The Pathways of Nurse Turnover in Long-term Care Hospitals

Abstract

Background: This study explores the pathways of nurse turnover in long-term care hospitals (LTCHs) and its underlying conditions in Korea. Although the factors of staying or leaving of nurses in LTCHs have been reported, few studies have examined the trajectory and conditions of nurses staying in and leaving LTCHs. Methods: A qualitative study design with a grounded theory approach was conducted. Data were collected in one-to-one interviews. Purposive and theoretical sampling led to the inclusion of 20 registered nurses from 15 LTCHs in South Korea. Results: Seeking work-life balance was the core category of the nurses' turnover pathway. The consequences of the nurses' turnover pathway were categorized into three groups: thriving, surviving, and leaving. Thriving nurses found meaning in their work, fostered good relationships, and saw opportunities for growth. Surviving nurses were enduring their jobs in LTCHs, having a work-life balance, and supportive nursing leaders. Leaving group nurses wished to leave LTCHs due to a lack of professional growth, unappealing work, continued conflict, and social stigma. Conclusion: This study provided the trajectory and conditions for nurses to enter, stay, move, or leave. Understanding the pathways for staying or leaving can be used as a strategy for successful retention of registered nurses in LTCHs.

INTRODUCTION

I. Background

Care for the elderly has shifted from home to hospitals, with the number of long-term care hospitals (LTCHs) increasing by 2.0 times in the last 10years in Korea (Korean Statistical Office, 2022). LTCHs are experiencing a shortage of nurses, with a turnover rate of 27.6%, far exceeding the average turnover rate of nurses (12.6%)(Hospital Nurses Association, 2016). Although the number of LTCHs is rapidly increasing, the quality of hospitals and services provided by these institutions is a concern (Park, 2021).

In particular, nurses are responsible for supervising nursing assistants, coordinating care provided by other staff, and managing nursing quality (Montayre J & Montayre J, 2017); thus, the low number of nurses results in difficulty ensuring quality management of nursing care. The shortage of nurses not only reduces the quality of care (Hassmiller & Cozine, 2006), patient safety (Buerhaus, Donelan, Ulrich, Norman, & Dittus, 2005) and increases the cost of management (Jones, 2008), it also hinders the formation and maintenance of a positive organizational culture (McNeese-Smith & Nazarey, 2001). The increased work and stress of other nurses can reduce organizational commitment, can cause other nurses to leave, and can affect hospital survival because of the declining number or closing wards (Lee, Kim, Lee, Kang, & Park, 2008). Therefore, to improve the quality of services, it is essential to secure sufficient nurses and to overcome challenges in the provision of competent and quality care.

To improve the quality and skill of nursing services provided, it is necessary to reduce the nurses’ turnover rate and increase their retention rate. To improve retention, it is important to understand the conditions, and its trajectory related to nurses’ intention to leave. By gaining an understanding of the underlying conditions and their processes, it will provide those in management positions with an opportunity to address the issues and make appropriate changes, hopefully leading to higher retention.

There have been plenty of studies of nursing staff in LTCHs focusing on exploring factors of turnover such as reward, work environment, organizational factors, and relational factors using quantitative research (Estryn-Behar, Van Der Heijden, Fry, & Hasselhorn, 2010; Flinkman, Laine, Leino-Kilpi, Hasselhorn, & Salantera, 2008; Hwang & Chang, 2009). Although several studies have used qualitative research methods to identify turnover and retention-related factors (Flinkman, Isopahkala-Bouret, & Salantera, 2013; Hayward, Bungay, Wolff, & MacDonald, 2016; Flinkman & Salantera, 2015), these studies have not identified the trajectory and its conditions of nurses’ staying and leaving. With the growing demand for LTCH services, it is time to gather available evidence to explore the trajectory and context by which nurses are staying in or leaving LTCHs. The purpose of this study was to understand the nurses’ turnover pathway in LTCHs over time and the related conditions.

METHODS

A grounded theory design was used to explore the trajectory of LTCH nurses turnover. Sampling, data collection, and analysis were conducted in a cyclical process. The goals of ongoing analysis guided decisions regarding theoretical sampling, interview questions, and coding, and data were progressively abstracted into a conceptual model as the study progressed (Corbin & Strauss, 2014).

