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J Adv Nurs. 2023;79:4455–4471.
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4455wileyonlinelibrary.com/journal/jan
Received: 28 Septem ber 2022
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Revised: 20 March 2023
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Accepted: 16 April 2023
DOI: 10.1111/jan.15696
REVIEW
Nurses' motivations to leave the nursing profession:
A qualitative meta- aggregation
Wilmieke Bahlman- van Ooijen1,2 | Simon Malfait3,4 | Getty Huisman- de Waal2,5 |
Thóra B. Hafsteinsdóttir1,6
This is an op en access arti cle under the ter ms of the Creative Commons Attribution-NonCommercial-NoDerivs License, whi ch permits use a nd distribution in
any medium, provided the original work is properly cited, the use is no n-commercial and no modi ficat ions or adaptat ions are made.
© 2023 The Authors . Journal of Advanced Nursing published by Joh n Wiley & Sons Ltd.
1Nursing Science, Program in Clinical
Health S cience s, Unive rsit y Medic al
Center, Utre cht, Th e Nethe rlands
2Depar tment of Surger y, Radboud
University Me dical C enter, Nijme gen, The
Netherlands
3Nursing Depar tment, Ghent Univer sity
Hospit al, Ghent, Belgium
4Faculty of Medicine, Ghent Univer sity,
Ghent, Belgiu m
5Scientific Cente r for Qualit y of
Health care (IQ Healthcare), R adbou d
University Me dical C enter, Radb oud
Instit ute for He alth Sciences , Nijmege n,
The Netherlands
6Nursing Science Depar tment, Juliu s
Center for Health Sciences and Primary
Care, University Medical Ce nter Utrecht,
Utrecht, The Netherlands
Correspondence
Wilmieke Bahlman- van Ooijen,
Depar tment of Surger y, Radboud
University Me dical C enter, Nijme gen, The
Netherlands.
Email: wilmieke.vanooijen@radboudumc.nl
Abstract
Aim: To systematically provide an overview of the qualitative evidence available on
the motivations for nurses to leave the nursing profession.
Design: A qualitative systematic review using the meta- aggregation design of the
Joanna Briggs Institute.
Data Sources: Qualitative studies in English, dating from 2010 until January 2023,
were obtained from CINAHL, PsycINFO and PubMed.
Review Methods: Studies were selected using predetermined inclusion and exclu-
sion criteria. Quality assessment was done using the Joanna Briggs Institute Critical
Appraisal Checklist for Qualitative Research. The assessment of confidence in the
review findings was done according to the ConQual approach.
Results: Nine papers that investigated nurses' motivations to leave the profession
were included. We developed four synthesized findings from 11 synthesized catego-
ries and 31 categories to reflect nurses' motivations to leave the profession, including
(1) challenging work environment, (2) emotional distress, (3) disappointment about
nursing reality, and (4) culture of hierarchy and discrimination.
Conclusion: This review provides an in- depth and meaningful understanding of moti-
vations for nurses to leave the profession. Among others, poor working conditions, a
lack of opportunities for career development, a lack of support from managers, work-
related stress, a discrepancy between nursing education and practice and bullying
behaviour were motivations to leave the profession, which calls for targeted action to
retain nurses in the profession.
Impact: Findings of this study shine a light on reasons why nurses leave the profession,
providing evidence to support nurse managers and policymakers to develop retention
strategies to move out of current crisis into recovery of sustainable global healthcare.
Patient or Public Contribution: There was no direct patient or caregiver contribu-
tion to this study because this study originated from the process of a Master study.
However, two of the authors are still involved in clinical nursing practice and provided
the necessary link between research and practice.
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1 | INTRODUC TION
The growing nurse shor tage is considered a critical global problem,
which is aggravated by the trend that many nurses are leaving the
profession (Flinkman et al., 2010). This trend is currently worsen-
ing due to the COVID- 19 pandemic (Fernandez et al., 2020), which
has shown that the need for well- educated and competent nurses
has never been more pressing. The shortage of nurses adversely af-
fects patient and healthcare outcomes, and therefore it is essential
to understand the reasons why nurses are leaving the profession
(Needleman et al., 2011). While most reviews focus on quantitative
study designs in order to understand the reasons behind nurse deci-
sions to leave the profession (Chan et al., 2013; Flinkman et al., 2010;
Halter et al., 2017 ), an overview of only qualitative research is lack-
ing. Understanding these reasons is vital to detect early signs of
nurses' intention to leave in order to develop retention strategies,
which may be used to support current healthcare systems to move
out of the current crisis of nursing short age into recovery.
1.1 | Background
Nurses are the largest group of healthcare professionals and are
a critical part of healthcare systems worldwide (WHO, 2022).
Sufficient staffing levels, also referred to as the mean patient- to-
nurse ratio, are essential to meet the growing healthc are demands
because nurses provide direct care to patients, promote patients'
health and improve their satisfaction with the healthcare ser vices
(Aiken et al., 2014). Insufficient nurse staffing is associated with
negative patient outcomes, such as increased hospital- acquired ad-
verse events, rates of patient falls, pressure soars, drug administra-
tion errors, missed care, delayed hospital stays (Wang et al., 2020),
decreased patient satisfaction (Winter et al., 2020) and even higher
mortality (Aiken et al., 2014). In addition, insufficient nurse staff-
ing is also associated with negative outcomes for nurses, such as a
higher degree of burnout among nurses, increased job dissatisfac-
tion and a higher intent to leave the job (Shin et al., 2018).
Currently, the world is confronted with a shortage of 5.9 million
nurses and midwives worldwide, which is expected to expand to a
global shortage of 9 million by the year 2030 (WHO, 2020). With the
COVI D- 19 pan d emi c , nu r ses are fa ced with unpr e ce d ent ed work pres -
sure at the frontline of healthcare, which leads to even more nurses
leaving the profession (Fernandez et al., 2020). An import ant as pe ct of
the nursing shortage is the fact that many active nurses are intending
to leave the nursing profession (Flinkman et al., 2010). The intention to
leave is the process of thinking, planning and making decisions about
leaving a job or profession, but does not always lead to the profes-
sional actually leaving (Sharififard et al., 2019). While this is the step
before the actual leaving, nurses' intention to leave accurately pre-
dicts the actual decision to leave the profession (Krausz et al., 19 95).
According to the integrative review of Flinkman et al. (2010), which
included 31 studies, the proportion of nurses intending to leave the
profession ranged from 4% in the United Kingdom to 54% in Belgium,
which represents considerable differences between countries and the
way healthcare is financed and organized. While some studies report
that young and newly graduated nurses are most likely to leave the
nursing profession within 2– 3 years (Salminen, 2012), ot he r st ud ies re-
port that senior and more experienced nurses have a higher intention
to leave the profession, resulting in a loss of knowledge and experi-
ence from the nursing workforce (Flinkman et al., 2010).
