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International Journal of Nursing Studies 42 (2005) 751–758
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Reasons for leaving nursing care and improvements needed forconsidering a return: a study among Swedish nursing personnel
Katarina Sjogrena,�, Grethe Fochsena, Malin Josephsonb, Monica Lagerstroma
aDepartment of Nursing, Karolinska Institutet 23 300, SE-141 83 Huddinge, SwedenbSection for Personal Injury Prevention, Department of Clinical Neuroscience, Karolinska Institutet,
Box 127 18, SE-112 94 Stockholm, Sweden
Received 23 June 2004; received in revised form 1 November 2004; accepted 9 November 2004
Abstract
Based on two research projects in Sweden during the 1990s, the aim of this study was to identify former nursing
personnel’s main reasons for leaving nursing care, and to find out under what circumstances they would consider
returning. Two open-ended questions in a questionnaire were analysed. The results showed that different aspects of
working conditions, mainly working schedule, management and status of profession were the dominating reasons both
for leaving and considering a return. The findings indicate that interventions required for retaining personnel in nursing
care need to be addressed both at the political and at the local level.
r 2004 Elsevier Ltd. All rights reserved.
Keywords: Nursing personnel; Leaving; Returning; Working conditions; Questionnaire
1. Introduction
A shortage of nursing personnel is a problem in
several countries including Sweden. In 10 European
countries, this problem is focused on the ongoing
NEXT-Study, nurses’ early exit study, (Hasselhorn et
al., 2003). The most common reasons for the shortage
are an ageing nursing workforce and problems with the
recruitment of young people to the profession (Chiha
and Link, 2003; Hasselhorn et al., 2003). Besides the two
above-mentioned reasons, Janiszewski Goodin (2003),
also identified a changing work climate and the poor
image of nursing as key contributors to the shortage of
nursing personnel. Duffield and Franks (2002) found
that nursing personnel leave nursing care for many
reasons, but three distinct areas can be seen: family
e front matter r 2004 Elsevier Ltd. All rights reserve
urstu.2004.11.001
ing author.
ess: [email protected] (K. Sjogren).
commitments/personal circumstances, professional rea-
sons and organisational factors. Other studies (Durand
and Randhawa, 2002; Fottler and Widra, 1995) found
that the most common reason for leaving nursing care
was pregnancy and childcare. Those who had left
thought it was likely that they would return to nursing
care some time in the future, when personal circum-
stances allowed (Bentham and Haynes, 1990). The
literature reviews mainly consider the situation for
registered nurses.
One possible way of increasing the number of nursing
personnel could be to re-employ those who have left
their occupation and thus, find out what reasons might
contribute to their return. Janiszewski Goodin (2003)
argues that solutions to the shortage show a similar
pattern, as do the contributing factors. They were
identified in four main areas: recruitment, retention of
personnel, the image of nursing, and legislation that
helps to rectify the shortage.
d.
ARTICLE IN PRESSK. Sjogren et al. / International Journal of Nursing Studies 42 (2005) 751–758752
In addition, flexible working hours, increased salaries
and appreciation from the management have been
highlighted as priority issues to get nursing personnel
back to nursing care (Durand and Randhawa, 2002).
Cowin and Jacobsson (2003) argue that if the work-
places do not find out the reasons why nursing personnel
have left, there is a real danger of losing those who have
recently been attracted back into the workplace.
Both reasons for leaving and improvements needed
for considering a return to nursing care are examined in
this study. The aim of the study is to identify former
nursing personnel’s main reasons for leaving nursing
care and find out under what circumstances they would
consider returning. Nursing care is defined here as a job
involving direct patient care in health care institutions.
The study includes both registered nurses and
assistant nurses. In Sweden, assistant nurses have upper
secondary school training and are comparable to
nursing assistants/health care assistants in the UK.
In contrast to most studies in this area, which have
focused on turnover intentions, a unique feature of this
study is the use of reports from nursing personnel who
have actually left nursing care.
