Why older nurses leave the profession

Leonie Walker Jill Clendon Jinny Willis About the authors: Léonie Walker, MSc, PhD, is an associate professor in the College of Health, Massey University, Te Kunenga ki Purehuroa, Wellington, New Zealand. Her correspondence address is: [email protected] Jill Clendon, RN, PhD, is acting chief nursing officer, Ministry of Health, Welllington.  Jinny Willis, BSc(hons), PhD, is the principal researcher at the New Zealand Nurses Organisation, Christchurch. This article was accepted for publication in July 2018.	ABSTRACT Aims: The aim of this study was to examine whether reasons reported in the international “intention to leave nursing” literature match those given by New Zealand nurses who left the profession before retirement age. Background: Concerns about nursing shortages have produced a rich literature on early nurse retirement. While causes of intention to leave have been reported previously, understanding more about the impact of these could guide retention strategies. Method: An online survey of nurses who had left the New Zealand Nurses Organisation (NZNO), citing they were leaving the profession, was conducted in September/October 2016, asking them about the factors leading to their decision, their decision-making processes, and workplace changes that may have helped them remain. Results were analysed by age cohort. Results: This paper reports results from 459 nurses aged 55-65 who had left nursing before the official retirement age. Issues previously reported in the literature also emerged as factors among this cohort. Key among these were workplace/organisational issues, and personal challenges related to health or burnout. Although reported by small numbers of respondents, previously unreported issues of loss of confidence, over-onerous professional development requirements and intergenerational tensions were also described. Conclusion: Issues identified in the “intention to leave” literature also figured highly as contributing to New Zealand nurses’ decisions to actually leave. Many of these issues relate to the intensification of nursing (higher acuity and bed occupancy), and the need for sufficient nursing resources, flexible management and better support for older nurses. Implications for nursing management: Retaining, or delaying the retirement of older nurses could lessen impending nursing shortages. Adequate staffing, flexible working conditions, attending to difficulties with shift work requirements, and good nursing leadership to support a positive work culture, are required.
KEYWORDS nurses, attrition, early retirement, New Zealand

INTRODUCTION

THERE IS EVIDENCE THAT nursing has shifted from being a “career for life” to being just one option in a career portfolio, with increasing reports of large numbers of nurses intending to leave the profession. Nursing shortages, caused by the demographic impacts of an ageing workforce and population, and changing workforce patterns, will be compounded if strategies to delay attrition and retirement are not implemented. Understanding why nurses do leave the profession, and what could be done to support them to remain for longer, may help guide the development of interventional strategies to address forecasted shortages. Using records of nurses who had resigned their NZNO membership, indicating they had left nursing, this study aimed to examine factors contributing to nurses exiting the nursing workforce and what interventions may have helped reduce or delay such attrition.

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BACKGROUND AND LITERATURE REVIEW

For more than two decades, nurse attrition has been identified as a risk to workforce planning (Lum et al, 1998). In many developed countries, concerns about looming nursing shortages are leading to a new focus on preventing workforce attrition (Leineweber et al, 2016; Ryan, Bergin, & Wells, 2017). The ageing of the nursing workforce, the options available for migrating nurses, and changing career patterns of younger generational cohorts have been widely identified as adding impetus to the need for better workforce retention (Nantsupawat et al, 2017).

In New Zealand, more than 43 percent of the nursing workforce is now aged over 50 (Nursing Council of New Zealand, 2015a) and up to 50 percent are expected to retire over the next 10 to 15 years (Walker & Clendon, 2013). There is evidence of increasing intention among nurses to leave the profession early (ie before the age of 65), which, if carried through, would cause substantial nursing shortages (Walker, 2017). On top of this, international shortages of skilled nurses may alter the patterns of nurse migration into and out of New Zealand, further exacerbating the problem.

More than 25 percent of nurses registered in this country initially qualified overseas, and nurses registered in New Zealand are automatically eligible to nurse in Australia. This makes New Zealand particularly vulnerable to the up and downturns of international nurse migration. Recent statistics show internationally qualified nurses (IQNs), who used to come predominantly from anglophone countries, are now more likely to come from Asia. The younger age profile of Asian IQNs may improve New Zealand’s ageing nurse profile (Nursing Council of New Zealand, 2015a). However, research into this Asian cohort shows many consider New Zealand a stepping stone to careers in countries such as Australia and the United States (Walker & Clendon, 2015; 2016). Additionally, many others may leave nursing altogether due to family responsibilities (Walker, Clendon & Cheung, 2016). Population growth, growing demand for health services, and an ageing international nursing workforce will all increase the demand for nursing services throughout the world. Retaining nurses in New Zealand will be essential to meet this growing demand, yet little work has been done to explore why nurses who carry through their intent to leave the profession have done so.