1. Participants and Setting

A total of 20 registered nurses working in 15 LTCHs in a metropolitan city of Korea were interviewed in this study. Eligibility criteria comprised (1) Korean registered nurses (RNs), (2) nurses participating in direct care for elderly patients, (3) over six-month’ experience of working in LTCHs, and (4) full-time employees. Nurses who had left LTCHs were excluded.

Participants were recruited conveniently and purposively. A theoretical sampling was also used to obtain the final sample size of 20 registered nurses. Sampling continued until saturation, or the point at which no new conceptual information was obtained in the data. Researchers introduced the study purpose and data collection method at an informal LTCH managers’ meeting and distributed flyers to put the researchers directly in contact with nurses who wanted to participate in interviews. Participants then introduced other nurses who fit the theoretical sampling profile. There were no recruiting issues because nurses were eager to discuss their experience in new and different working environments in Korea (Lee, personal communication, 2016). All participants were female with a mean age of 38.7 years (range 26~51). Eleven were staff nurses, and nine were head nurses. The mean length of nursing career experience in LTCHs was 3.6 years (range 0.8~8.1 years). Fourteen participants were married, and six were unmarried. Five had a diploma of 3 years of education, eight had a bachelor’s degree, and seven had a master’s degree (Table 1).

Table 1. Characteristics of Participants (N=20)

^†Recruited in 2012; ^‡Recruited in 2021.

The participants have comprised of three new nurses, ten reentry nurses, and seven transfer nurses (from long-term care hospital to another longterm care hospital). The experience of nurses was measured from their initial recruitment point in LTCHs. The new nurses comprised those who had begun working at LTCHs after graduating nursing school with an average career of 1.2 years (range 0~2 years). Moreover, two of them were promised jobs in grand acute hospitals when any position would be available, and they were working in LTCHs in the meantime. The reentry nurses had reentered LTCHs after a parenting break with an average career of 4.8 years (range 1~8 years) in acute care hospitals. Moreover, in terms of age, seven, one, and two of the reentry nurses were in their 30s, 40s, and 50s, respectively. They were divided into a younger group, comprising those that had taken a shorter break for parenting or further study, and an older group, with those who had taken more extended parenting breaks. Transfer nurses comprised those who had transferred from acute care hospitals with an average career experience of 13.3 years at acute hospitals (range 6.0~24.3 years). Two of seven transfer nurses had retired early from acute care hospitals. The discourse extracts in the text are labeled to indicate the data source (P: Participant with interview number and abbreviation for N: New nurse; RY: Reentry Young nurse; RO: Reentry Old nurse; T: Transfer nurse).

The settings comprised 15 LTCHs located in a metropolitan city in Korea. The mean number of beds in the 15 LTCHs was 215 (range 30~500). Eleven of the owners of LTCHs were physicians, and three were non-medical personnel.

2. Data Collection and Analysis

A grounded theory approach was used in this study, which was deemed fit for understanding the pathway and conditions to turnover of nurses in LTCHs. Once ethical approval had been obtained, data were collected by convenience sampling at the beginning of the study and by purposeful sampling as the study progressed. Data collection and analysis was an ongoing process, and constant comparative analysis and theoretical sampling were used to saturate categories and generate a conceptual model (Corbin & Strauss, 2014). For example, the authors recruited participants to ensure variation in age and length of LTCH career experience. Moreover, the interview questions were changed as the data collection progressed, from general working experiences to more detailed information.

Data collection and analysis were accomplished four times from June 2012 to September 2021 to identify the pathways of nurse turnover over time: the first round was conducted in June 2012, the second round was from March to August 2013, the third round was in December 2016, and the final round was in September 2021. The final round was used for verification since no new conceptual information was obtained from the data. Each participant was interviewed face-to-face for the first data collection, and additional phone call interviews were conducted to gather supplementary information. The average interview time was approximately 50 mins (min 35 mins~max 90 mins). Having completed interviews with 20 interviewees, the authors considered conceptual saturation to be sufficient as no new data were appearing to explain the conceptual model.