2. Methods
This study is based on two research projects carried
out in Sweden during the period 1992–1995. The first
project was an intervention study conducted at a county
hospital in central Sweden (Josephson, 1998). The
overall aim of the study was to decrease musculoskeletal
symptoms and to enhance job satisfaction. A total of
754 persons participated in the training programme and
completed a questionnaire on four different occasions.
The other project was an epidemiological study,
aiming at identifying risk factors for work-related back
injuries among nursing personnel (Engkvist, 1999). The
study base consisted of nursing personnel employed in
the county hospitals of Stockholm from 1992 to 1994.
The project had the design of a case-referent study, the
266 cases had reported a work-related back injury while
the comparison group of 691 nurses had not.
The source population of the present study consisted
of the participants from the above-mentioned research
projects, i.e. a sample of 1711 subjects. Subjects aged 65
and older (n ¼ 135) and subjects who had died (n ¼ 18)
were not included in the study. Available civic registra-
tion numbers were used to obtain addresses of the
participants from the address register of the Swedish
population (SPAR). 51 persons could not be identified
in the address register due to missing or erroneous civic
registration numbers.
Finally, a questionnaire was posted to 1507 persons in
January 2003. During a period of 10 weeks three
reminders were given if necessary, one of which was by
telephone. The response rate was 73% (n ¼ 1098).
The study sample includes the 288 respondents who
reported that they had left nursing care. The study
includes two groups, registered nurses and assistant
nurses. Assistant nurses include both enrolled nurses
and nurse’s aides due to the similarities in work tasks
and the smaller number of nurses’ aides in the study
sample. The findings did not differ by the two groups.
The study of the 288 respondents, 36% were registered
nurses and 64% were assistant nurses. A majority of the
respondents, 88% were female. The average age was
45.7 years and the average number of years in a nursing
job was 17.
3. Analysis
These analyses emanate from two open-ended ques-
tions. The first question was ‘‘What do you consider
your main reason for leaving nursing care’’? The second
question was ‘‘What would make you consider a return
to nursing care’’? The respondents were asked to write
down and rank the three most important reasons,
beginning with the most important one. For both
questions, only the first reason has been analysed,
because of a large falling off on the other two.
The question concerning reasons for leaving nursing
care was answered by 228 of the 288 leavers. Those who
had left nursing care as a consequence of health
problems (n ¼ 44), were given notice or never got a
permanent post (n ¼ 47), were not requested to respond
to the question about returning, because most of them
had no choice about the decision to leave. Of the 288
levers, 133 responded to what could make them consider
returning.
In the analysis of the statements a manifest content
analysis was used. According to Kondracki et al. (2002),
analysis of what a text says deals with the content aspect
and depicts the visible, clear components, referred to as
the manifest content. Latent content analysis on the
other hand deals with the relationship aspect and
involves an interpretation of the underlying meaning
of a text. This study, based on open-ended questions,
must therefore be seen as a manifest content analysis.
The statements were read through several times and a
pattern of categories emerged. To ensure reliable
interpretation, all responses to the open-ended questions
were read through, analysed and categorised indepen-
dently by the authors. All the statements were compared
and when there was a disagreement, the rating was done
again until consensus was achieved. It was important to
remain as faithful as possible to the views of respondents
and their own words.
ARTICLE IN PRESSK. Sjogren et al. / International Journal of Nursing Studies 42 (2005) 751–758 753
The authors sorted out the responses to the open-
ended questions manually. Six main categories of
reasons for leaving nursing care emerged from the
analysis. Reasons for considering a return to nursing
care were classified into four main categories. For most
of the categories found, quotations are presented. They
are selected on the basis of their representativeness for
the category.
4. Results
4.1. Reasons for leaving nursing care
Six main areas related to leaving nursing care were
found (Table 1).
4.1.1. Working conditions
Twenty-six per cent of the respondents mentioned
that they were not satisfied with the working conditions
of the organisation and had left nursing care for that
reason. This category includes a number of subgroups
and, the subgroups with numbers of respondents are
listed in Fig. 1.
Among the working conditions, the most important
reason for leaving nursing care was workload. The
respondents expressed the opinion that the situation was
precarious. There were too many and heavy lifts, and
too high physical strain caused by personnel reductions
as well as more and more older and exacting patients.