The intention to leave occurs among nurses worldwide indepen-
dent of healthcare settings, including hospital settings, home care
and nursing homes (Tummers et al., 2013), which suggests a wide
range of complex factors that af fect nurses' intention to leave. The
following predictive factors were reported to be associated with the
intention to leave, like high patient- to- nurse staffing ratios, inflexible
interprofessional collaborative relationships, low job satisfaction, in-
adequate resourced environments (Hämmig, 2018; Lee et al., 2020;
Nowrouzi- Kia & Fox, 2020; Van den Heede et al., 2013), unsatisfac-
tory nurse- physician relationships, low levels of nursing leadership,
little participation in hospital affairs (Heinen et al., 2013), dissatisfac-
tion with salary, limited opportunities for professional development
(Flinkman et al., 2010), deteriorated external work environment,
physical and emotional workload, organizational commitment (Chan
et al., 2013) and la ck of perc eiv e d jo b con t rol and wo rk– fa mil y con f lic ts
(Yamaguchi et al., 2016). Fac tor s sp e ci fic all y re por ted fo r ne wly grad u-
ated nurses were feelings of stress and anxiety caused by nursing re-
sponsibilities, difficulties with adjusting to the new role, experiencing
sho ck when facing the real it y of nu rsing as a new gradua ted nur se and
the amount of support from senior nurses (Gardiner & Sheen, 2016).
The majority of the studies, which identified the aforemen-
tioned factors, are using quantitative cross- sectional study de-
signs, making it impossible to analyse behaviour over a period
of time or determine if there is a causality of the behaviour (Li
et al., 2020). Furthermore, there are concerns that quantitative
methodologies may prove to be too abstract to discern the com-
plex decision- making around the intention to leave the nursing
profession (Flinkman et al., 2008) because such a decision is a
multi- stage process consisting of various, subjective components
(McCar thy et al., 20 07; Takase, 2010). In contrast with quantita-
ti ve st udi es, qu al itat iv e evi den ce fac il itates data an aly sis of hum an
experiences and comprises data that are expressed in terms of
the meaning or experiences rather than in terms of a quantit ative
measurement (Lockwood et al., 2015). Thereby, the contribution
of qualitative research findings in improving the quality and rele-
vance of healthcare practice is increasing, which provides credible,
KEYWORDS
intention to leave, meta- aggregation, motivations, nurses, nursing profession, nursing
shortage, systematic review
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BAHLMAN-vanOOIJEN et al.
complementary data to address pra ct ice- and policy- related ques-
tions (Lockwood et al., 2015). Furthermore, systematic reviews of
qualitative research can improve the understanding of sensitive
issues, provide rich conclusions and have an import ant role in
informing the delivery of evidence- based healthcare (Lockwood
et al., 2015). Therefore, summarizing the findings of qualitative
studies conducted can provide an understanding of the real rea-
sons behind nurses' decisions to leave, which offers a more in-
depth view of the subject (Flinkman & Salanterä, 2015) and can
be helpful to produce lines of action regarding nursing retention
that have applicabilit y to healthcare policy or practice (Lockwood
et al., 2015). To the best of our knowledge, no systematic synthe-
sis of qualitative findings has been conducted on the subject, and
therefore there is a pressing need to provide a deep and mean-
ingful overview of the reasons and motivations affecting nurses'
intention to leave the nursing profession, in order to enable stake-
holders and policymakers to respond to these pressing issues and
to take targeted actions to retain nurses in the field.
2 | THE REVIEW
2.1 | Aims
The aim of the review was to provide an overview of evidence
from qualitative studies exploring nurses' motivations to leave the
nursing profession. The aim of the study was devel ope d accord ing
to PICo mnemonic, whereby the populatio n are nurse s, work ing in
all healthcare settings, of dif ferent ages and levels of work exper i-
ence. The phenomenon of interest regarded nurses' motivations,
whereby the context reflected intending or leaving the nursing
profession.
2.2 | Design
This review was designed as a qualitative meta- aggregation using
the guidelines of the Joanna Briggs Institute (JBI, 2022). Meta-
aggregation includes different qualitative study designs and aims to
examine the essence of papers by maintaining the original mean-
ing (Hannes & Lock wood, 2011). The process of meta- aggregation
includes the following steps: (1) line- by- line extraction of findings
from the included studies; (2) developing categories according to
similarities and (3) developing synthesized findings for at least two
categories (JBI, 2022). The study was reported according to the
Enhancing Transparency in Reporting the Synthesis of Qualitative
Research (ENTREQ) guidelines (Tong et al., 2012).
2.3 | Literature search
Relevant articles were identified using the electronic database in-
dexes CINAHL, PsycINFO and PubMed on 13 January 2022 and
updated on 16 Januar y 2023. The comprehensive search strategy
included the combination of (MESH) terms such as ‘nurses’, ‘mo-
tivations’, ‘intention to leave’ and ‘qualitative studies’, among oth-
ers. Included were studies conducted among nurses, working in all
healthcare settings, of different ages, levels of work experiences and
reporting on motivations for intent to or to leave the nursing pro-
fession. Studies published between January 2010 and January 2023
in the English language were included. The decision to only include
articles published since 2010 was chosen because of organizational
and technological changes in healthcare settings, which may affect
nurses' intention to leave. Excluded were studies conducted among
midwives or paediatric intensive care nurses. Additionally, the refer-
ences of suitable studies were manually checked in order to identify
studies not captured by the databases. Rayyan was used to man-
age the search result s (Ouzzani et al., 2016). The overview of search
terms is shown in Data S1 .
2.4 | Search outcome
The search strategy identified a total of 268 articles. After re-
moving duplicates, the titles and abstracts of 206 articles were
screened, leaving 15 relevant articles, which were read full text and
assessed using the predetermined inclusion and exclusion criteria.
Eventually, nine articles were included in the review. Reasons for
exclusion were as follows: a study design, population or outcome
that did not fit the eligibility criteria. No new studies were identi-
fied with manual checking of references of the included studies.
Each step of the literature selection was performed by two re-
searchers independently (WO and SM). After each step, the re-
sults were compared and discussed, whereby disagreements were
resolved. An overview of the screening and selec tion process is
shown in Figure 1.
2.5 | Quality appraisal
The methodological quality of each ar ticle was assessed with
the JBI Critical Appraisal Checklist for Qualitative Research (JBI)
(Table 1). The purpose of the appraisal is to assess the methodo-
logical quality of a study and to determine the extent to which a
study has addressed the possibility of bias in its design, conduct
and analysis (JBI). The checklist includes 10 questions, including
questions about the congruity among the research methodology,
research question, data collection, data analysis and the interpre-
tation of the results, and questions addressing the researchers'
statement culturally or theoretically, the researchers' influence
on the study, adequate representation of the participants' voices,
ethical approval and a logical conclusion from the data (JBI). Each
item is given a score of 1 if it is evidenced in the paper, and 0 oth-
erwise, resulting in a total score of 0– 10 (Banwell et al., 2021). The
following quality ranks were used for the studies, after discussion
in the research group: high (8– 10 points), medium (4– 7 points) and
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BAHLMAN-vanOOIJEN e t al.
low (0– 3 points). The quality of the papers was checked indepen-
dently by two researchers (WO and SM). Disagreements were dis-
cussed until consensus was reached.
2.6 | Data abstraction
Individual data of the included studies were abstracted using the JBI
QARI Data Extraction Tool for Qualitative Research, including au-
thor, year, country of origin, study design, phenomena of interest,
participant selection, data collection method, analysis technique and
key themes (JBI) (Table 2).