Participants were interviewed after completing their shifts and at a place of their convenience: either in the author's office or at a quiet cafe. The interview questions were as follows: "Tell me about your working experiences in an LTCH"; "Tell me about your motives for choosing to work in an LTCH"; "Tell me about the advantages and disadvantages of working in an LTCH"; "If you had difficulties working in an LTCH, what was helpful to overcome them?"; "What helped you to stay longer in the LTCH?". However, these questions differed for each participant and were not asked sequentially for each participant. The interview was initiated with a general question on working experience in LTCHs, and the subsequent questions were more focused on more detailed information.

The researchers attempted to listen attentively and positively in all interviews and to adopt a neutral attitude without indicating the pros and cons of the participants’ statements. All interviews were audio-recorded on two recorders and transcribed verbatim to a computer document as soon as possible after the interview. During the data collection, note-taking was conducted to record details of the interview situation and participants’ nonverbal expressions.

Grounded theory analysis was used, focusing on open coding and a paradigm analytic tool (Corbin & Strauss, 2014). In the open coding, line-by-line analysis was conducted, focusing on each word, expression, and sentence to identify as many characteristics as possible. Next, constant comparative analysis was conducted to scrutinize the similarities and differences among categories. Then, using the paradigm tool, coding around categories was used to identify the relationships with each category of conditions, actions-interactions, and consequences. Finally, integration was conducted to develop a conceptual model to explain the process of nurses’ turnover pathways for LTCHs, while memoing was used for constant comparative analysis and theoretical sampling from the beginning of the study to guide the research direction, construct the next interview questions, and draw diagrams.

To ensure rigor in qualitative research, team analysis, memoing, confirmation of transcripts by participants, and member checking were conducted in relation to the findings (Corbin & Strauss, 2014). Team analysis was conducted regularly to share ideas and to avoid authors’ preconceptions and biases in the analysis. The research team was composed of four faculty members with advanced education in nursing and in qualitative health research, all of them were female registered nurse having Ph.D. degree. Moreover, the research team have conducted long-term care and qualitative researches. Consistent analysis process was extensively performed throughout the study for data analysis and analytic process. Transcripts were returned verbatim to participants and confirmed at the beginning of the data-gathering process. Two of the nurses working in LTCH reviewed and confirmed the findings.

3. Ethical Considerations

Ethical approval of the study was granted by the Institutional Review Board of Ethics at University-affiliated authors (IRB No. 12-148) before data collection, and informed written consent was obtained from each nurse who volunteered for the study. Participants were informed regarding the study purpose, data collection method, assurance of anonymity, confidentiality of the research data, right of refusal to answer questions, and the right to withdraw from the study at any time. To ensure confidentiality, interviews were conducted in private spaces.

RESULTS

1. Nurses' Trajectories and Conditions in Long-term Care Hospitals

Participants reported entering long-term care hospitals to achieve a good work-life balance, or due to the difficulty of finding a job in a large acute care hospital. They had moved from one LTCH to another and eventually remained in current hospitals and separated into three groups: thriving, surviving, or leaving (Figure 1).

Figure 1. The pathways of Nurse Turnover in Long-term care hospitals.

All participants reported that they chose to work in an LTCH to achieve a good work-life balance. Work-life balance means balancing one’s personal life (such as home and hobbies) with one’s occupation. Work-life balance, identified by all participants as an important factor, includes geographical proximity from home, the limited number of required weekend shifts, and flexible work shifts. Geographic proximity from home saved both transportation costs and the time required for family responsibilities. The flexibility of work time was described by all nurses as the ability to negotiate work shifts in advance of employment, aligning the future work schedule with personal life and obligations outside of work, including family schedules or study time, to advance their careers.

I wanted to care for my kids simultaneously⋯ This hospital is very close to my house and convenient in terms of caring for my kids⋯ and this hospital gave me the working conditions that I wanted. Working time is from nine to five. It’s a good time to take care of my kids. Also, I can take every Sunday off. These working conditions were suitable for me, so I came here. (P7RO)

Besides work-life balance, the difficulty of finding a job in a large acute care hospital was another motivating factor for entering LTCHs. Nurses who were new to the practice, nurses who had been on long career breaks, and early retired transfer nurses referenced the limited opportunities available to obtain a job in large acute care hospitals due to conditions of recruitment timing, ability, and age, which contributed to their decision to work in an LTCH. Newly qualified nurses added that, due to their current limited opportunities, LTCH was an effective way to launch their careers by allowing them to gain experience in nursing while they were wait-listed for grand acute care hospitals.