Sometimes the space at the wards was too small and this
made the physical workload even heavier.
Table 1
The main areas for leaving nursing care
Area for leaving Proportion (%) of answers
(n ¼ 228)
Working conditions 26
Employment conditions 21
Health status 19
Development 16
Salary 10
Personal factors 8
Workload
n = 26
Working schedule
n = 15
M
Working cond
Fig. 1. Working conditions that made nu
Because of the high workload the respondents
expressed a constant feeling of inadequacy, which they
mentioned led to a high degree of stress. They also felt it
was difficult to give the patients dignified and satisfac-
tory care, and that they were not able to take
responsibility for the quality of the care given.
There was too much stress. I didn’t have time for
patient-oriented work, which was the reason I was
working in the health care sector. (Registered nurse,
Female 35 years old)
Leaving nursing care because of the working schedule
was based on irregular working hours, weekend duty
and overtime work, especially for those with a family.
The respondents described the management as im-
personal. There were too large gaps between the
management and the staff, and too much hierarchy
and prestige.
I couldn’t influence my work situation. I felt like an
unimportant cog in big wheel. (Registered nurse,
Female 42 years old)
They testified to an organisation that was not
interested in or did not take any notice of the staff’s
competence. No appreciation or feedback was given and
the personnel were not seen as individuals.
Nobody saw me or was interested in what I could
contribute. My knowledge was not in demand or was
not taken advantage of. (Registered nurse, Female 47
years old)
Another expressed reason for leaving nursing care was
problems with co-workers. Those who had left for that
reason thought there were too many intrigues and
conflicts.
The work environment was depressing and boring,
and so were my colleagues. (Assistant nurse, Female
35 years old)
Both registered and assistant nurses were of the
opinion that the status of the profession was very low.
Among the assistant nurses there was a feeling that both
the management and registered nurses distrusted their
professional status.
anagement and social climate
n = 7
Status of profession
n = 6
itions
rsing personnel leave nursing care.
ARTICLE IN PRESS
Table 2
The main areas for considering a return to nursing care
Area of change Proportion (%) of answers
(n ¼ 133)
Working conditions 38
Salary 29
Personal factors 11
Development 5
Do not want to return 16
K. Sjogren et al. / International Journal of Nursing Studies 42 (2005) 751–758754
I was good enough to teach someone who just had
qualified as a registered nurse, but I was not trusted
to do the tasks by myself. (Assistant nurse, Female 37
years old)
Both groups felt that their authority and tasks were
taken away and given to the other group. They both also
described conflicts between the groups.
A lot of the registered nurses shirked and didn’t take
part in the nursing care. Instead, they hid in the office
and spent hours and hours doing paper work. The
assistant nurses had to work alone and worked
themselves to death. (Assistant nurse, Female 45
years old)
Some of the registered nurses felt that their profession
was becoming impoverished.
The Swedish registered nurse is becoming more like
an assistant nurse in other countries. Nursing care for
me means a good knowledge of pharmacology,
anatomy and physiology and an enormous human
interest. (Registered nurse, Female 59 years old)
4.1.2. Employment conditions
This category includes both negative and positive
experiences of leaving nursing care. The negative
experiences are represented by those (n ¼ 34) who had
been given their notice, principally on account of
reduction of staff, scarcity of work and reorganisations.
There were also those who never got a permanent post
and had left because of the insecurity.
I was transferred to another hospital. From there I
was given notice, because they didn’t think I was
qualified enough (Assistant nurse, Female 42 years
old)
The other part of the category includes those with
positive experiences. Thirteen of the respondents had
been offered a new role in the organisation and had left
nursing care because of this. While other reasons for
leaving nursing care had been due to negative experi-
ences, this one must be seen as being positive for the
individual, as it involved advancement to e.g. a post as
head nurse or a research position.
I was offered a new and interesting employment by
the staff management (Assistant nurse, Female 56
years old)
4.1.3. Health status
Musculoskeletal problems, principally back and
shoulder pain were the most common health problem.
The work was so heavy that I had aches and pains all
over, especially in my knees. I had to take painkillers
and antibiotics. (Assistant nurse, Female 47 years
old)
The leavers also reported other health problems.