Nurses who leave the profession are difficult to contact for research purposes: they are no longer members of professional organisations, and frequently no longer hold practising certificates. Internationally, there is research examining the phenomena of nurses’ intent to leave nursing for reasons other than retirement. Reasons for this intent can be categorised into groups: workplace concerns; personal challenges; career factors; and family reasons (Ryan, Bergin & Wells, 2017). Workplace concerns include high workload, inadequate staffing, shift work, bullying and violence, inconvenient scheduling of shifts, and a lack of support (Black, Spetz & Harrington, 2008; Bogossian, Winters-Chang & Tuckett, 2014; MacKusick & Minick, 2010; Sjögren, Fochsen, Josephson & Lagerström, 2005; Tuckett, Winters-Chang, Bogossian & Wood, 2015). Personal challenges include burnout, stress, the physical demands of the job, fatigue, exhaustion, health reasons and emotional distress related to patient care ( Black et al, 2008; MacKusick & Minick, 2010; Sjögren et al, 2005). Career factors include remuneration seen as low for the difficulty of the work and when compared to other professions, dissatisfaction with nursing as a career, and lack of professional development (Bogossian et al, 2014; Drennan, Halter, Gale & Harris, 2016; Sjögren et al, 2005). Family reasons include child-care demands and family obligations such as caring for older relatives (Walker & Clendon, 2013; 2015).

New Zealand research into the topic is limited, though Bogossian et al (2014) reported on a large cohort of New Zealand and Australian nurses recruited to the E-Cohort study. This qualitative work exploring currently practising nurses’ perceptions of intention to leave the profession found workload, shift work, violence, remuneration, lack of support and undervaluing of the nurse’s role were all contributing factors to nurse attrition (Bogossian et al, 2014). A recent New Zealand cohort study followed 2596 registered nurses for the first eight years after registration and found 42 percent were no longer practising (Nursing Council of New Zealand, 2015b). There are no details on why these nurses are no longer working as nurses. Other research has identified that the career requirements of younger nurses may differ from those of previous generations (Clendon & Walker, 2012) and that there can be conflict between these generations in the workplace, in part based on those different requirements (Burke, Walker & Clendon, 2015).

As reported by O’Connor (2015) in the NZNO membership magazine, New Zealand nurse leaders report family considerations, overseas travel, further study, and a change in career may contribute to nurses leaving nursing. However, to date there has been no study of nurses from New Zealand who actually left nursing and their reasons for doing so.

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METHOD

Design

An exploratory descriptive study, using an online survey, was conducted to examine the views of New Zealand nurses across all scopes of practice who had chosen to exit the nursing workforce. Review of the literature suggested that the most common factors contributing to leaving the profession were workplace concerns, personal challenges, career factors, family reasons and retirement. Accordingly, these factors formed the initial basis for investigation in the cohort.

Ethics

Ethics approval was obtained from the Victoria University of Wellington’s human ethics committee (#23547). No conflict of interest is noted for any of the authors.

Sample and setting

The New Zealand Nurses Organisation (NZNO) is a professional and industrial organisation with a total membership of more than 49,000 nurses, midwives, health-care workers and students (NZNO, 2017). Reasons for resignation are invited and recorded, and data held for 10 years post-resignation. Many resigning members select “left nursing” as a reason, suggesting the opportunity existed to ascertain why they left the profession and what, if anything, could have been done to support them to stay. Sampling was performed by sequential examination of the membership database – selecting regulated nurses who self-identified as having resigned from NZNO between July 31, 2013, and July 31, 2016 – a period of three years. An online survey, hosted on the Survey Monkey (Pro) platform, was sent by email to the last recorded address of these 4170 registered and enrolled nurses and nurse practitioners. This paper reports the findings from the older nurse cohort aged 55 to 65.

Survey instrument

The short survey (previewed by four senior nurse advisors) introduced the purpose of the survey, and explained how recipients had been selected to take part. Initial screening questions checked that the recipient was no longer nursing. The characteristics of the last nursing role they had held (sector, shift type, full-time/part-time and the field of nursing practice), were followed by standard demographic questions including gender, age, qualifications and ethnicity. Questions then asked why they had decided to leave nursing (comprising items from the literature and a free-text option), whether they planned to return, and a free-text question asking what, if anything, would enable them to return. Questions then explored the process, time and consultation underpinning the decision to leave, and sought more detail on the factors leading to the decision. Participants were asked what factors would enable them to remain in nursing (with options based on items from the literature, plus a free-text option). Final free-text questions invited comments on their experience of working as a nurse, or on their nursing career.