2.7 | Synthesis
Data were synthesized inductively using the JBI method of meta-
ag grega tio n, whic h has thr ee it era ti ve st age s ( Table 3) (JBI). First, the
results of the included studies were extracted line- by- line according
to its meaning and content with an accompanying illustration (i.e.
quotes) (JBI). A finding is a verbatim extract of the author's analytic
inter pret ation of thei r re su lt s or dat a (JBI). Eac h ar ticl e wa s re ad sys-
tematically and repeatedly in order to note these findings accurately
in the Results section (JBI). Second, the abstracted findings were
grouped in order to develop categories and synthesized categories
based on similarity in meaning (Lockwood et al., 2015). Third, syn-
thesized findings were created for at least two overall synthesized
categories (Lockwood et al., 2015). These synthesized findings and
categories form the basis of the meta- aggregation and are illustrated
with quotes from individual studies (Lock wood et al., 2015). The pr o-
cess of data synthesis was performed by the executive researcher
(WO) and supervised by a senior researcher (SM) in collaboration
with the research group (TH).
2.8 | Assessment of confidence in the
review findings
The JBI ConQual process was used to evaluate the dependability
and credibility of each synthesized finding (Munn et al., 2014). First,
all included studies were assessed on dependability. Dependability
was assessed using five items from the JBI critical appraisal checklist
(Table 1) (Munn et al., 2014). Dependabilit y was rated high if 4– 5
questions were answered as yes, moderate if 2– 3 questions were
answered yes and low if 0– 1 question was answered yes (Munn
et al., 2014). Second, to assess credibilit y, all study findings were
rated as unequivocal, credible or unsupported (Munn et al., 2014).
Third, the overall ConQual score for each synthesized finding was
FIGURE 1 Flow diagram for article selection (From: Moher et al., 2009).
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BAHLMAN-vanOOIJEN et al.
labelled as high, moderate, low or very low (Munn et al., 20 14). All
synthesized findings started with a high ranking due to the inclusion
of only qualit ative studies (Munn et al., 2014). The ConQual score of
the synthesized finding downgraded one level for each synthesized
finding having findings from studies with moderate dependability
ratings, and for having a mix of unequivocal and credible findings
(Munn et al., 2014) (Table 4).
3 | FINDINGS
The studies were conducted across six countries: Canada (Chachula
et al., 2015), China (Zhu et al., 2 014), Finland (Flinkman et al., 2013;
Flinkman & Salanterä, 2015), Germany (Roth et al., 2022), Iran
(Alilu et al., 2016; Alilu et al., 2017; Valizadeh et al., 2016) and The
Netherlands (Kox et al., 2020). A total of 138 nurses took part in
TABLE 1 Summary of the results of JBI critical appraisal checklist of qualitative research.
Alilu et a l.
(2016)
Alilu et a l.
(2017 )
Chachula
et al. (2015)
Flinkman et al.
(2013)
Flinkman and
Salanterä (2015)
Kox et al.
(2020)
Roth et al.
(2022)
Valizade h et al.
(2016)
Zhu et al.
(2014)
Is there congruity bet ween
the stated philosophi cal
perspective and the
research methodology?
0 0 1 1 0 0 1 0 1
Is there congruity bet ween
the rese arch methodology
and the re search quest ion
or objec tive?a
1 1 1 1 1 1 1 1 1
Is there congruity bet ween
the rese arch methodology
and the methods used to
collect data?a
1 1 1 1 1 1 1 1 1
Is there congruity bet ween
the rese arch methodology
and the re presentatio n
and anal ysis of dat a?a
1 1 1 1 1 1 1 1 1
Is there congruity bet ween
the rese arch methodology
and the interpretation of
results?
0 0 1 1 1 1 1 0 1
Is there a s tatement locating
the rese archer cultur ally
or theoretically?a
0 0 0 1 1 0 0 0 1
Is the influence of t he
researcher on the
research, and vice- versa,
addressed?a
0 0 0 0 0 1 0 0 0
Are par ticipants, a nd their
voices, adequately
represented?
1 1 1 1 1 1 1 1 1
Is the res earch et hical
according to current
criteria or for recent
studie s, and is t here
evidence of ethic al
approval by an appropriate
body?
1 1 1 1 1 1 1 1 1
Do the con clusions drawn
in the res earch re port
flow from the anal ysis, or
interpretation, of the d ata?
0 1 1 1 1 1 1 0 1
Dependability ratingbM M M H H H H MH
Total of plus ratings 568 9 8 8 8 5 9
Overall rating M M H H H H M M H
Note: 0: No. 1: Yes. L: Low. M: Moderate. H: High.
aDependability questions.
bDependabilit y rated high if 4– 5 dependability questions were answered yes, moderate if 2– 3 dependabilit y questions were answered yes and low if
0– 1 dependabilit y questions were answered yes.
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TABLE 2 Study characteristics.
Authors, Year, Country Methodology/design
Method/data
collection Phenomena of interest Setting Participants Data analysis Key themes/subthemes
Alilu et al. (2017 )
Iran
Grounded theory Semi- structured
interviews
To explore the
developmental process
of the intention to le ave
the profe ssion
Different wards of
governmental
teaching hospitals
21 nurses, age
24– 45 ye ars and
work experience
1.5– 18 year s
Constant
comparative
analysis
Powerlessness
Feeling s of wort hlessness
Phenomena
Social image of nur sing
Culture and str ucture of
bedside care
Alilu et al. (2016)
Iran
Not described Semi- structured
interviews
To underst and bar riers a nd
facilitators of clinical
nurses' intention to
leave the nursing
profession
Different wards of
governmental
teaching hospitals
21 nurses, age
24– 45 ye ars and
work experience
1.5– 18 year s
Content analysis
method
Spoiled identity
Frustration
The experience of hard lab our
Chachula et al. (2015)
Western C anada
Grounded theory Semi- structured
interviews
To explore the facto rs
influencing the newly
graduated nurse to
permanently leave the
nursing profession
Not mentioned 8 nur ses, age 26– 3 4
years an d work
experience less
than 5 years
Line- by- line
analysis
Navigating constraint s of the
health care system an d
workplace
Negotiating social
relationships, hierarchies
and trou blesome
behaviour
Facing fears, traumas an d
challenges
Flinkman et al. (2013)
Finland
Longitudinal
qualit ative case
study with an
interpretative,
narrative
approach
Open interviews
(twice)
Writing a narrati ve
story
Drawing pathway as
a nurse
To investigate in depth w hy
young nur ses leave the
nursing profession
Not mentioned 3 nur ses, age
29– 32 years
Holistic content
method
Narrat ive anal ysis
Thematic
approach
Nursing as a second caree r
choice
Demand ing work content an d
poor practice environment
The inability to identify with
the ster eotypical images
of nurses
Flinkman and
Salante rä (2015)
Finland
Descriptive approach Semi- structured
interviews
To underst and why young
nurses had left their
organizations and why
they also intende d to
leave the profession
early in t heir career
Acute and n on- acute
settings such a s
intensive care,
medical or surgical
settings, op erating
theatres, mental
health , geriat rics,
midwife ry and
community health
15 nurses, age
24– 29 years
Conventional
content
analysis
Poor nursing practice
environments
Lack of su ppor t, orientation
and mento ring
Nursing as a ‘second best ’
or serendipitous career
choice
Kox et al. (2020)
The Netherlands
Exploratory
qualitative study
Semi- structured
interviews
To explore Dutch novice
nurses' motives for
leaving t he profe ssion
Emergency department,
medical- surgic al
units and intensive
care
17 nurses, age
21– 40 yea rs and
work experience
0– 2 year s
Thematic analy sis Lack of ch allenge
Lack of pa ssion
Lack of perceived competence
Lack of jo b satisfaction due to
heavy workload
Lack of work capa city due to
non- work- relate d healt h
conditions
Lack of fe eling of belongi ng
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BAHLMAN-vanOOIJEN et al.
