Background
Retention and intention to stay or leave a job are commonly used to evaluate employment outcomes in the nursing industry, and one concept that falls under this category is turnover. Retention is defined as a nurse remaining in their position, including registered nurses who leave their current role but continue working for the same organization in a different capacity (Lee & Jang, 2020). Nurses comprise 60% of the world’s healthcare workforce and are responsible for providing around 90% of essential healthcare services, making them the largest group of healthcare workers worldwide (World Health Organization, 2020). However, recent research on nurse staffing trends suggests this is no longer the case (Seitovirta et al., 2017). The issue of how to retain nurses is still subject to debate, but the prevailing notion is that having enough nurses on staff will enhance patient safety and, consequently, increase nurse retention.
Turnover can have negative effects on hospital organizations. This phenomenon has had a detrimental impact on the financing of human resources, as hospitals may lose competent employees, leading to disruptions in organizational, service delivery, and administrative functions (Labrague et al., 2020). For example, the turnover of nurses may require the employment of more trained and skilled nurses in their respective fields (Al Sabei et al., 2020; Labrague et al., 2018). Moreover, turnover can increase the financial costs of recruitment fees, overtime, and training programs for new employees. High turnover rates within organizational management can result in compromised patient safety, leading to serious medical errors, adverse patient incidents, mistakes, and poor quality of patient care (Belton, 2018; Hu et al., 2022).
On the other hand, some experts argue that turnover can have a positive impact on organizations by improving efficiency. Turnover is needed to eliminate employees with the lowest performance (Labrague et al., 2020). However, turnover rates must be controlled to ensure that the organization benefits from the increased performance of new employees. Additionally, organizations typically spend more on turnover costs than on recruitment fees. However, to maintain stability, turnover should be monitored, as many of the employees who leave are competent and loyal (Dewi & Wulanyani, 2017). One way to address turnover is to identify the factors contributing to turnover intentions, allowing for preventive measures to be taken before making a decision to leave.
In the United States, 23.7% of hospitals reported a vacancy rate above 10%, with the average nurse turnover rate increasing from 16.2% in 2016 to 18.2% in 2017 (NSI Nursing Solutions, 2020). A survey of 23,000 nurses working in surgical and medical healthcare settings across eleven European countries found that 33% of nurses intended to change their professions in the current year, while 9% were considering leaving the profession. The turnover rate for leaving the profession varied from 5% to 17% in ten countries (Loft & Jensen, 2020). Indonesia also faces challenges related to high nurse turnover rates, with an annual prevalence of approximately 27.3% (Fitriasari, 2020). Studies conducted in Surabaya have shown nurse turnover rates of 13.67%, 13.69%, and 16.91% from 2014 to 2016 (Asmara, 2018). Similarly, research conducted in Batam has reported nurse turnover rates in private hospitals of 15.4%, 14.3%, and 18.9% over the last three years (Christiani & Ilyas, 2018).
High nurse turnover rates have been observed worldwide, and various factors have been identified as contributing to the problem. These factors include personal development, job satisfaction, organizational culture, commitment, interpersonal relationships, and promotion opportunities (Akgunduz & Eryilmaz, 2018; Al Sabei et al., 2020; Christopher et al., 2018; Gebregziabher et al., 2020; Labrague et al., 2018). In addition, stress, fatigue, and the work environment are internal and external factors associated with nurse turnover (Yu & Lee, 2018). Faraz (2017) has highlighted three contributing factors to nurse turnover: role ambiguity, self-confidence, and competence; personal attributes such as educational background, work experience, and supervision; and job satisfaction, including professional autonomy and quality of professional relationships, and interpersonal relationships.
Despite extensive research on the factors contributing to nursing turnover, limited studies have been conducted on nurse turnover in hospital settings in Indonesia (Dewanto & Wardhani, 2018; Dewi et al., 2020; Lukman et al., 2020). In addition, the studies were mostly conducted before the COVID-19 pandemic, which provides a lack of understanding of nurse retention. As stated by Marzilli (2022), the nursing profession recognizes that it cannot revert to the pre-COVID-19 era, as the previous nursing practices have become obsolete, and it is now essential to design the future of nursing. Innovation necessitates creativity, leadership, optimism, foresight, and planning. Therefore, this study aimed to explore the current experiences of Indonesian nurses in retaining their jobs in order to create a new retention strategy in hospitals.
Methods
Study Design
This study used a descriptive phenomenology design to explore nurses’ experiences who retain their jobs in hospitals. Using a descriptive phenomenological approach based on Husserl’s writings, it is possible to describe these meanings without the need for interpretation (Sundler et al., 2019).