It was hard for me to enter acute care hospitals because I had a very short nursing career in hospital, and had stayed at home too long after marriage. I forgot everything⋯. (P7RO)

When I was getting old, it was so stressful studying at my work. In the previous acute hospital, I had to continually study and teach younger nurses⋯ That was why I came here. I wanted to have a more relaxed life. (P8T)

Trajectory-related conditions were categorized as work environment, organization, relationship, and intrapersonal conditions. Nurses were seeking a better work environment related to systems, equipment, payment, and opportunities. Organizational conditions included opportunities for development and role ambiguity. Relationship-related conditions included seeking less conflict, having good relationships, and having a supportive nursing leader. Lastly, intrapersonal conditions comprised finding meaning in the profession and avoiding social stigma.

Over time, some participants stayed at the same hospital while others moved on to new LTCHs. Ten participants stayed in the same LTCH that they had first entered. These nurses were younger and had had shorter nursing careers than those who moved. Work-life balance was important to them as well as having a supportive manager who influenced their decision to stay in the same hospital. Nevertheless, participants sometimes wanted to quit the hospital due to the physical burden or conflict with coworkers. At this point, the supportive role of head nurses to change them to a more relaxed schedule or to encourage staff nurses had an important influence on their decision to stay at the same LTCH.

My head nurse always encouraged me to stay here. Whenever I was so exhausted, she made my schedule more suitable for me. She tried her best for me to stay here. Because of her, I could not leave here. I could not betray her great help. I am still working here because of her. (P14N)

Ten participants had experience moving within LTCHs with a maximum of two moves. These nurses were older and had had longer nursing careers than those who stayed. In this moving process, work-life balance was also revealed as the common cause. Participants moved to be closer to their homes in a bid to find a better work-life balance. Participants also moved hospitals to seek better compensation.

This hospital gave me more holidays... and more salary (quietly), a little bit⋯ so I moved here. (P15RY)

Participants also moved hospitals to seek better organizations with a better owner philosophy and equipment. Participants presented profit-seeking owners as a salient reason for moving. They discussed LTCH owners’ concerns about making or saving more money through examles of patients’ documentation methods and restrictions of the resources required in nursing care. This ownership directly affected nurses’ negative feelings towards LTCHs, decreased their morale to work there, and eventually induced nurses to move to another organization.

The hospital manager was not a medical-oriented person. He was just a businessman. So, we-nursescould not talk with him about the stuff we needed. Whenever we asked for something to be bought for patient care, he always rejected it. I was so shocked at him and left just one month later. (P9T)

Participants also moved to new LTCHs due to better equipment, including hospital computer systems (OCS). Nurses commented that in most LTCHs, they had to write all patients’ documentation by hand because OCS was not common. However, sometimes re-entry nurses did not want to use OCS because they were not familiar with them. Transfer nurses from acute care hospitals, on the other hand, were good at using OCS, and this was revealed as a moving condition for transfer nurses.

The computer system, OCS, was the most important reason I came here. In other places, nurses have to write tons of paperwork by pencil, then write and erase with ‘white’ (eraser), and write it again⋯ that job made my wrist and hands hurt so much. OCS was the biggest merit of working here. (P9T)

Therefore, seeking a better working environment and organization was identified as the other reason for participants moving to new LTCHs. The final moving condition of participants was seeking less conflict with a nursing manager. They perceived nursing managers to lack the leadership skills required to manage nursing staff and their work. If nurses had several conflicts with nursing managers regarding communication and jobs, they left and moved to new settings.