Authors, Year, Country Methodology/design
Method/data
collection Phenomena of interest Setting Participants Data analysis Key themes/subthemes
Roth et al. (2022)
Germany
Explorative
qualitative study
Semi- structured
interviews
To advance und erst anding
of facto rs that keep
German nurses in
nursing and explore
their pe rceptions of
factors that co ntribute
to nurse s leaving or
staying in the profession
Four hospitals, includ ing
two universit y
hospit als and t wo
smaller public
hospitals
Inpatie nts wards with
a small number
of nurses from an
intensive care unit
21 nurses, age
22– 60 ye ars and
work experience
0– 44 years
Qualitative
content
analysis
Limited c areer prospe cts
Generational barriers
Poor public image
Workplace pressure
Valizade h et al. (2016)
Iran
No specific stu dy
design is
mentioned
Semi- structured
interviews
To explore the experiences
and perceptions of
nurses who have the
intention to leave
nursing
Interna l medicine,
surger y, infectious
disease, poison
control , intensi ve
adult care and
emergency nursing
care
13 nurses , age
24– 47 yea rs and
work experience
2– 15 years
Content analysis
method
Entry routes into nursing
Defects in dignity
Working in n on- ideal working
environment
Dissatisfac tion with worki ng
conditions
Zhu et al. (2 014)
China
Grounded theory In- depth interviews To underst and why nu rses
leave nursing practice
Different areas of
clinical care
19 nurses Constant
comparative
analysis
Mismatch ed expe ctat ions:
individual vs.
organizational
Individual perception of power
TABLE 2 (Continued)
the studies with the number ranging from 3 to 21 participants per
study. Participants were mainly female, 21 to 66 years of age and
the majorit y had a baccalaureate degree. Years of work experience
ranged from 0 to 44 years. Eight studies were conducted in a clinical
care setting, whereas one study was also conducted in home care,
rehabilitation care and nursing homes (Kox et al., 2020).
The data of interest were abstracted into the four following syn-
thesized findings: (1) challenging work environment; (2) emotional
distress; (3) disappointment about nursing realit y and (4) culture of
hierarchy and discrimination. In total, 175 findings were identified,
whereby 31 categories were created along with 11 synthesized cat-
egories and 4 synthesized findings (Figure 2). These findings rep-
resent what is known to date about nurses' motivations to leave
the nursing profession. The findings are suppor ted by participant s'
quotations from the individual studies to illustrate the categories,
synthesized categories and synthesized findings.
3.1 | Challenging work environment
The challenging work environment strengthened the motivation for
nurses to leave the profession. Nurses experienced poor working
conditions, inadequate salary and contract, a lack of opportunities
for career development and a lack of support.
3.1.1 | Poor working conditions
The nurses described poor working conditions as a motiva-
tion to leave the nursing profession (Alilu et al., 2016; Alilu
et al., 2017; Chachula et al., 2015; Flinkman et al., 2013; Flinkman
& Salanterä, 2015; Kox et al., 2020; Roth et al., 2022; Valizadeh
et al., 2016; Zhu et al., 2 014). Conditions described were a heavy
workload, staffing shortages, work pressure, no ideal ratio of pa-
tients to nurses, demanding patient care, like, for example, con-
stant time pressure during patient care, large number of shifts,
inflexible rostering choices and working over time when col-
leagues were sick or to fill unpopular gaps in the work schedule.
Moreover, shiftwork made the work burdensome because of
the high frequency of shifts (Alilu et al., 2016; Alilu et al., 2017;
Valizadeh et al., 2016), struggles to adjust to shiftwork (Chachula
et al., 2015), difficulties in recovering from night shifts (Alilu
et al., 2017; Flinkman et al., 2013) and the shift work had a nega-
tive impact on family and social life (Flinkman et al., 2013; Kox
et al., 2020).
‘I worked days and nights, and it was killing me. The
switching, the nights - it was just awful’. (Chachula
et al., 2015)
‘[…] more flexible working hours, more possibilities,
everything is still too rigid’. (Roth et al., 2022)
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‘Heavy workload is high and tires me too… and I
cannot get to a lot out of my work… For example,
yesterday when I arrived home, I only slept… be-
cause the shifts are so heavy… each nurse had to
work with a high number of patients… for each of
us, there are 12 or 13 patients, and in the infec-
tio us war d, pat ients gi ve a ntibiotics to o and work-
ing with so many sick people is hard work… it is
not allowing good care for the sick…’ (Valizadeh
et al., 2016)
3.1.2 | Inadequate salary and contract
Inadequate salary particularly in relation to the given responsibili-
ties was described by the nurses as a negatively influencing factor
streng thening the intention to leave the profession (Alilu et al., 2017;
Flinkman et al., 2013; Kox et al., 2020). Moreover, fixed short-
term contracts, and not having permanent contracts, caused job
insecurity, which was also found to streng then the intention to leave
(Alilu et al., 2017; Flinkman et al., 2013).
‘But I found the salary very minimal. I thought, we have
to promote ourselves much more as a profession and
then the salaries can also increase’. (Kox et al., 2020)
‘There were these fixed- term contract which could be
fr om tw o we eks to th ree mont hs or th e n fo r si x mon ths .
They couldn't give me their word that there would be
longer periods which made me feel really insecure
when I thought about my future’. (Flinkman et al., 2013)
3.1.3 | Lack of opportunities for career
development
Some studies reported lack of opportunities for career develop-
ment as a reason to leave the profession (Alilu et al., 2017; Flinkman
Findings Categories
Synthesized
category Synthesized finding
Inadequate contr acts (Alilu
et al., 2017); Credible
Inadequate
contracts
Inadequate salary
and contract
Challenging work
environment
Inadequate contr acts
(Flinkman et al., 2013);
Unequivocal
Deficiencies in comparative
salaries (Alilu
et al., 2017); Credible
Deficiencies in
salary
Too low wages in relation
to responsibilit y (Alilu
et al., 2017); Credible
Dissatisfaction with
salaries in comparison
with responsibilities
(Flinkman et al., 2013);
Unequivocal
Salar y was an issue
(Kox et al., 2020);
Unequivocal
TABLE 3 An example of a synthesized
finding, synthesized category, categories
and its accompanying findings on nurses'
motivations to leave the profession.
TABLE 4 Quality appraisal of synthesized findings using the ConQual approach.
Synthesized finding Type of research Dependability Credibility
ConQual
score
Challenging work environment QualitativeaDowngrade 1 levelbDowngrade 1 levelcLow
Emotional distress QualitativeaDowngrade 1 levelbDowngrade 1 levelcLow
Disappointment about nursing reality QualitativeaDowngrade 1 levelbDowngrade 1 levelcLow
Culture of hierarchy and discrimination QualitativeaDowngrade 1 levelbDowngrade 1 levelcLow
aEach synthesized finding started with a high ranking for qualitative studies.
bDowngraded 1 level for each s ynthesized finding having findings from studies with high and moderate dependability ratings.
cDowngraded 1 level for having a mix of unequivocal and credible findings.