I was depressed. I had difficulty concentrating and
problems sleeping. (Registered nurse, Female 45
years old)
4.1.4. Development
Lack of personal or professional development was the
fourth most important reason for leaving nursing care.
Those who had left because of lack of personal
development said that they had had enough and would
like to move on.
I was interested in trying something new. I was tired
of the health care sector. (Registered nurse, Male 44
years old)
The ones who had left because of lack of professional
development mentioned e.g. bad career opportunities
and not being able to affect the organisation as reasons
for leaving. They felt that there were no future prospects
and no opportunities to try new things in the organisa-
tion.
There was no development in my career, even though
I did courses in my free time, took initiatives of my
own on the ward and so on. (Registered nurse,
Female 47 years old)
4.1.5. Salary
Those who had left nursing care because of an
unsatisfactory salary thought that their salaries were
not in proportion to their efforts, and there was no
chance of getting a rise. They felt that they did not get
back what they put in.
We were poorly paid compared to how much we
worked. (Assistant nurse, Female 32 years old)
4.1.6. Personal factors
Leaving because of personal factors was based on
statements concerning moving to another district, family
reasons, pregnancy or childcare.
ARTICLE IN PRESSK. Sjogren et al. / International Journal of Nursing Studies 42 (2005) 751–758 755
4.2. Improvements needed for considering a return to
nursing care
In Table 2, the five main areas for improvements
needed in order to consider a return to nursing care are
presented.
4.2.1. Working conditions
Most of the statements about considering a return to
nursing care, as well as leaving it, were connected to
working conditions. The subgroups with numbers of
respondents are listed in Fig. 2.
The leavers thought that more staff, and thus less
workload and more time for each patient, could be a
reason for considering a return to nursing care. Better
quality of care and increased time for the patients were
two recurrent statements, as well as the human aspect.
Having the right staff is important, not only in terms
of the number of staff but also their knowledge and
competence. (Assistant nurse, Male 50 years old)
More flexible working hours was something the
leavers called for, and the majority wanted to work
only Monday–Friday, not evenings, weekends and
holidays.
I would like to have working hours that can be
adjusted to my social life and not only to the
conditions of the management. (Registered nurse,
Female 61 years old)
The respondents wanted to have more opportunities
to influence the organisation and participate in the
decision-making. They also wanted to be able to change
their work tasks and thus develop in their profession.
I would like to have more opportunities to plan and
influence my own work. Often the structures are old
and the hierarchy is old-fashioned. (Assistant nurse,
Female 40 years old)
Much higher professional status was demanded by
both registered nurses and assistant nurses. Both groups
felt that their original authority had been taken away
and wanted to have it back.
I’m a trained nurse, not a cleaner, a laundress or a
chef. The economic cuts create odd demands and
tasks. (Registered nurse, Female 35 years old)
More staff
n = 14
Working schedule
n = 14
Influences
n = 8
Working cond
Fig. 2. Working conditions that need to be im
An essential reason for assistant nurses to consider a
return was that their competence was appreciated.
Recognition of competence based on experience, and
not only on being a registered nurse. (Assistant nurse,
Female 37 years old)
The importance of competent and clear management
as a reason for considering returning was also men-
tioned. The respondents thought it was essential for the
head nurse to be a skilled person with qualities of
leadership. Another expressed reason for returning was
if the struggle for power and quarrels between different
professions disappeared.
4.2.2. Salary
A considerably higher salary and a positive wage
trend were two mentioned reasons to return to nursing
care.
The main reason for me to return to nursing care
would be if I were given a salary that’s in proportion
to the responsible work I do. (Registered nurse,
Woman 42 years)
One respondent mentioned that it was important that
new employees and those who had just qualified did not
get a higher salary than those who had worked for many
years.
4.2.3. Personal factors
Changed family circumstances and need for money
could be reasons to return. There were also leavers who
expressed that they missed nursing care and the contact
with the patients.
I’ll return when my longing for taking care of
patients gets too strong. (Registered nurse, Female
38 years old)
4.2.4. Development
Leavers mentioned opportunities for development
and further education as a reason for returning to
nursing care. Assistant nurses suggested that they should
be given priority to get into nursing training.