In the previous LTCH, the nursing manager was very obsessive about the work, too obsessive⋯ so I could not be patient with her. She was just controlled by the hospital owner to earn money. (P3T)

2. Thriving, Surviving, and Leaving

Over time, participants separated into three groups: thriving, surviving, and leaving. Participants in the thriving and surviving groups wanted to stay longer in LTCHs in contrast with the leaving group who intended to leave. The thriving group represented nurses who enjoyed their work in LTCHs, even though they perceived the setting as lacking opportunities for professional growth and lacking recognition. They were also confronted with the unappealing everyday working conditions, had conflicts with people at work, and perceived there to be social stigma, just like the surviving and leaving groups. Age was not relevant to the thriving experience; these participants had a will that could not be swayed by external conditions. One participant said that if she had the opportunity over again to obtain a job as a new nurse, she would definitely select LTCHs as a working place without hesitation.

The conditions for thriving were finding meaning, making good relationships, and seeing opportunities to improve. Such participants perceived their job as intrinsically valuable and were satisfied with gerontological work.

When I go to work in the morning, I have a new expectation every day. When I go back home after finishing my duty, I am always thinking about my patients⋯ It’s my pleasure...Every female patient looks like my grandma. I feel my worth as a nurse working in LTCH. (P14N)

Another salient condition that contributed to nurses thriving in LTCHs was forming good relationships with elderly patients and their families, and nursing staff. Thriving nurses spoke with patients about everyday life, family issues, and even their secrets. Therefore, they knew everything about the patients: their characteristics, preferences, families, and even very personal matters. Thriving nurses described patients as their new family members but real ones made while working in LTCHs. Moreover, when patients’ families perceived the good relationship they had with their parents, the family responded with a reciprocal relationship to the thriving nurses. Furthermore, when patients’ families visited their parents, the thriving nurses explained their parents’ conditions using common vocabulary to ensure ease of understanding. Finally, elderly patients and their families felt close to and trusted thriving nurses. These good relationships were not limited to elderly patients and their families; they also had good relationships with nursing staff, including nursing assistants and care workers. Thriving nurses respected these staff personally, listened to their demands, and helped them with their difficulties. This behavior fostered good mutual relationships with nursing staff in LTCHs.

I talk with them about everyday life. They open their minds to me so that I know everything about their lives. They are the family that I have here. My patients and their families trust me. They like me very much and rely on me. (P14N)

I try to respect them (nursing assistants (NAs), care-workers) as precious nursing staff, and to listen to what they want. When they made trouble while working here, I always tried to understand their position⋯ When I treat them well, they do the same to me. (P3T)

The final condition necessary for participants to thrive was seeing opportunities to improve the unorganized hospital system. Participants proposed and changed the system in LTCHs, focused on patient-centered care, and developed nursing staff care quality.

I changed the rounds system in the morning. When I went to see patients, I took all of them (the NAs) together and I explained and showed them the nursing care suitable for each patient in front of them, for them to learn. In the past, only a nurse went on patients’ rounds, so they (NAs) did not know anything about the patient’s conditions. (P13RY)

Therefore, those nurses who found meaning made good relationships, and saw opportunities to improve the hospital system were thriving in LTCHs. The surviving group nurses mentioned that they were merely enduring their jobs in LTCHs without finding any meaning. These were the oldest of the three groups.

Because this working condition fits me, I am trying to stay day after day. That’s all. I do not have any value here⋯ this is too sad (weak voice). (P5RY)

The work-life balance was the salient condition for surviving groups in LTCHs.

Though the salary is small, it is close to my house and I can live in a more relaxed way than before. I think there is a good place for me to work after the age of fifty. (P9T)

Another condition that induced surviving nurses to stay was having a supportive nursing leader, either a head nurse or nursing manager. Whenever they experienced difficulties with others or completing their work, the nursing leaders managed the difficulties, duty schedule, and work to support participants to stay on. These supports prevented nurses from leaving LTCHs.

My head nurse controlled them (NAs) so that they did not exert territorial power over me. I was so much younger than them and I did not know about the LTCH system. They were trying to catch me in their nest. Without her (head nurse) help, I would had been left here. (P12N)

When I considered leaving here, my head nurse considered me very much. She changed my schedule from day to evening, because evening duty is easier than day. She also encouraged me to stay here. Because of her, I endured⋯. (P6T)

Some participants also perceived their jobs to be dead-end because of the limited job opportunities that emerged from LTCHs due to their old age.