Data collection

Data were collected between September 9 and October 25, 2016. One reminder was sent, three weeks after opening the survey. A total of 1260 responses were received, representing a 30.3 percent response rate, once email “bounce backs” were discounted.

Data analysis

Responses were sorted to remove those who were still nursing but had not rejoined NZNO (n=382), and 220 incomplete responses were excluded. Nurses who exited nursing before age 55 were analysed separately as part of an “early attrition” cohort (n=204). This left 459 valid responses from nurses who had “left nursing” aged ≥ 55 years, including those who had retired before the nominal retirement age of 65, and it is these results that are presented here. The quantitative responses were analysed descriptively using Microsoft Excel. Free-text data were explored thematically using Nvivo, guided by the literature.

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FINDINGS

Demographics

Table 1 outlines demographic information about survey respondents. Note, not all figures total 459, as some question sets allowed multiple answers (specifically: ethnicity, qualifications and employment), and some questions were not answered by all respondents. Government-funded superannuation is available in New Zealand from 65 years of age, meaning 65 years is the nominal retirement age. In our survey, 47 respondents under the age of 65 at the time of answering (14.6 percent) had retired, though it is not possible to calculate how many of those over the age of 65 at the time of the survey had also retired prematurely within the five-year span of the sample selection.

Table 1: Demographics

		%	n
Gender	Female Male	98.0 2.0	444 9
Age	55-59 60-64 65-69 >70	11.6 21.4 47.5 19.6	53 98 218 90
Ethnicity	NZ Māori NZ European Other European Pacific Asian Other	5.5 87.7 8.4 4.8 6.4 5.1	25 398 38 22 29 23
Initial nursing qualification	Enrolled nurse qualification Registered nurse — hospital trained Bachelor of nursing Nurse practitioner	17.1 66.5 21.71 –	74 288 94 0
Employment prior to leaving	Full time Part time Scheduled and rotating shifts ‘Office hours’ Permanent night shift	21.9 73.01 28.8 25.4 7.3	99 330 130 115 33
Work sector prior to leaving	District health board (DHB) Primary health care Aged care Private hospital and hospice Nursing education	40.5 23.9 19.9 11.3 5.3	183 108 90 51 24
Number of years nursing prior to leaving	0-10 11-20 21-30 31-40 >40	3.1 6.3 16.3 16.7 57.6	14 28 73 75 258

Characteristics of those who had left nursing

Some 66 percent (n=297) of the cohort of nurses in this study leaving the profession were hospital-trained and 22 percent (n=99) held a nursing degree. More than half of those leaving the profession (57.6 percent, n=259) had worked in nursing for more than 40 years, and an additional 16.7 percent (n= 75) had completed 30 years in the role. Almost three quarters (73 percent, n=328) of nurses over 55 who left the profession had been working part-time, with around a quarter of respondents working office hours only. The most common fields of practice for the oldest cohort were primary health care and aged care. When examined by reasons for leaving, older nurses were more likely to cite retirement, family reasons, seeking better work-life balance, or a loss of confidence. Frustrations with paperwork, loss of job satisfaction related to workload and less time for patient care figured prominently in free-text comments.

Respondents were asked if they intended to return to nursing at a later date. Of 454 who replied, 2.2 percent (n=10) indicated they intended to return. Of note, four of these had left nursing to travel, and a further four had left to care for family members. Eighty-five percent (n=386) had no intention of returning and 12.8 percent (n=58) were unsure. Despite their intention not to return to nursing, more than a quarter (28.4 percent) of respondents still held a nursing registration.

Post-nursing activities

Since resigning from their last nursing position, 342 (82.2 percent) had retired. Of these, 308 were at or over the nominal retirement age at the point of returning the survey (though some may have been under 65 at resignation). Of the 87 (21 percent) individuals who were employed, only 13 individuals had accepted another nursing role. Around 20 percent of participants answering this question were involved in unpaid activity such as studying, or care of family. Respondents were allowed to choose more than one option.

Reasons for leaving nursing

Respondents were asked to identify their reasons for having left nursing. Of the 303 who answered the question, 14.4 percent (n=44) left due to illness or injury, and 26.3 percent (n=79) simply no longer wanted to nurse. A follow-up question explored these reasons in more detail. This was a free-text question that was then coded into themes based on the categories developed from the literature: workplace concerns; personal challenges; career factors; family reasons; and retirement. This approach enabled calculation of thematic coding frequency.

