ORIGINAL ARTICLEA qualitative study of experienced nurses’ voluntary turnover:learning from their perspectivesDana Hayward, Vicky Bungay, Angela C Wolff and Valerie MacDonaldAims and objectives. The purpose of this research was to critically examine thefactors that contribute to turnover of experienced nurses’ including their decisionto leave practice settings and seek alternate nursing employment. In this study,we explore experienced nurses’ decision-making processes and examine the personal and environmental factors that influenced their decision to leave.Background. Nursing turnover remains a pressing problem for healthcare delivery. Turnover contributes to increased recruitment and orientation cost, reducedquality patient care and the loss of mentorship for new nurses.Design. A qualitative, interpretive descriptive approach was used to guide the study.Methods. Interviews were conducted with 12 registered nurses, averaging 16 yearsin practice. Participants were equally represented from an array of acute care inpatient settings. The sample drew on perspectives from point-of-care nurses andnurses in leadership roles, primarily charge nurses and clinical nurse educators.Results. Nurses’ decisions to leave practice were influenced by several interrelatedwork environment and personal factors: higher patient acuity, increased workloaddemands, ineffective working relationships among nurses and with physicians,gaps in leadership support and negative impacts on nurses’ health and well-being.Ineffective working relationships with other nurses and lack of leadership supportled nurses to feel dissatisfied and ill equipped to perform their job. The impact ofhigh stress was evident on the health and emotional well-being of nurses.Conclusions. It is vital that healthcare organisations learn to minimise turnoverand retain the wealth of experienced nurses in acute care settings to maintainquality patient care and contain costs.Relevance to clinical practice. This study highlights the need for healthcare leaders to re-examine how they promote collaborative practice, enhance supportiveleadership behaviours, and reduce nurses’ workplace stressors to retain the skillsand knowledge of experienced nurses at the point-of-care.Key words: decision making, interviews, nursing, retention, turnover, workenvironmentWhat does this paper contributeto the wider global clinicalcommunity?• A more nuanced understandingof how nurses experience determinants of turnover and howthese experiences ultimatelyaffect their decision to leave theirjob.• A nurse’s decision to leave isincredibly complex and can takeup to two years thereby highlighting key points of intervention for retention.• Limited leadership support andinterprofessional working relationships remain substantial challenges for nurses that maynegatively affect nurses’ mentaland physical health – highlighting the need for more interventions in acute care to redressthese workplace issues.Accepted for publication: 5 January 2016Authors: Dana Hayward, MSN, RN, Clinical Nurse Educator-SurgicalIn-patients, SDC, SOP and PAC, Peace Arch Hospital, White Rock,BC; Vicky Bungay, PhD, RN, Associate Professor, Michael SmithFoundation for Health Research Scholar, School of Nursing, Universityof British Columbia, Vancouver, BC; Angela C Wolff, PhD, RN, Director, Clinical Professional Development, Professional Practice, Vancouver, BC; Valerie MacDonald, MSN, RN, Clinical Nurse SpecialistOrthopaedics/Surgery, Fraser Health Authority, Burnaby HospitalAdministration, Burnaby, BC, CanadaCorrespondence: Vicky Bungay, Associate Professor, Michael SmithFoundation for Health Research Scholar, School of Nursing,University of British Columbia, 121-2176 Health Sciences Mall,Vancouver, BC V6T1Z3, Canada. Telephone: +1 604 833 7933.E-mail: [email protected]© 2016 John Wiley & Sons Ltd1336 Journal of Clinical Nursing, 25, 1336–1345, doi: 10.1111/jocn.13210IntroductionExperienced registered nurses (RNs) (herein referred to asnurses) are an essential part of the global healthcare workforce. They enhance quality patient care, provide mentorship for new graduates, and assume critical leadershiproles in health service delivery (Duffield et al. 2011). Thereis growing evidence that turnover among experiencednurses is a pressing concern. Experienced nurses are leaving their employing agencies and are also frequentlychanging their practice settings (Leurer et al. 2007). Moreover, alarming numbers of nurses are leaving the profession altogether (Duffield et al. 2011). The impact ofexperienced nurse turnover has been well documented,contributing to rising costs associated with orientation ofnew staff, the loss of mentorship for new graduates, andreduced quality of patient care (Roberge 2009, O’BrienPallas et al. 2010).Scholars have