I am old, so it seems hard to work in other places. I think this is suitable for me, so I’m just here⋯. (P9T)

Despite the good work-life balance, leaving group nurses wished to leave LTCHs. These were the youngest group and had an entire nursing career of over five years. The conditions contributing to the intent to leave were a lack of professional growth, unappealing work, dissatisfaction with managers, continuing conflict, and social stigma. These participants felt that their nursing knowledge and skills were becoming old-fashioned, due to the lack of opportunities to learn in LTCHs. Some participants expressed their eagerness to learn about the required care of the elderly: medications, fall prevention, counseling, hospice, and end-of-life care.

I feel that I am becoming out-of-date day by day. I can’t remember the medical terms that I used so often before. I am falling behind, so I have thought about moving to an acute hospital several times. LTCH doesn’t give me any chance to develop my career (such as) in hospice, end of life care⋯. (P15RY)

Some participants declared their dissatisfaction with managers, both nursing managers, and hospital owners, as the condition influencing their leaving intention. They strongly perceived that they had not received any recognition for their effort in working in LTCH due to the biased personnel assessment from the nursing manager.

I always think about leaving here. I didn’t receive any reward for my master’s degree⋯ and I had a terrible experience. I acted as a substitute for the head nurse and nursing manager while they were away but I didn’t receive any rewards on my job in my performance appraisal. (P1RY)

Participants also cited bad hospital managers, who were not concerned about staff morale, as a leaving condition.

I do not have any satisfaction or pride as a nurse and so I want to leave LTCH. Moral support for staff is urgent. But we don’t get it here. If the hospital owner continues to act like this, then lots of staff will leave here including me⋯. (P11RY)

Another reason for leaving LTCHs was the unappealing work conditions, including elderly deaths and lots of paperwork. Some participants discussed the difficulties of elderly deaths as an unappealing job condition since they felt frustrated by the amount of death they saw in a day.

When patients are discharged with recovery, nurses can feel that their work has some value. But here in the LTCH, most patients are only discharged when they die. I feel so depressed when I see so many death cases here. I can’t find any value in working here as a nurse. So, I seriously think of leaving. (P5RY)

Head nurses actively reported paperwork as another unappealing job condition because head nurses played a role in regular governmental evaluation.

That regular accreditation evaluation is obligatory for LTC hospitals. But it gives too much paperwork to do. That pile of papers. When it arrives, the patients are almost left alone. We don’t have time to take care of them. Nurses are always saying, ‘I will leave before this coming accreditation.’ (P15RY)

Continuing conflict with nursing assistants was another reason cited by participants for wanting to leave LTCHs. They discussed how LTCHs are a nursing assistant-driven setting because NAs outnumber RNs as nursing staff and play a similar role to RNs. Therefore, nurses perceived NAs as having power in LTCHs and reported that if nurses could not endure this environment, then they could not work in LTCHs. This continuing conflict was prominent in transfer nurses, who mentioned that the structure was very different from acute care hospitals.

The hardest job in here is to manage them (NA) as a head nurse. They have power here to control things because there are more of them than (registered) nurses and they are also older than us (RNs). I have heard that the previous head nurses left here because of them. It’s a hard job for me⋯. (P3T)

The final condition for leaving was the social stigma. Participants perceived this from elderly patients, their families, acute care nurses, and nursing teachers. They also perceived their ignorance as unknowledgeable nurses compared to acute care nurses. They described how elderly patients and their families tested their medical knowledge. Even nursing teachers were curious about why participants would choose to work in LTCHs. This social stigma prompted participants to leave LTCHs.

(My teacher asked me) Why are you working there as a young (nurse)? That’s a place for old nurses who can’t get a job anywhere else. My friends don’t know that I am working here. I have not told them. I am not sure, but I feel a little ashamed. Frankly, I do not want to stay here any longer. (P16N)

Therefore, nurses entering LTCHs for a work-life balance, either staying in the same place or moving to a new place, were finally divided into thriving, surviving, and leaving groups over time. The most noticeable condition in this passage was work-life balance, although thriving participants had also found new meaning at work. Therefore, seeking a work-life balance and meaning through caring were the essential components of the turnover pathways for nurses working in LTCHs.

