they had left the nursing profession, some had moved on to other roles in healthcare such as university teachers, ward managers, or working with healthcare development.As these are vocations in which Sweden clearly needs nursing competence, one must question why these nursing graduates felt that they had left the profession.Further research is needed to investigate whether nurses themselves see a distinction between leaving the profession and carving out a career elsewhere in healthcare, such as in academia or management: is remaining "in the profession" solely associated with clinical practice?
In this study, data quality did not allow for coding of the "underlying" meaning (i.e., it was not considered possible to derive any themes).Terefore, the analysis resulted in a descriptive manifest level of the data [24].Te quality of data varied from concise answers to more expansive descriptions.At times, it was problematic to separate mutually exclusive categories, and the right level of abstraction was sometimes hard to determine.Tis was partly due to the interconnectedness of content, i.e., descriptions of a series of events that all afected one another.For example, working in a context in which it feels possible to provide high-quality care to patients is a prerequisite for feeling both that one is working efectively and that one is supported by the organisation, and various organisational aspects might explain why nurses felt that they had no time for recovery.
Being aware of potential errors in the coding process, the authors checked and discussed coding precision during the analysis.As the units of analysis provided insight into experiences of work motivation, ITL, and departures from the nursing profession without direct interaction between the researchers and informants, interviewer bias could be avoided [42].One obvious limitation was the lack of opportunity to ask follow-up questions to deepen contextual understanding.Another disadvantage was the absence of information from nurses who did not answer the openended questions.Tat said, postal surveys can be assumed to exert minimum pressure on respondents to give 'socially acceptable' responses.So, it may have been easier for some groups to respond-for example, those with critical opinions, those who are more reticent or nurses on sick leave-and harder for others, such as nurses with reading and writing difculties.Te strength of the study was the large national sample with a wide range of experience gained in many parts of the healthcare sector, which improved the prospects of shedding light on a range of experiences relating to work motivation and turnover.Te transferability of results is restricted by the fact that this is a "self-selected" subsample within the LANE study.However, by representing a subsample of the larger national LANE study, the context of the sample was well defned [21] and represents 46% of the nurses in the LANE study cohorts.

Conclusions
Although motivation, intention to leave the profession, and turnover are complex phenomena infuenced by multiple factors, by exploring them together, it was possible to identify important clues as to how the profession might retain more experienced nurses.Based on the results of this study, we conclude that ensuring that nurses have a manageable workload, that they have autonomy, that their competence is utilised, and that they enjoy adequate support from management will go some way to addressing the forecast shortage of nurses, by promoting the wellbeing of and motivating experienced nurses and decreasing staf turnover.Furthermore, according to nurses with over ten years of professional practice, a sustainable working life is dependent on collegiality, being able to work in competent teams, and being aforded multiple career opportunities.When deciding whether to remain in or leave the profession, recognition of the demands of the profession and individual knowledge and skills in the form of a fair and reasonable salary are considered key factors.Te result of this study also indicates that what may be considered hygiene factors in some contexts may function as motivation factors in nursing.Finally, the study makes clear that an organisation must be alert to and able to address the early signs of workrelated ill health in its employees if it is to mitigate ITL and staf turnover.

Figure 1 :
Figure 1: Illustration of the result including subject areas (horizontal), categories, and subcategories (vertical).

Table 1 :
Te open-ended questions from the LANE survey and the number of answers in the form of written comments to each question (total number of comments 1,542).

Table 2 :
Example of the analysis process and verbatim quotes to each subcategory.ref.no.04-587 and ref. no.2016/793-32).All respondents in the study gave informed consent to participation.A cover letter emphasising the voluntary nature of participation and the option to terminate participation in the study at any time was attached to the survey, as was information on how to contact the research team.All participants gave informed consent.
MotivationI consider appreciation of the work one does to be vital to wellbeing.Temost important factor is an adequate salary.Tis is why I have worked as a travel nurse for the last two and a half years.Tis provides me with a good salary.I can infuence my own working hours and I am appreciated at work every day Good and fair salary Fair salary Recognition ITL In my current workplace, there is little possibility to afect my salary even if I continuously develop my competence and take on greater responsibility Little opportunity to afect salary No infuence on the salary Recognition Turnover Te working hours and high workload cause ill health.I no longer wish to work for the regional health authority because of the poor pay and dreadful salary development Poor pay and salary development Not the right salary for the job performed Recognition Motivation ----ITL Te stress of my job afects me physically.I don't want to become ill with stress.I would like to have a job without responsibility for other people's health.Te responsibility is too great Worries about the own health Fear of developing health issues Health issues Turnover Stress and the dreadful working conditions, with such weak leadership, made me ill [. ..].I didn't see how I could ever be well as long as I remained in the profession Didn't think I could stay and get well (