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BAHLMAN-vanOOIJEN et al.
et al., 2013; Flinkman & Salanterä, 2015; Kox et al., 2020; Roth
et al., 2022; Valizadeh et al., 2016). Nurses experienced their work
as repetitive, and lacking diversity (Flinkman & Salanterä, 2015; Kox
et al., 2020). They experienced limited opportunities to develop in
clinical leadership, to take the lead in innovations and they missed
more challenging and complex nursing work with use of knowledge
and skills (Kox et al., 2020). Nurses also wished to have a stronger
voice, but they generally felt too weak to initiate changes in health-
care (Roth et al., 2022). Furthermore, nurses felt unable to do an-
ything with their ambitions (Kox et al., 2020), and experienced a
lack of professional development opportunities (Alilu et al., 2017;
Flinkman et al., 2013; Flinkman & Salanterä, 2015; Valizadeh
et al., 2016).
‘It is the sort of job that I can't see as a career until
retirement’. (Flinkman & Salanterä, 2015)
3.1.4 | Lack of support
The nurses experienced a lack of support which contributed to the
des ire to ex it nursin g. First , a lack of su pp or t an d en courage me nt from
managers was repor ted (Alilu et al., 2016; Alilu et al., 2017; Flinkman
& Salanterä, 2015; Valizadeh et al., 2016; Zhu et al., 2014). Nurses
felt that managers did not understand how physically demanding
nursing work was (Alilu et al., 2017), and that they had very unreal-
istic ideas about how to develop patient care (Flinkman et al., 2013).
Furthermore, nurse managers did not compliment nurses on what
they were good at (Flinkman et al., 2013), and nurs es fe lt a lack of sup-
port for the retention of nurses (Zhu et al., 2014). Nurses experienced
managers' behaviour as distant, bureaucratic and rushed (Flinkman &
Salanterä, 2015), which led to confusion (Valizadeh et al., 2016). Last ly,
the impact of political decisions was described as possible influencing
factor in nurses' intention to leave the profession (Roth et al., 2022).
FIGURE 2 Overview of categories, synthesized categories and synthesized findings.
4464
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BAHLMAN-vanOOIJEN e t al.
‘We tell our problems to the head nurse or supervi-
sor but we feel we aren't taken seriously…’ (Valizadeh
et al., 2016)
Second, a lack of support was also described as a lack of positive
feedback from colleagues, or just overly negative critical feedback
(Alilu et al., 2016; Chachula et al., 2015; Flinkman et al., 2013; Kox
et al., 2020). Kox et al. (2020) described that especially nurses with
pre- existing non- work- related diseases, such as chronic, physical
and mental health problems, were confronted with a hostile attitude
to their limited employability, which resulted in a lack of understand-
ing and support from colleagues. Roth et al. (2022) described that
nurses perceived differences between the younger and older gen-
eration of nurses. Older nurses had a different mindset, which made
it challenging to find common ground between the two generations,
which was demotivating.
‘No matter what you do and even if you do your
work in the best way, nobody is satisfied, and cer-
tainly a fault will be found with your work’. (Alilu
et al., 2 017)
‘And that is not in the mind of the nurses, that is
mainly a generational problem. It works better with
the younger ones [younger nurses], it's easy to get
them on board, but my generation or my level of
education is not yet in a position to perceive it at
all. Very few people are, that's my experience. And I
think that… they are… Many of them [older nurses]
just want to do their work in peace, […] they want
to do their work in the best possible way in the area
where they feel comfortable. I think that's the dif-
ficulty, to get the generations together a bit’. (Roth
et al., 2022)
Third, newly graduated nurses perceived a lack of support, espe-
cially having sufficient adequate orientation in the workplace, and re-
ported that they were feeling alone in the transition as new nurses
(Flinkman & Salanterä, 2015). They missed a back- up from more expe-
rienced and senior colleagues (Kox et al., 2020).
‘I was shown the places for coffee and the procedures
as well for the archive, fax and the key for the med-
ication cabinet. That was my orientation. That was
awfully scary’. (Flinkman & Salanterä, 2015)
3.2 | Emotional distress
Nurses who left or considered leaving the nursing profession experi-
enced strong emotional distress, like work- related stress, and a huge
responsibility, including fear of failure.
3.2.1 | Work- related stress
Work- related emotional distress, including experiences of frustra-
tion, dissatisfaction, stress, burnout, hopelessness, exhaustion, fa-
tigue, sleeping problems, nightmares, lack of confidence, frequent
crying and losing the joy of nursing, was reported as a motiva-
tion for nurses to leave the profession (Alilu et al., 20 17; Chachula
et al., 2015; Flinkman & Salanterä, 2015; Kox et al., 2020; Roth
et al., 2022; Valizadeh et al., 2 016; Zhu et al., 2014).
‘My husband came to pick me up from work and then
I started to cry that I cannot take this anymore, this is
terrible. I cannot. I feel like nobody takes good care of
these patients’. (Flinkman et al., 2013)
‘Most people never go to a morgue, or have to bag
a dead body; these are big things to deal with. You
often bring the emotional side of things home with
you’. (Chachula et al., 2015)
3.2.2 | Huge responsibility and fear of failure
Nurses experienced a great sense of responsibility for their pa-
tients affecting their intention to leave (Alilu et al., 2016; Flinkman
et al., 2013; Flinkman & Salanterä, 2015; Kox et al., 2020; Zhu
et al., 2014). Possible causes for this sense of responsibility were
highly demanding patient care (Flinkman et al., 2013), ethical dilem-
mas (Zhu et al., 2014), no clear role boundaries (Zhu et al., 2014),
increasing responsibilities of patient care and sole responsibility or
responsibility together with inexperienced staff (Kox et al., 2020).
This resulted in the nurses feeling unable to provide sufficient
quality care (Alilu et al., 2017; Flinkman et al., 2013; Flinkman &
Salanterä, 2015; Kox et al., 2020; Zhu et al., 2 014), increased aware-
ness of the high risk of clinical practice (Zhu et al., 2014) and being
afraid of making mistakes or serious medical errors (Chachula
et al., 2015; Flinkman & Salanterä, 2015; Kox et al., 2020).
‘Nurses are responsible for informing patients about
fee collection, which should not be their duty. … It
is terrible when the responsibilities are not clear…
I mean when you tr y to work well it will become
your extra daily work and your responsibility…’ (Zhu
et al., 2014)
(Kox et al., 2020). ‘ Yes. And that really gnaws at you,
that when you're at home you start thinking, yes, hm,
hm. Even when incidents happen that you're not di-
rectly involved in, you still think about them. I [as a
district nurse] had a client who died very suddenly. I'd
given insulin in the morning, and in the af ternoon she
was admitted with a hypo. And she died in the hospital
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that night; I thought, did I give her the right thing? Did
I perhaps work in too much of a hurr y? Well, in ret-
rospect it turned out to be something else, but I felt
very guilty about it for two days. Because you're just
… you, you need to double check everything […], but
in the end you get round the rules, because how can I
double check things when I'm working on my own and
the patient is blind as anything’
3.3 | Disappointment about nursing reality
Nu r s ing as a se con d- b est ca r e er ch oic e, a di scr e pan cy be twe e n nurs-
ing education and practice and the social image of nursing streng th-
ened nurses' disappointment in the realit y of nursing prac tice, which
increased their intention to leave the profession.