DISCUSSION

This grounded study has attempted to deeply and integrally explore the pathways of nurse turnover regarding working in long-term care hospitals and their related conditions. The key condition in the process of moving to another long-term care hospital was work-life balance. The major reason for joining and remaining in an LTCH was also work-life balance. Nurses prefer to have flexible working hours, such as working a fixed shift or avoiding weekend work. Another major preference is the short commute time from home to the hospital. By reducing the time required for commuting, more time can be reserved for family. If a nurse finds a more flexible schedule or better working hours in another hospital than in their current hospital, or a shorter commute time than their current employment, they are more likely to leave the current hospital.

This finding provides support for previous studies, which found that work-family conflict was positively related to turnover intention and negatively related to job satisfaction (Brewer, Kovner, Greene, & Cheng, 2009; Chen, Brown, Bowers, & Chang, 2015). McGilton, Boscart, Brown, and Bower (2014) asserted that nurses stay because of proximity, shift predictability, and personal life roles, such as taking care of family. Family-friendly policies and environments, which have favorable effects on reducing work-family conflict, increasing positive attitudes toward the job, and attracting and retaining employees, are suggested (Skinner & Chapman, 2013). The result of this turnover and retention pathway led us to identify three groups: the thriving group, surviving group, and leaving group. These three groups had common moving conditions: compensation, work system, and interpersonal relationships.

Better work systems and sufficient resources with a computerized record management system were perceived as contributing to job satisfaction and retention. Several nurses stated that their employers were seeking profit and limited necessary medical resources to reduce costs. This was not only immoral but also seriously deteriorated the quality of care. Consistent with their responses, Castle (2006) noted that for-profit ownership is associated with higher nurse turnover. Computerized data management systems were also identified as related to the turnover phenomenon. Many documents must be prepared and managed due to regular evaluations of certified hospitals, and without a computerized system, medical records must be written by hand, which unnecessarily increases the time required for administrative work. Other studies also reported the increasing demand for paperwork, which deprives direct patient care time of nurses (Choi, Flynn, & Aiken, 2012; McNeese-Smith, 1999).

Compensations affecting turnover include receiving a good amount of money. Nurses expect to receive higher remuneration than nurse assistants since they have a higher level of education and more qualifications than them. However, since the distinction in role between nurse and nurse assistant is ambiguous, leading to role conflicts, nurses are not always financially rewarded. As mentioned by Park and Yeom (2016), the nursing job delegation of unclear regulations leading to role conflict, frustration, and dissatisfaction can impact turnover intention. The positive relationship between inadequate monetary benefits with turnover intention has been commonly reported in previous studies (Choi et al., 2012; McNeese-Smith, 1999).

As suggested by Sellgren, Kajermo, Ekvall, & Tomson (2009), salary has become increasingly important, the issue of financial incentives must be addressed. The issues of inadequate financial and professional incentives referring to the non-financial incentives, which contribute to a sense of professionalism among nurses, have combined to form a vicious cycle. Nurses who are unsatisfied with their salary seek other rewards, such as recognition from themselves and others. Apart from the monetary issue, evidence from previous studies has upheld the unprotected doctor’s job performance of nurses, and unsystematic nursing assistant management was noted (Park & Yeom, 2016). To solve this problem, researchers asserted the importance of understanding nursing work and the context of the practice of nurses (Spitzer, 2006).

Interpersonal relationships at work have also been found to enhance nurses’ coping abilities (AbuAlRub, Omari, & Al-Zaru, 2009). Nurses’ relationships with patients and their families, colleagues, managers, or supervisors affected their intent to stay. In cases where nurses have communication problems or conflicts at work, they are more likely to leave the hospital. However, nurses who recognized themselves as having social support from managers and supervisors reported a high level of intent to stay in the hospital. Findings from previous research advocate the importance of social support from colleagues, which influences the intention of nurses to leave (Choi et al., 2012).