Many respondents identified multiple contributing factors. Reasons given that did not fit within the categories developed from the literature were also identified and recorded as “other” categories. Descriptions, coding frequencies and exemplar quotes for all the categories identified are shown in Table 2.

Table 2: Categories promoting attrition

Major categories	Exemplar quotes	n
Workplace concerns: High workload, inadequate staffing, shift work, bullying and violence, inconvenient scheduling of shifts, lack of flexibility, fundamental system issues eg poor management, too much paperwork, change in nursing approach, unsafe working environment, lack of time to care for patients, lack of support.	‘My workplace was toxic and I was beginning to have anxiety whenever I thought about work.’   ‘It became an unsafe environment to work in. No managerial support. The culture was not one of working as a team. Finger-pointing culture.’ ‘No support from management. Huge amounts of paper work. Work chaotic and complicated. Bullying from another staff member. Frustration, frustration!!!’ ‘In the latter years of my employment, I noted the increasing pressures faced by nurses with the diminishing numbers of staff rostered on due to less nurses being employed. I believe this compromised optimum patient care. Also increasing amounts of documentation.’	97
Personal challenges: Burnout, stress, the physical demands of the job, fatigue, exhaustion, emotional distress related to patient care, health reasons such as injury or illness.	‘I found it hard to work with the callers to the mental health line where I worked. It became overwhelming for me.’   ‘Expected to do a lot of night shifts, which I really struggled with.’   ‘Following shoulder surgery I wasn’t sure whether this would be fully functional and I felt it unfair on my colleagues to ‘carry’ me in tasks I couldn’t manage.’	75
Career factors: Lack of professional recognition, intergenerational differences, low remuneration, dissatisfaction with nursing as a career, lack of professional development, lack of career progression, lack of job satisfaction.	‘No progression of career. No acknowledgment for upskilling and working in a highly stressful job.’   ‘I felt undervalued, isolated and unchallenged.’   ‘No scope for advancement in aged care. Poor wages. Very minimal clinical support after hours. Too much responsibility for whole retirement village after hours.’	38
Family reasons: Child-care demands, family obligations such as caring for older relatives or spouse.	‘My husband required care.’   ‘I left because: a) family bereavement, b) returned to home town with family.’	28
Retirement:	‘Time to retire and enjoy freedom.’   ‘My husband has been retired for eight years already and though I am younger, it was time for us to do other things together.’	125
Other categories	Exemplar quotes	n
Lack of confidence (in self and in practice)	‘I was not performing to my own expected level of ability, nor did I feel capable of working in the areas I was interested in.’   ‘I had reached the end of the road, and felt it was better to go before I started making mistakes.’   ‘I was finding it harder to keep up with the knowledge required to nurse safely in that area.’	9
Leaving for overseas (for travel or work)	‘I wanted to have more time with my husband, who is European, and have the freedom of travelling for two or three months at a time.’   ‘To pursue another opportunity overseas.’	5
Unwillingness or inability to complete education requirements	‘I came to the conclusion that I no longer wanted to submit to the constant need to prove oneself capable of doing the job that I had done for so long, and so well.’   ‘I wasn’t able to maintain the hours and professional development required to keep my practising certificate within the three-year period. So left and let my certificate lapse.’	5
Change in career	‘Career change, opened a restaurant.’   ‘Having gone through yet another restructure process, I decided I was undervalued and had the means to take a different direction in life – so I did.’	56
Work/life balance	‘I just want to have some normality in my life. To be stress-free and wanted more time to pursue activities.’   ‘I had the choice to stop paid employment and switch to a variety of voluntary jobs requiring much reduced hours and enjoying other aspects of my life.’	2
Unable to find nursing work (unemployment or redundancy)	‘I am still a registered nurse, but for the moment I have stopped nursing because I was unable to get a job.’   ‘I have had many interviews over the last two years and all of them have said the same: Good interview, great CV. We will get back to you. I never once have heard back from any application interview I have had. They see me and my age and that is as far as they will take it.’	15

The greatest concerns were expressed about issues in the workplace, with inadequate nurse staffing, a lack of time to deliver appropriate patient care (especially due to increased “paperwork”), and a culture of bullying all contributing to poor work experience and the desire to leave.

In the final comment section, 52 percent (n=162) of this cohort, while also expressing the concerns above, were very positive overall about nursing when looking back on their career. Of 81 nurses who had retired before the age of 65, 15 percent (n=12) also expressed very positive sentiments about nursing as a career.

Decision-making process

Nurses reported seriously contemplating leaving for some time before making the decision, with nearly half taking more than six months to decide. Free-text comments showed that planned age-related retirement sometimes changed at short notice due to financial constraints (need to remain) or health issues (need to leave) intervening. While partners were most commonly involved in the decision process, around 30 percent discussed their plans with colleagues, and 20 percent with their managers some time before resigning.