4.2.5. Do not want to return
Sixteen per cent of the leavers mentioned that they
never wanted to return to nursing care. They considered
Status of profession
n = 7
Management and social climate
n = 6
itions
proved before returning to nursing care.
ARTICLE IN PRESSK. Sjogren et al. / International Journal of Nursing Studies 42 (2005) 751–758756
their choice as permanent and were satisfied with their
new work situation.
Table 3
The most common working conditions for leaving and
considering returning to nursing care
Working conditions
that made nursing
personnel leave
Working conditions
that need to be
improved before
5. Discussion
5.1. Methodological considerations
Responses from open-ended questions make it possi-
ble to understand the world as seen by the respondents,
and provide the opportunity to understand and capture
the people’s opinions (Patton, 2002). The structure of
this study is based on the model of Graneheim and
Lundman (2004) and their report on how to use
qualitative content analysis in nursing research. Accord-
ing to them, a central part of content analysis consists in
creating categories. A category is a group of content that
shares a commonality and refers principally to a
descriptive level of content; as a result it can be seen
as an expression of the manifest content of the text.
A weakness of the study design is that the data was
not conducted in close connection with the nursing
personnel’s decision to leave. The time between leaving
and the data collection varied in the study sample. It is
possible that the current working conditions and private
life of the respondents may have influenced their
responses.
However, nearly fifty per cent of the respondents had
worked in a nursing job for 17 years or more. With so
much experience and time invested in nursing care the
reasons for leaving and considering returning would
probably be based on a well-considered decision and are
likely to be recalled even, retrospectively.
The results from the study are not necessarily
representative of all registered and assistant nurses in
Sweden. They reflect reasons for leaving and considering
returning to nursing care expressed by nursing personnel
who have been employed in two different places in
Sweden; the capital and a smaller town in the middle of
the country. In the decision to leave and return, regional
differences might exist when it comes to contributing
aspects outside the workplace, such as the labour market
and work opportunities outside nursing.
nursing care returning to nursingcare
Workload X
Staff X
Working
schedule
X X
Management
and social
climate
X X
Status of
profession
X X
Influences X
5.2. Result discussion
The aim of this study, as stated in two open-ended
questions, was to identify former nursing personnel’s
main reasons for leaving nursing care, and to find out
under what circumstances they would consider return-
ing. The reasons for leaving agree with the improve-
ments needed for considering a return to nursing care,
but some differences can be seen. Working conditions
were found to be the dominating reasons for both
leaving and considering a return. There were several
aspects of working conditions (Table 3).
The most dominating reason for leaving was work-
load. This is in concordance with the request for more
staff that would lead to a decrease in workload, which
was mentioned as an important reason for considering a
return to nursing care. Too high physical workload can
lead to the occurrence of musculoskeletal disorders. It
has been found that patient transfer, for example
assisting a patient from their bed to a wheelchair, is
one cause of musculoskeletal problems (Marras et al.,
1999). Musculoskeletal complaints are frequent health
problems, seen by nursing personnel (Kemp, 2000;
Trinkoff et al., 2002). Musculoskeletal problems, princi-
pally back- and shoulder pain were found to be the most
common health problem in this study, where 19% of the
respondents had left nursing care because of health
problems.
Working schedule was found to be a central reason
both for leaving and considering a return to nursing
care, and the respondents wanted to have more
flexibility and influence over their working hours. This
was surprising, since individual working schedules have
become more and more common in Sweden during
recent years. The result may have been affected by the
fact that the data was not collected in close connection
with the nursing personnel’s decision to leave. As this
study is based on two studies from the 1990s the
situation might have changed during these ten years.
Sullivan and Reading (2002) found that more flexibility
at the workplace, leads both to a significant reduction in
sick leave and improved retention of nursing staff.