3.3.1 | Nursing as a second- best career choice
The nurses described that being a nurse was not their dreamed-
off profession (Flinkman et al., 2013; Flinkman & Salanterä, 2015;
Kox et al., 2020), but a serendipitous decision (Flinkman
et al., 2013; Flinkman & Salanterä, 2015), an involuntary transfer
(Zhu et al., 2 014) or an escape from military services (Valizadeh
et al., 2016). Prior to starting the job, some nurses described that
they missed a lack of calling or vocation and had no realistic ex-
pectations of the job (Kox et al., 2020; Valizadeh et al., 2016; Zhu
et al., 2 014).
‘But a nursing career was never a dream job for me.
It's not as if I had thought that I would like to work in
a hospital. Maybe this has been more like destiny that
I have gone there’. (Flinkman et al., 2013)
3.3.2 | Discrepancy between
education and practice
Newly graduated nurses described a huge disconnect bet ween the
classroom and the reality of clinical practice, where nursing teaching
seemed to be very theoretical and not in line with reality (Chachula
et al., 2015; Flinkman & Salanterä, 2015; Kox et al., 2020). This re-
sulted in a huge transitional gap from being a student to becoming a
more autonomous professional nurse (Kox et al., 2020), resulting in
feelings of being thrown into the deep end and feeling overwhelmed
while performing professional skills for the first time (Chachula
et al., 2015; Flinkman & Salanterä, 2015).
‘So when I graduated and got my papers last
Christmas, I hardly knew anything about anything and
I felt that I was just thrown in there – “do what you do
– screw up what you screw up” and ever yone knew
that if you fail, no one will stand by you’. (Flinkman &
Salanterä, 2015)
3.3.3 | Social image of nursing
Stereotypical pictures of nurses given in the media or perceptions
of societ y, for instance, that a nurse should be nurturing and willing
to serve, were not recognized by nurses and were reported as a mo-
tive to leave nursing (Alilu et al., 2016; Flinkman et al., 2013; Roth
et al., 2022; Valizadeh et al., 2016). The assumption existed that one
could be too talented and ambitious for a nursing career (Flinkman
et al., 2013). Society, in general, lacked understanding of what the
nursing' profession entailed, which was shown in stereotypes like
nursing being seen as ‘nonprofessional’ and ‘not perceived as a
fully- fledged profession’ (Alilu et al., 2017; Valizadeh et al., 2016).
The nurses further described that people, in general, have no idea
how demanding nursing or the work of nurses is, and which profes-
sional nursing skills are required to provide patient care (Flinkman
et al., 2013; Roth et al., 2022). In addition, Roth et al. (2022) de-
scribed that nurses felt a need for societ y to better understand the
wide spectrum of responsibilities and competencies of nursing.
‘Personally speaking, I think it would be much more
beneficial for the nursing profession if we showed a
certain amount of transparency. It is… I notice that in
my patients, there are many who have no idea about
what we actually do here. All the hospital series like
“Grey's Anatomy” and I don't know what else, we
have already been asked whether we really have re-
lationships with our physicians. Yes, so you have to
listen to things like that. Of course, it is completely
mispresented, even if you watch private channels like
SWR or ARD and all the others, that this is not the job
or the day of a nurse. There are very few nurses who
stand up and say: “No, we do much more than just
supporting patients with personal hygiene. We do
much more than just prophylaxis.”’ (Roth et al., 2022)
3.4 | Culture of hierarchy and discrimination
Nurses experienced a hierarchical culture during their nursing job,
which resulted in feelings of being subordinate to other profession-
als like physicians, and bullying behaviour among nurses, which con-
tributed to nurses' desire to leave the profession.
3.4.1 | Feeling subordinate
Nurses experienced the working culture as very hierarchical, which
was shown in the unequal relationship between nurses and phy-
sicians, with the nurses being subordinates to physicians (Alilu
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et al., 2016; Alilu et al., 2017; Flinkman et al., 2013). Also, a lack of
collaboration between nurses and physicians was described, which
resulted in negative professional relationships and supported the
nurses' motivation to leave the profession (Zhu et al., 2014 ).
‘The nurse must request permission from the physi-
cian for ever ything’. (Alilu et al., 2017).
3.4.2 | Bullying behaviour
The studies reported also a hierarchy among the nurses (Chachula
et al., 2015; Flinkman et al., 2013), whereby nurses experienced hor-
izontal abuse, bullying, criticism, discrimination, blame, humiliations
and ridicule (Alilu et al., 2016; Alilu et al., 2017; Chachula et al., 2015;
Flinkman et al., 2013; Valizadeh et al., 2016; Zhu et al., 2014). This
was especially the case with newly graduated nurses, who reported
incident s of horizontal abuse (Chachula et al., 2015; Kox et al., 2020).
Conflicts in communication and disrespect of medical staff were also
reported (Alilu et al., 2016; Alilu et al., 2017; Valizadeh et al., 2016).
In addition, violent behaviour of patients and their relatives contrib-
uted to a feeling of unsafety and discrimination (Alilu et al., 2017;
Kox et al., 2020), which contributed to the nurses' intention to leave
the profession.
‘There was a [hierarchical] picking order and I came in
at the bottom’. (Chachula et al., 2015)
‘How they [colleagues] behaved towards one another,
it was a real revelation to me. Because it was, well,
it was a women's world in fact . And that's what you
feel, it's so nasty, it's so sly, so underhand, so …’ (Kox
et al., 2020)
4 | DISCUSSION
This meta- aggregation provides a comprehensive overview of the
integrated findings of qualitative studies exploring nurses' motiva-
tions to leave the nursing profession. The four following synthesized
findings were identified: challenging work environment, emotional
distress, disappointment about nursing reality and culture of hier-
archy and discrimination. Our findings correspond broadly with the
results from earlier quantitative reviews (Chan et al., 2013; Flinkman
et al., 2010; Halter et al., 2 017).
The first synthesized finding identified in our review was the
‘challenging work environment’. Nurses decided to leave the nursing
profession because of staffing shortages, a heavy workload, demand-
ing patient care and the repercussions of shiftwork in combination
with private life. Recently, the International Council of Nurses (2022)
described that there are a number of commonalities across all coun-
tries influencing intention to leave, including poor working condi-
tions and failure to adopt safe staffing levels, which shows the actual
challenges of the nursing work environment (Stewar t et al., 2022).