Moreover, previous studies have reported that good communication with supervisors is positively associated to remain at a job (Estryn-Behar et al., 2010; Bakker, Killmer, Siegrist, & Schaufeli, 2000). Furthermore, nurses who have a good rapport with patients and their families and those who have developed reliability have a sense of job satisfaction and thus thrive at their jobs. This was consistent with Choi et al.(2012), which revealed strong professional values and satisfaction gained from the recognition of care recipients. Hwang and Chang (2009) reported that “workgroup friendliness and warmth” was negatively to leave because it contributed to conflict reduction. This observation is consistent with the reports of informants on mutual respect, meeting the requirements of counterparts, and helping each other, which can reduce conflict and thus lead to prosperity. The supportive interpersonal relationship among colleagues symbolically represents intimacy, trust, and connectedness in supporting their work (Choi et al., 2012).

The reorganization of the workload, reallocation of resources, and provision of supportive leadership by nursing management are crucial factors in increasing nurses’ intention to stay. By offering support and maintaining good communication, leaders can help counteract complaints and exhaustion of nurses caused by a high-demand work environment (Bakker et al., 2000). The establishment of a social support system and management skill training is suggested.

The salient condition in the retention of thriving nurses was finding meaning at work; recognition of work and profession. Regardless of the influence of demanding and unfavorable work environments as well as relationship problems, thriving nurses in this study demonstrated professional values that helped them sustain themselves at the same hospital. They recognized their work as meaningful. They had professionalism, which was strengthened by patients in LTCHs. Consistent with these results, Choi et al. (2012) noted that nurses gained professional value from care recipients.

Apart from gaining satisfaction, these nurses acquired a sense of accomplishment from advancing their skills in comprehensive care and care coordination at work. Nurses achieved professional development through holistic care for older adult patients. Furthermore, in addition to providing direct care, nurses acquired a sense of accomplishment by focusing on indirect nursing tasks, such as overseeing medication management, close surveillance of direct care activities provided by other staff members, and educating nursing assistants and care workers. Moreover, apart from gaining a sense of professionalism and accomplishment, advanced knowledge gained through the patient care process is crucial for retention.

Professional incentives, such as the opportunities provided to fulfill their potential, were commonly identified in previous studies. McNeese-Smith (1999) noted that the lack of learning related to the turnover of nurses, and similarly, informants of the leaving group subsequently left because of fewer development opportunities. They wanted to start their careers in LTCHs with an expectation of professional growth; however, these needs were unmet over time. Moreover, several nurses complained about the social stigma attached to nurses in LTCHs, with an informant describing this job as a “dead end.” The perspective of nurses on LTCHs needs to be changed as a specialized work environment, where they can train in hospice, end-of-life care, counseling, elderly-specific medication, and nursing. Since career opportunities and practice environments are crucial in improving nurse satisfaction, career advancement opportunities should be provided for nurses specializing in gerontology.

CONCLUSION

This study has revealed the nurses’ turnover pathway in LTCHs and the conditions that influence either staying or leaving. Work-life balance was the most salient condition impacting these decisions in LTCHs. The consequences of nurses’ turnover pathways were categorized into three groups; thriving, surviving, and leaving. Thriving nurses in LTCHs find meaning in their work, foster good relationships, and see opportunities for growth. Surviving nurses in LTCHs were enduring their jobs in LTCHs, having a work-life balance, and being supported by nursing leaders. Leaving nurses wished to leave LTCHs due to a lack of professional growth, unappealing work conditions, continued conflict, and social stigma. The common moving conditions for all three groups were compensation, work system, and interpersonal relationships. Understanding the pathways to thriving, surviving, or leaving, serves as a guide to successful retention for registered nurses in LTCHs. This study provides an overview of the nurses’ turnover pathway in LTCHs over time and the related conditions relating to nurses’ intention to leave or stay in employment in LTCHs, confirming current knowledge about turnover among nurses in LTCHs. However, the findings are restricted to informants working in LTCHs, and informants who had left LTCHs were not included. It is suggested that related factors, conditions, and pathways of nurse retirement be investigated in further study. Additionally, although our analytical approach to explaining the turnover pathways of nurses in LTCHs over time was proven successful, the analysis did not focus on legal regulation changes such as reinforced accreditation standards. Future research needs to consider and evaluate the nurse turnover pathways regarding legal regulation and system changes.