Participants
The participants were selected based on specific criteria, including 1) nurses working in all hospital departments, 2) nurses with more than five years of experience, and 3) nurses who could articulate their experiences clearly. Purposive sampling was employed to identify nurses who were willing to share their opinions on the comfort of their workplace. The research team provided an explanation of the study’s objectives and methods to the nurses, who were then asked to participate. To promote the sharing of diverse experiences, the study employed a maximum variation sampling approach. This approach involved selecting participants based on their department, age, education level, marital status, and gender.
Data Collection
The study was conducted using semi-structured interviews in a private hospital in Batam, Indonesia, between January and March 2022. The primary questions for the interviews were: 1) What has kept you working in this hospital for more than five years? 2) Could you describe your pleasant and unpleasant experiences? 3) What suggestions do you have for improving nurses’ work in this hospital? In addition, the researchers probed the participants’ responses by asking follow-up questions such as “Could you explain more about this?” to explore their experiences further. Before the interviews began, participants were informed about the study’s objectives and confidentiality and signed a consent form. All interviews were recorded, and each interview lasted approximately 45 minutes. Data collection continued until saturation was reached, at which point no new topics emerged during the interviews. It is noted that the researchers had no prior relationship with the participants.
Data Analysis
The data analysis in this study utilized a conventional content analysis method (Creswell & Creswell, 2018; De Chesnay, 2015). To ensure the transcripts’ quality, the researchers double-checked them. First, the researchers conducted a verbatim transcription of the interviews and read through them repeatedly to fully comprehend the participants’ perspectives. Next, the researchers coded and categorized the data based on their similarities through comparisons and discussions, and the codes were grouped into more general categories. These categories were then compared and organized into themes. Finally, the study team discussed the codes and categories to ensure agreement and enhance rigor before finalizing them.
Trustworthiness
Data credibility was attained by implementing a suitable data collection strategy through a semi-structured interview guide. The data analysis was comprehensively described to ensure reliability, and the source material was appropriately cited. The interviews were individually coded by the researchers, who held meetings to review the initial findings and reach a consensus on the codes and themes. These meetings served to establish the conformability and consistency of the study. In addition, the study explained the background, participant selection, data collection, and analysis procedure to enhance the transferability of the findings.
Ethical Considerations
The study received ethical approval from the Universitas Indonesia ethics committee after undergoing an ethical review process (Ethical approval number: Ket-08/UN2.F12.D1.2.1/PPM.00.02/2022). The study considered four ethical principles: respect, autonomy, beneficence, non-maleficence, and justice. The researcher explained the objectives and the process clearly to the participants, and each participant signed an informed consent form before being enrolled in the study.
Results
Characteristics of Participants
Ten nurses with an average total work length of 10.4 years and an average age of 35.6 years (with a minimum age of 28 years and a maximum of 44 years) participated in this study. The majority of the participants were female (n = 7), held bachelor’s degrees (n = 6), and were married (n = 8) (Table 1).
| ID | Sex | Age | Work Length | Education | Marital Status | Department |
|---|---|---|---|---|---|---|
| P1 | F | 35 | 9 | Bachelor | Married | Polyclinic |
| P2 | M | 28 | 6 | Diploma | Unmarried | Emergency |
| P3 | F | 37 | 12 | Bachelor | Married | Polyclinic |
| P4 | F | 29 | 6 | Diploma | Unmarried | Pediatric |
| P5 | M | 40 | 14 | Bachelor | Married | Intensive care |
| P6 | F | 44 | 16 | Bachelor | Married | Surgical |
| P7 | F | 29 | 6 | Diploma | Married | Polyclinic |
| P8 | F | 33 | 7 | Diploma | Married | Emergency |
| P9 | M | 39 | 13 | Bachelor | Married | Intensive care |
| P10 | F | 42 | 15 | Bachelor | Married | Pediatric |
F = Female | M = Male
Thematic Findings
The study identified three major themes: (1) good teamwork, (2) compensation, and (3) professional career development (Figure 1).