Participants were asked to identify which of the factors identified in the literature might have helped them remain in nursing. This relative importance is illustrated in Table 3. They have been grouped together post-survey for analytical purposes.

Table 3: Factors aiding retention

Factors	%	Mean for group
Patient-related
More time for patient care Less paper work More staff	52.6 52 44.9	49.8%
Support-related
More support from an immediate manager More support from employing organisation Better support from colleagues	41.1 35.6 19.5	32%
Career-related
Greater recognition of my skills Less demand for professional development Better pay Better career prospects Being given more responsibility Greater professional challenges	47.4 44.9 27.9 8 7.1 4.0	23.2%
Work/life integration
More flexible working hours More leave Better access to elder care	23.8 9.3 2.8	9.3%

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DISCUSSION

The findings from this study confirm that older nurses do leave the nursing profession for many of the same reasons identified in the “intention to leave” literature. These included the previously known factors of workplace concerns, personal challenges, career factors, family reasons and retirement. However, for a minority of respondents, lack of confidence, seeking greater work/life balance, changes to professional development demands perceived as onerous and bureaucratic (rather than being relevant to improving patient care) and simply wanting a change in career were also offered as reasons for leaving nursing.

Workplace concerns, including workplace culture, workload and staffing numbers, were the most common reason given for leaving nursing in this study, which also reflects existing literature (Ryan, Bergin & Wells, 2017). Dissatisfaction with the nursing workplace was also the most common reason given for nurses working outside of nursing in studies by Black et al (2008) and Sjögren et al (2005).Findings from qualitative studies also indicate workplace concerns are one of the biggest reasons for nurses leaving nursing (Bogossian et al, 2014; MacKusick & Minick, 2010; Tuckett et al, 2015). The high importance placed by these respondents on workplace culture echoes the findings of others (Moseley, Jeffers & Paterson, 2008; Tourangeau & Cranley, 2006). The requirement for greater support and recognition from managers and colleagues alike was identified by participants in this study as particularly important. This is a specific characteristic of the generation known as baby boomers (those born between 1945 and 1964) for whom the possibility of retirement is rapidly approaching. Many of those who are now coming through as managers may come from different age cohorts, who have other characteristics and priorities. Specialist human resources expertise and management training may be needed to help bridge such intergenerational differences (Burke, Walker & Clendon, 2015).

Older participants particularly noted many health-related challenges to continuing their nursing career. This confirms other reports of difficulties due to the physical, cognitive and emotional demands of nursing in older age (Clendon & Walker, 2015). Shift work in particular is reported to be very challenging for many aged over 50 (Clendon & Walker, 2013; Winwood, Winefield & Lushington, 2006). Loss of confidence, as a prompter for leaving nursing, may have roots in reality: for example, inability to respond to changes in technology or nursing practice. However, confidence may also be damaged by loss of seniority, as older nurses cut their hours or move to new areas of practice to improve their work/life balance or attend to family support needs. This, combined with non-supportive work cultures, may also undermine confidence.

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IMPLICATIONS FOR NURSING MANAGEMENT

Systemic issues (staffing levels, professional development mechanisms and relationship management, especially of tensions and bullying at all levels) lie at the heart of much dissatisfaction in the workplace. While some of these issues depend on funding and other factors outside immediate management control, many others do not.

Evidence from this study shows many older nurses go through a long “contemplation of leaving” stage, with little involvement of managers in this planning and decision-making process. This would imply that if managers were more proactive in exploring workplace issues important to older nurses, this could provide opportunities to delay or prevent their retirement – particularly early retirement. Using flexibly deployed, experienced older nurses to mentor less experienced nurses could help address skill shortages while providing a more satisfying end of career.

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LIMITATIONS

As with all surveys, sampling bias and response bias may have influenced the findings. Recall bias too, over a five-year time span, may have meant that painful details had become magnified or reduced with time. While the degree of concordance with previous literature indicated the results may have general applicability, the use of such literature to guide the closed question options may have contributed to a circular argument.

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CONCLUSION

More than two decades of research across the world has consistently identified common issues and suggested remedies for the problem of older nurses retiring early from the profession. The picture in New Zealand appears similar. The need to support and retain older nurses to remain in the workforce may emerge as one of the most important and complex challenges for nursing management. Further research is needed to explore the introduction and outcome of initiatives to improve workplace culture.

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ACKNOWLEDGEMENTS

The authors would like to thank the participants who gave their time to provide the data for this study, and Di Cookson for her work on the literature.

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