The importance of having a flexible working schedule
can be related to the fact that in Sweden women work
even when they have small children. Private or public
childcare is more comprehensive compared to other
ARTICLE IN PRESSK. Sjogren et al. / International Journal of Nursing Studies 42 (2005) 751–758 757
countries in Europe, and this makes it possible for
parents with infants to stay on the labour market. While
other studies have found that the most common reason
for leaving nursing care was pregnancy and childcare
(Durand and Randhawa, 2002; Bentham and Haynes,
1990; Fottler and Widra, 1995), this is a minor problem
in Sweden. The dilemma here is not to get people back
to working life, but to get them back to nursing care.
Increased influence was a recurrent demand, not only
concerning working schedule. Influence over decisions
as well as more opportunities to influence the organisa-
tion and participate in the decision-making, were of
importance to consider a return. Participating more in
the decision-making means being more visible. Since
many of the respondents mentioned that they were not
seen as individuals by the management, and that they
did not perceive that anyone was interested in or took
notice of their competence, this is something that must
be given attention. This can lead to low motivation,
frustration and feelings of powerlessness and hope-
lessness.
Many respondents described that they were never
shown any appreciation or given feedback for work
performed on the wards. One of the main motivating
factors for health care workers is appreciation by the
managers (Dieleman et al., 2003; Jameson, 2003). Good
and supportive management can be difficult to define,
but it is vital for inspiring the staff to improve their
work. Nursing managers play an important role in
enhancing nursing personnel’s autonomy by delegating
authority and responsibility for decision-making (Mray-
yan, 2004).
Being more visible and autonomous in the organisa-
tion can give a higher status to the profession, which was
something that both registered nurses and assistant
nurses wanted to have. An essential reason for assistant
nurses to consider a return was that their competence
was appreciated, and that competence and knowledge is
more than an academic degree. Hertting (2003) also
found that assistant nurses experienced that their
knowledge was not used, and that they felt invisible in
the organisation, but that they had difficulties in
assessing and marketing their knowledge. As a con-
sequence of this, assistant nurses often place themselves
at the bottom of the organisation.
Registered nurses have their academic degree that
provides them with better promotion prospects and
gives them more power to assert themselves. Both
registered nurses and assistant nurses play an essential
role in the health care sector, where a central factor is
not only the number of staff, but also their knowledge
and competence. Competence finds expression in an
increased level of efficiency (Benner, 2001).
During recent years, the poor salaries of nursing
personnel have been given much attention in the public
debate in Sweden. In this study, salary was seen to be the
second most important reason for considering a return
to nursing care, but only the fifth reason for leaving.
Other studies have found different results regarding the
importance of salary for leaving nursing care. Ahlburg
and Brown Mahoney (1996) and Schumacher (1997)
focused on how salary affects the retention of nurses and
both found that wages have significant, but small effects.
On the other hand, economic studies by Holmas (2002)
and Shields and Ward (2001) showed that salary played
a central role in nurses’ decision to leave nursing care.
The health care sector is developing quickly, particu-
larly as regards medical and technical knowledge, and
there is a tremendous amount of information about this
new knowledge. Today’s patients are more knowledge-
able and thus more eager to receive adequate informa-
tion and, this makes great demands upon the nursing
personnel. For most of the nursing personnel, this is a
new experience and an important reason for further
education and development, which were two other
motives both for leaving and considering returning to
nursing care.
The respondents wanted not only to have further
education but also to be able to change work tasks, and
thus develop in their profession. Lack of skills
development has been found to be a strong reason for
nursing personnel to consider leaving their jobs (Petter-
son, 1997). According to Jameson (2003), continuous
education is important for motivation, which is the
key to creating a team of consistent and long-term
employees.
6. Conclusion
The findings from this study indicate that interven-
tions required to retain personnel in nursing care need to
be addressed both at the political and at the local level.
The heavy workload and the need for more resources to
the health care sector require measures at the political
level. In the effort to keep and recruit competent nursing
personnel, improvements in working schedules, manage-
ment and social climate and increased influence for the
nursing personnel seem to be of importance. These
factors are primarily issues for the local workplaces and
for the work organisation, and should as such be
possible to improve.
Acknowledgements
The study received financial support from the Swedish
Council for Working Life and Social Research.
ARTICLE IN PRESSK. Sjogren et al. / International Journal of Nursing Studies 42 (2005) 751–758758
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