Theme 1: Solid teamwork
This theme explores how teamwork can affect nurses’ job retention. During the interviews, all ten participants mentioned that a solid and responsible team is essential for retaining their jobs. The following are some of the participants’ statements about teamwork:
“A solid and responsible team is essential.” (P1)
“The teamwork in my hospital is outstanding.” (P2)
“We support each other.” (P4)
“The family system that applies to my teamwork makes the work atmosphere comfortable.” (P5)
Several participants believed that having supportive colleagues can contribute to solid teamwork. Some participants shared the following:
“The relationship between colleagues is excellent and fun, and the supervisors are unified and mutually supportive. These make a perfect team.” (P3)
“The work environment is so far so good; the communication in my team is excellent.” (P8)
“If someone is unable to attend, others are willing to replace the service shift.” (P2)
Some participants think that supervisors who provide exemplary support lead to excellent teamwork. They shared the following:
“Our supervisor does not pressure us as workers, but they create a comfortable working environment. It is suitable for motivating me to give the best in my team.” (P5)
“My supervisor gives me feedback to improve my skills.” (P7)
“We are not considered only as employees, but we feel like friends. Thus, the work environment is comfortable even though we have to go through the COVID-19 pandemic.” (P6)
“The supervisor allowed me permission if there was an urgent situation.” (P1)
Theme 2: Adequate compensation
Nonetheless, the study participants also identified other factors that contribute to their job retention. The interviews revealed that adequate compensation is another essential factor that provides comfort. The following participants expressed this sentiment:
“I am satisfied with my professional income, which includes salary, allowances, and insurance. I believe it is higher than in other hospitals in the area” (P2)
“During the COVID-19 pandemic, we received specific incentives and facilities” (P3)
“For instance, if I fall sick, I receive an allowance for both outpatient and inpatient care. We also have access to the health BPJS” (P4)
“Here, we receive a bonus twice a year” (P2)
Theme 3: Professional career development
Professional career development is a significant factor that motivates nurses to continue their jobs. During the interviews, five participants emphasized how having a clear career path encourages them to remain in their positions. Some participants shared:
“The nursing career path levels are well-explained” (P7)
“The career path is clearly defined, starting from level 1A, then 1B, and so on”
“We are categorized into several levels according to the career path” (P8)
“Education also plays a crucial role in my career path here” (P6)
“Since the career path guidelines exist, I am eager to follow and improve my career” (P9)
“Position levels are determined based on the duration of work, education level, and performance, which will eventually lead to salary increments” (P10)
Additionally, the participants shared information about the opportunities for professional development, such as:
“I was given a chance to continue my bachelor’s degree and received financial support” (P6)
“I attended professional training in the intensive care unit” (P9)
“They provided us with opportunities for learning, such as training and formal education” (P3)
Discussion
The current study emphasizes the crucial elements for experienced nurses in retaining their intentions to stay in the hospital. Our findings suggest that the nurses’ decision to remain in their current roles is complex and influenced by multiple factors, including teamwork, compensation, and professional career development. Although no single factor could be identified across all participants, these themes were significant to many respondents. Our study also found that the prestige of the specialty or department’s classification did not affect nurses’ intention to stay. Despite having diverse expertise, the nurses shared similar experiences and perceptions, indicating that feelings of peace, security, and confidence were essential factors influencing their decision to remain. These feelings were associated with effective teamwork, adequate pay, and opportunities for professional career development.
The main themes describing nurses’ experiences and perceptions of working in the hospital consist of various factors contributing to their retention. The themes highlighting good teamwork and adequate compensation can make nurses feel more comfortable in their workplace. Numerous studies have demonstrated that teamwork and rewards can impact a person’s decision to remain in their job. Good teamwork, in particular, is a significant factor that influences nurses to stay in the hospital. Conversely, a work environment that lacks support can negatively affect nurses’ intentions to remain in their positions (Yu & Lee, 2018).
Additionally, nurses with positive expectations regarding their leaders’ and colleagues’ support and a manageable workload are more likely to continue in their careers. Thus, an effective leadership style is necessary, which includes supervisors’ reliability and ability to manage and motivate staff in the workplace (Sugianto et al., 2022; Suliman & Aljezawi, 2018). Moreover, the support of supervisors has a positive impact on the work environment and strengthens the team (Wang & Ahoto, 2022).
Maintaining the nurse-patient relationship, nurse-nurse relationship, and nurse-doctor interaction is crucial for retaining nursing positions, as noted by Ramli et al. (2021). A strong sense of collegiality among nurses is a significant factor in their decision to remain in their current roles. As a result, most nurses consider their coworkers crucial to their decisions. Nursing staff who have good relationships with each other enjoy going to work, making teamwork an essential strategy in nursing care. Good teamwork is characterized by attributes such as communication and an environment that fosters support, while team size and individual attitudes also contribute to it. Communication is the most important aspect of teamwork, especially within the critical team in carrying out joint activities to improve nursing services. Adequate communication within the team is essential, meaning that the communicating colleagues must have the same understanding of the information conveyed. The processes of exchanging messages that produce clear feedback should also be considered (Brommelsiek et al., 2019). The interview results conclude that good teamwork can provide a comfortable work environment.