Ferramosca et al. (2023) reported that working in shif ts that are un-
derstaffed and with poor collaboration leads to disruption of nurses'
work. As a consequence, the disruption of work organization and
work processes lead to work pressure and stress on nurses, all to-
gether with inadequate staffing, which leads to a downward spiral,
whereby nurses are intending to leave the profession. Therefore,
building healthy work contexts is essential for nursing workforce
retention (Ferramosca et al., 2023). Redesigning work systems by
guaranteeing adequacy of staffing, proper work schedule and a
balance of skill mix is highly impor tant (Ferramosca et al., 2023). In
addition, stimulating nurses' participation as main actors in the iden-
tification of appropriate solutions to improve nurses' work organiza-
tion is also highly impor tant to sustain the change process through
active decision- making (Ferramosca et al., 2023). Nurses who have
the ability to exert autonomy and control over their work, and have
greater participation in decision- making have positive influence on
nurses' professional engagement (Copanitsanou et al., 2017). Lastly,
Roth et al. (2022) described that nurses perceived differences be-
tween the younger and older generations of nurses. Each genera-
tion of nurses (i.e. Generation X, Generation Y and Generation Z)
has different work values, communication st yle and expectations of
their leaders and the work environment (Hampton & Welsh, 2 019;
Stanley, 2010). Understanding each generational group allows lead-
ers and managers an opportunity to grasp what it is that may drive
or motivate each group to develop strategies to attract and retain
nurses from the generational spectrum (Hampton & Welsh, 2019;
Stanley, 2010).
‘Emotional distress’ was the second synthesized finding identi-
fied in our review. Nurses experienced huge stress during their work
and experienced a great responsibility leading to a fear of failure.
The stressful nature of the nursing work environment often leads
to poor nurses' outcomes like burnout (Copanitsanou et al., 2017).
Nurses' burnout caused by emotional exhaustion and deperson-
alization is reported as a significant push fac tor for nurses' inten-
tion to leave (Sasso et al., 20 19). Also, high physical and emotional
workloads are identified as significant fac tors for nurses' intention
to leave (Coomber & Barriball, 2007; Hämmig, 2018). The emotional
burden of nurses seemed to worsen due to the unprecedented pres-
sure of the COVID- 19 pandemic (Da Rosa et al., 2021). During the
COVID- 19 pandemic, nurses needed more psychological help like
mutual support or psychological counselling from nurse managers to
enhance their mental well- being (Sasso et al., 2019). A broad range
of interventions have been identified and investigated to address
nurses' mental health, well- being and physical health, like for exam-
ple, mindfulness and cognitive- behavioural therapy- based interven-
tions, to reduce stress, anxiety and depression (Melnyk et al., 2020).
In daily practice a wide range of initiatives are offered to nurses to
support their mental well- being, but how to keep nurses physically
and psychologically healthy remains however an important issue
(Stewart et al., 2022).
The third synthesized finding was ‘disappointment about nursing
reality’. Especially newly graduated nurses described a discrepancy
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BAHLMAN-vanOOIJEN et al.
between the nursing education and the nursing practice, which they
did not expect. The discrepancy between expectations and experi-
ences of the realit y of nursing in new licensed nurses has been re-
ported previously as a transition shock, explained as an immediate
and dramatic stage in the process of professional role adaption for
the new nurse, which is associated with feelings of anxiety, insecu-
rity, inadequacy and instability (Duchscher, 2009). This dissonance is
also reported in nursing students, caused by a different programme
from what they expected or increasing doubts about the profession
(Bakker et al., 2019). These experiences can lead to a downward spi-
ral of increasing problems whereby nurse students lose their grip on
the learning process, ultimately leading to dropping out of nursing
education (Bakker et al., 2019). In order to decrease the experience
of a transition shock, it is recommended to create more realistic ex-
pectations by providing proper information about the degree pro-
gramme of nursing education (Bakker et al., 2019). Recently, ICN
strongly encouraged policymakers of healthcare systems around the
world to emphasize the importance of higher education for nurses
and to provide more educational opportunities for nurses globally
(Stewart et al., 2022). This will further drive the healthcare system
to deliver care that individuals and communities need, by increasing
confidence in clinical and leadership skills, and increasing job sat-
isfaction and retention, which will be a great cat alyst for positive
transformation (Stewart et al., 2022). Furthermore, more attention
should be paid to strengthening and empowering newly graduated
nurses when they enter nursing practice, for example, how to be-
come a strong, self- supportive, knowledgeable and emancipated
professional (WHO, 2020). Therefore, a supportive culture of care
is badly needed, wherein mentorship is provided to novice nurses to
support and empower them to take on the challenges of their daily
work (Duchscher, 2009). Mentoring is an established mechanism for
support in early career nursing, with the mentor/mentee relationship
again central to the success of the inter vention, and the clarification
of mentoring objectives (Brook et al., 2019). Providing mentorship is
consistently linked to positive practice environments and increased
nurse retention (Brook et al., 20 19). However, elements of mentor-
ship are embedded in clinical practice, but there is still room for im-
provement to develop and refine mentorship.
‘Culture of hierarchy and discrimination’ was the last synthe-
sized finding identified in our review, whereby bullying behaviour
was an important motivation for nurses to leave the nursing profes-
sion. Bullying within the nursing culture is a highly prevalent issue
to date, as many as 75– 85% of nurses may have experienced verbal
or non- verbal bullying from managers or colleagues during their ca-
reers (Shorey & Wong, 2021). The consequences of such behaviour
can be far reaching for nurses who may see leaving the profession
as the only solution (Shorey & Wong, 2021). Bullying behaviour can
be prevented by managers paying more at tention to the issue and
being more present, by creating behavioural norms and controlling
deviations from these norms (Johnson, 2015). Supportive leadership
is helpful to create more positive work environments, reduce nega-
tive behaviour and reduce mental and physical work- related strains
(Sasso et al., 2019). Supportive transformational relational- oriented
leadership included encouragement, understanding the needs of
individuals, reflection and transparency, resulting in a wide range
of positive nurse outcomes (Cummings et al., 2018). For example,
workforce outcomes, like culture and climate, perceived support,
st af fing and nurs e reten ti on, wer e pe rceived to be bett er when lead-
ers employed supportive and relational leadership st yles (Cummings
et al., 2018). Furthermore, our findings showed that nurses de-
scribed a culture of hierarchy among nurses, where nurses were dis-
criminated by other nurses and felt subordinate to physicians. The
quality of the nurse– physician relationship plays an import ant role in
nurse retention (Van den Heede et al., 2013). Until today, there are
often barriers for nurses to participate as full partners with physi-
cians (Stewar t et al., 2022). Therefore, nurse leadership is needed at
every level across all settings to provide quality care, and to take the
lead in developing individual care plans, organizational policies and
plans and boardroom decision- making (Stewar t et al., 2022).
Nurses' motivations to leave the profession were quite similar
between countries. It is, however, interesting to note that feelings
of subordination to physicians were mainly repor ted in studies from
Iran and China (Alilu et al., 2016; Alilu et al., 2017; Zhu et al., 2 014),
but this was also found in a study conducted in Finland (Flinkman
et al., 2013). The discrepancy between nursing education and clin-
ical practice was mainly reported in studies conducted in Europe
or Canada, which was also the case for the inadequate orienta-
tion of newly graduated nurses (Chachula et al., 2015; Flinkman &
Salanterä, 2015; Kox et al., 2020). The other motivations were quite
similarly reported in the included studies. Therefore, we cautiously
conclude that the ongoing challenges of the nursing work environ-
ment, the investment in nursing leadership and the need for sup-
port from nursing management are highly relevant and important
for the global nursing workforce, respecting the cultural and socio-
economic differences bet ween countries (Stewart et al., 2022).
In order to identify retention strategies that may be used
across countries, we organized nurses' motivations to leave the
profession into individual- related factors, organizational- related
fac tors and soci etal- re lated f ac tors, which c an be used to res pond
to the worldwide nursing shortage. First, individual- related moti-
vations for leaving the profession were described as work- related
stress, feelings of huge responsibility and fear of failure, which
all seem related to a certain level of job satisfaction. The level of
job satisfaction is an important factor related to one's individ-
ual motivation to leave nursing. Therefore, it is recommended to
improve nurses' job satisfaction, for example, by implementing
interventions like professional identity development, or train-
ing regarding spiritual intelligence, which focuses on building a
professional meaning at work to foster job satisfaction (Niskala
et al., 2020). Second, this review identified a lot of factors regard-
ing organizational- related motivations. Nurse turnover because
of poor practice environments could be avoidable, as organi-
zations have many possibilities to influence this organizational
characteristic (Aiken et al., 2012). Strategies to create positive
work environments are empowering work structures, which are
characterized by nurses' being involved, informed and supported
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in organizational policies and procedures, imbedding evidence-
based practice in clinical practice and collaborative nurse– patient
relationships (Twigg & McCullough, 2014). Nurses with further
professional, personal and intellectual ambitions should be given
more career opportunities to develop further, for example, by pro-
viding clinical career ladders (Twigg & McCullough, 2014), the de-
velopment of a tailored personal development plan and supervisor
support (Kox et al., 2020). Third, society- related motivations for
leaving nursing have been related to opinions from society about
the nursing profession, and disappointment about the reality of
nursing during universit y or after graduation. Nurse turnover re-
sulting from a compromised career choice is unavoidable by or-
ganizations because organizations lack possibilities to influence
whether nurses leave for this reason (Flinkman & Salanterä, 2015).
There seems, however, a role for universities in informing students
correctly and aligning nursing education and clinical practice. The
WHO has recognized the importance of creating a long- lasting
legacy that will promote the nursing profession and boost its pro-
fessional status (WHO, 2020). National and international politics
should acknowledge the current issues around the professional
status of nurses.
4.1 | Strengths and limitations
In terms of strengths, this is the first review aggregating findings
of qualitative studies on motivations for nurses to leave the pro-
fession. It was possible to combine the findings from qualitative
studies with various designs and small sample sizes to find similar
experiences (Lockwood et al., 2015). Furthermore, the results of
this meta- aggregation provide connections and relations between
the concepts, which is impossible to do based on the quantitative
studies because of their cross- sectional study designs. Besides, con-
ducting a meta- aggregation according to the JBI guidelines is con-
sidered a solid methodology (Munn et al., 2021). Some limitations of
the study need also to be addressed. First, not all included studies
described age and level of work experience in the baseline charac-
teristics of the par ticipating nurses, or did not specify their findings
regarding these characteristics. Literature showed, however, that
young nurses differ in many ways from the older generation (Currie
& Carr Hill, 2012), but there is no way to check for age distribution in
the included studies, which could have led to an under- or overrepre-
sentation of certain age groups, or other conclusions. Nevertheless,
differentiation between these characteristics was applied to a feasi-
ble extent. Second, we only included studies published in the English
language, which could have led to the exclusion of relevant articles
in other languages. The findings of the included studies were broadly
similar in their results and were mainly varying in the details regard-
ing their reasons for leaving nursing. Therefore, we expect this to
have only a limited impact in getting insight into nurses' motiva-
tions to leave the profession. Lastly, the main focus of this review
was nurses' perceptions and experiences regarding motivations to
leave the nursing profession. We did not conduc t a mixed- methods
review wherein we take into account quantitative measures to leave
the profession. Although quantitative measures are of great impor-
tance and add many useful insight s, they did not give an in- depth
insight into the psychological processes that nurses undergo while
considering leaving the nursing profession. In addition, mixed meth-
ods have several limitations, including the fact that quantitative and
qualitative paradigms are incommensurable and the increased time
taken to complete the overall study (Whitley et al., 2020).
4.2 | Implications for research
At first, further research is recommended to distinguish motivations
between several generations of nurses because it is reported that
work values seem to be dif ferent between generations of nurses
(Hampton & Welsh, 2019; Stanley, 2010). The hypothesis is that these
work values lead to different motivations to leave the nursing profes-
sion. Further research could be meaningful to develop targeted re-
tention strategies for each generation. Second, strengthening nurses'
leadership and control over nursing practice seems a promising solu-
tion to invest in the nursing job and to retain nurses in the profession.
It is imperative that nurses have to take the lead to become involved
in decisions on different levels in the organization. However, the ac-
tual interpretation and practice of these concepts remain unclear,
especially in daily nursing care. Therefore, further research is recom-
mended to develop interventions to improve nursing leadership as
well as nurses' autonomy and control over clinical nursing practice.
5 | CONCLUSION
This meta- aggregation provides an overview of qualitative evidence
available on nurses' motivations to leave the nursing profession.
Four synthesized findings were created which reflect the diversity
of moti vations for nur ses to exi t th e profes sion, including a cha ll en g-
ing work environment, emotional distress, disappointment about
nursing reality and a culture of hierarchy and discrimination. Poor
working conditions, a lack of opportunities for career development,
a lack of suppor t from managers, work- related stress, a discrepancy
between nursing education and practice and bullying behaviour,
were, among others, motivations for nurses to leave the nursing
profession. Targeted actions from nurse managers, stakeholders and
policymakers, like redesigning the nursing work environment, sup-
porting transformational leadership and developing nursing leader-
ship, job autonomy and control over nursing practice, are all badly
needed to support and develop a sustainable global nursing work-
force for further healthcare worldwide.
AUTHOR CONTRIBUTIONS
All authors have contributed to the conception and writing of
the paper. All authors have had a significant doing in drafting and
revising the article for important intellectual content and have
agreed upon the final version. WO, SM and TH: Made substantial
|
4469
BAHLMAN-vanOOIJEN et al.
contributions to conception and design, acquisition of data or
analysis and interpretation of data; WO, SM, GH and TH: Involved
in drafting the manuscript or revising it critically for important in-
tellectual content; WO, SM, GH and TH: Given final approval of
the version to be published. Each author should have participated
sufficiently in the work to take public responsibilit y for appropri-
ate portions of the content; WO, SM, GH and TH: Agreed to be
accountable for all aspects of the work in ensuring that questions
related to the accuracy or integrity of any part of the work are ap-
propriately investigated and resolved.
ACKNO WLE DGE MENTS
Not applicable.
FUNDING STATEMENT
This research received no specific grant from any funding agency in
the public, commercial or not- for- profit sec tors.
CONFLICT OF INTEREST STATEMENT
No conflict of interest has been declared by the author(s).
PEER REVIEW
The peer review history for this article is available at h t tp s : //
www.webof scien ce.com/api/gatew ay/wos/peer- revie w/10.1111/
jan.15696.
DATA AVA ILAB ILITY STATE MEN T
The data that support the findings of this study are available from
the corresponding author upon reasonable request.
ORCID
Wilmieke Bahlman- van Ooijen https://orcid.
org/0000-0001-9251-4874
Simon Malfait https://orcid.org/0000-0001-7287-6034
Getty Huisman- de Waal https://orcid.org/0000-0003-2811-4176
Thóra B. Hafsteinsdóttir https://orcid.
org/0000-0003-2466-0276
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