In addition, material and non-material rewards serve as incentives for nurses to keep their jobs, recognizing their hard work and professionalism. The six primary rewards important to registered nurses (RNs) are monetary compensation and benefits, a balance between work and personal life, work content, professional growth, appreciation, and effective leadership. These rewards motivate nurses to perform their duties well and increase job satisfaction. Nurses dissatisfied with their pay are more likely to leave, and compensation was ranked higher than other rewards (Seitovirta et al., 2017). Furthermore, compensation is a crucial factor in retaining nurses in their jobs.
Compensation can also be grouped into monetary and non-monetary incentives. Financial incentives include bonuses, personal supplementary compensation, pension benefits, performance-based pay schemes, company perks, and fringe benefits. Additionally, non-monetary incentives such as providing individual nurses with more control over their work and offering professional development opportunities can increase job satisfaction among nurses. By providing incentives, nurses can enhance their performance and resilience, resulting in improved quality of work and increased job satisfaction (Al Sabei et al., 2020; Labrague et al., 2018).
A professional career path also influences the retention of nurses. The existence of a professional career path has been shown to impact the intention of nurses to leave their jobs. Career barriers and support greatly affect professional commitment. Therefore, reducing obstacles and increasing support can decrease nurses’ intentions to leave their profession. A professional career path can serve as a means of retaining nurses and motivating them to improve their work performance, thus enabling them to progress at every stage of their career (Chang et al., 2019; Diño et al., 2022).
Four major factors have been identified as significant barriers to career development: lack of workplace support, inadequate prospects for clinical career development, excessive working hours, and restricted access to further education based on merit (Christopher et al., 2018; Gebregziabher et al., 2020). Career development involves planning and implementing a career path that places nurses at a level commensurate with their expertise and provides better opportunities based on their abilities and potential. Formal education is pursued through advanced studies to increase the level of education, while non-formal education is pursued through training, seminars, and workshops. The evidence-based results on career explanations demonstrate the main benefits of implementing career stages, enhancing professional development, improving performance, increasing job satisfaction, and fostering a work culture of recognition. These factors are related to the decision to remain in the hospital (Christopher et al., 2018; Gebregziabher et al., 2020). Providing opportunities for workforce growth within proper role frameworks is an effective tool to improve work satisfaction, organizational engagement, and, ultimately, the retention of nurses. It has been consistently found that work satisfaction is a significant and most influential indicator of nurses’ intentions to remain in their current positions and the nursing profession.
Implications for Nursing Management and Hospital Policy
The study results might not be novel, but these are based on the participants’ perspectives. There are several implications from this study: 1) From the study findings, developing and implementing effective teamwork strategies are necessary. Hospital and nurse managers should create policies that foster good teamwork among nurses and prioritize effective communication, mutual support, and collaboration among team members. The hospital should also invest in programs that promote team-building and encourage a sense of collegiality among staff; 2) The hospital should develop policies that provide nurses with adequate monetary compensation and non-monetary incentives to motivate them to perform their duties well; 3) The hospital should create policies that promote professional development opportunities for nurses. These policies should encourage formal and non-formal education opportunities, training, seminars, and workshops to enhance nurses’ skills and knowledge; 4) Nurse managers should advocate for policies that support the career development of nursing professionals and establish a clear career path; 5) The hospital should develop policies that provide support for nurses’ career development, reduce barriers to career progression, and increase access to further education based on merit. These policies should encourage a work culture of recognition, improve performance, and increase job satisfaction; 6) Nurse managers should monitor and address workplace factors that negatively impact nurse retention, such as excessive workload and inadequate support. Implementing these recommendations can help hospitals to retain experienced nurses, improve job satisfaction, and ultimately improve the quality of patient care.
Limitations
The study was only conducted in a private hospital, providing a partial understanding of nurses’ experiences. Therefore, future research could investigate government or public hospitals, which may offer distinct perspectives.
Conclusion
Based on the findings, the retention of experienced nurses in hospitals is influenced by multiple factors, including teamwork, compensation, professional career development, and a supportive work environment. Good teamwork, effective leadership, and collegiality among nurses can create a comfortable and supportive work environment that can positively impact nurses’ intentions to stay in their current roles. In addition, adequate monetary and non-monetary compensation is crucial in retaining nurses, along with opportunities for professional career development. Finally, the existence of a professional career path that places nurses at a level commensurate with their expertise and provides better opportunities can decrease nurses’ intentions to leave their profession. By addressing these factors, hospitals can create a positive work environment that supports nurses, resulting in improved quality of care and patient outcomes.