documented that elements of nurses’ workenvironments are key determinants of turnover, includingincreased workloads, higher patient acuity, moral distress,burnout, lack of leadership support and poor interprofessional working relationships (Erenstein & McCaffrey2007, Roberge 2009, MacKusick & Minick 2010, Duffieldet al. 2011, Lu et al. 2012, Collini et al. 2015). Age, education and health status have also been associated withturnover but the findings across studies have been inconsistent (Hayes et al. 2012). External factors such asemployment opportunities and migration have morerecently been identified as relevant (Hayes et al. 2012). Todate, research has focused almost singularly on nurses’intent to leave their positions and the related determinants. There is a relative dearth of information identifyingthe subjective factors that influence nurses who decide toleave their practice settings. Understanding the perspectivesof experienced nurses who have chosen to leave is ofutmost concern given the increasing nursing shortagesworldwide and the identified priority of addressing thisworkforce issue (Zeytinoglu et al. 2007, El-Jardali et al.2009, Roberge 2009, Duffield et al. 2011). Effectivestrategies to address retention, reduce escalating workforcecosts associated with turnover, and retain the clinical support necessary for quality patient care may be seriouslycompromised if the everyday experiences of nurses are notfully understood. In this article, we contribute to understandings of nursing turnover by sharing the results fromour qualitative investigation into the factors thatinfluenced experienced acute care nurses to leave their previous employment positions and seek alternate nursingwork.BackgroundVoluntary turnover has been a focus of concern for decadesas evidenced by the growing body of international researchseeking to understand turnover determinants and its consequences for nurses health care organisations, and patientcare (Price & Mueller 1981, Heinen et al. 2013). Voluntaryturnover refers to nurses electing to leave their current position to transfer to another job within their employingorganisation, leave their organisation completely, or quitthe nursing profession (Hayes et al. 2012, Tummers et al.2013). Theoretically turnover has been discussed as a multi-stage process consisting of psychological, cognitive andbehavioural components (Takase 2010) or as a throughputfactor that provides mediating effects between systeminputs (e.g. patient and nurse characteristics) and outputs(e.g. patient outcomes) (O’Brien-Pallas et al. 2010).To date, most researchers have studied turnover and itsrelated determinants by assessing nurses’ intent to leave theirwork setting, agency or the profession – a concept known asturnover intention (Hayes et al. 2012, Tummers et al.2013). International comparisons of turnover intention rateshave demonstrated significant consistency, particularlyamong industrialised nations. Research examining turnoverintention in Canadian and Australian hospital settings, forinstance, illustrated that one-fifth of experienced nurses (i.e.those with more than five years clinical experience), reportedintention to leave their current work place (Roche et al.2015). Heinen et al. (2013) illustrated that 9–11% of nursesacross 10 European countries reported intention to leave theprofession. In the USA, up to 50% of newly graduatednurses are reported to leave their current workplace withinthree years of entering practice (MacKusick & Minick2010). There is also growing evidence that these types ofturnover precede leaving the profession altogether (Krauszet al. 2006, Shacklock & Brunetto 2012).Scholars have invested considerable effort into identifyingturnover intention determinants. This research has emphasised organisational and work environment elements, personal factors and more recently external factors related tomigration, pay equity and job opportunity (Hayes et al.2012). Leadership support, professional developmentopportunities, interprofessional working relationships andautonomous practice have been demonstrated to be organisational and workplace factors of utmost concern.Researchers internationally (e.g. van der Heijden et al.2010, Gormley 2010, Tummers et al. 2013) have demonstrated that poor leadership support has a direct negativeeffect on turnover intention. Furthermore, several studiesillustrated that low levels of leadership support function as© 2016 John Wiley & Sons LtdJournal of Clinical Nursing, 25, 1336–1345 1337Original article Experienced nurses and turnovera mediator to negatively affect job satisfaction, organisational commitment, level of professional engagement andprofessional development opportunities which furtherincrease the likelihood of turnover intention among nursingstaff (Roche et al. 2015, Takase et al. 2015). By contrast,high levels of leadership support were reported to contribute to improved organisational commitment and jobsatisfaction, even in the presence of inadequate staffing andhigh patient acuity (Heinen et al. 2013). Other researchers,however, have indicated increased workloads and highpatient acuity decrease nurses’ job satisfaction and contribute to turnover intention (Zeytinoglu et al. 2006, 2007,Erenstein & McCaffrey 2007, Lu et al. 2012).Negative and disrespectful professional working relationships among nurses and physicians and nurses can directlyaffect turnover intention. In their study with 832 hospitalnurses in Italy, for example, Galletta et al. (2013) illustrated that negative nurse-physician working relationshipsundermined the quality of the working environment andwere associated with higher turnover intention than foundon units where nurse–physician relationships were morepositive. Moreover, Laschinger et al. (2009a,b) illustratedthat coworker incivility (e.g. disrespectful and discourteousbehaviour) was positively correlated with low levels of jobsatisfaction and organisational commitment, and increasedlikelihood of turnover intention. Poor working relationshipshave also been linked to reduced job satisfaction, stress andburnout with consequences for elevated turnover intention(Roberge 2009, MacKusick & Minick 2010, Duffield et al.2011, Lu et al. 2012).Studies on the interrelationships between individual factors such as age, education, marital status, hours of workand turnover intention have produced inconsistent findings.Heinen et al. (2013), for instance, illustrated that older ageand working full time were associated with higher rates ofturnover intention. In their study of generational comparisons and turnover intention Shacklock and Brunetto (2012)showed that age was insufficient to predict turnover intention. Among younger nurses attachment to work was thestrongest factor influencing turnover intention, whereas lowlevels of nursing leadership support influenced older nurses.Recently, there is a growing body of research concernedwith the consequences of nurse turnover. The estimatedcost of managing increased turnover rates has been reportedto be as high as 5% of hospitals’ annual operating budgets(El-Jardali et al. 2009). In Canada, it was estimated to cost$42,000 CAD to replace a nurse (O’Brien-Pallas et al.2010); in New Zealand, the cost of nurse turnover was estimated at $29,000 NZD per nurse, the major costs associatedwith temporary staff replacement (North and Hughes 2006).Furthermore, during periods of high turnover and nursingshortages, a higher incidence of nurse-sensitive outcomes,such as pneumonia, urinary tract infections, medicationerrors and falls have been reported (Griffiths 2009, O’BrienPallas et al. 2010). Deleterious consequences for nurses’health have also been noted in conjunction with turnover.O’Brien-Pallas et al. (2010) demonstrated that nurses working on units with high rates of turnover experienced deterioration in mental health status and lower job satisfaction.Despite the current knowledge about turnover, minimalresearch has explored these factors from the perspective ofexperienced nurses who did in fact leave their position.Among those limited studies that empirically measured thereasons nurses had left their positions, poor working relationships, lack of autonomy over practice (O’Brien-Pallaset al. 2010) and limited opportunities for career advancement (Duffield & Franks 2002) were identified as maindeterminants. A better understanding of how nurses perceive the factors that influenced and shaped their decisionto leave a position is essential to develop specific retentionstrategies, reduce escalating workforce costs associated withturnover and retain the clinical support necessary for quality patient care.Study aimThe primary aim of our study was to explore the personaland environmental factors that influenced experiencednurses’ decisions to leave a practice setting and seek analternate position in nursing.MethodsDesignThis study employed a qualitative approach grounded inThorne’s (2008) interpretative description design. Thisapproach provided the groundwork for data collection andanalysis, exploring everyday nursing practice within thecontext of social, personal and organisational constructs.Ethical approval was obtained from the relevant universityand health authority research ethics review boards. Participants provided informed consent and received a $20 (CAD)coffee card in appreciation for their contributions.The sampleWe employed purposeful sampling, defined as the strategicselection of information rich cases that can speak to thetopic under investigation (Thorne 2008). Drawing from the© 2016 John Wiley & Sons Ltd1338 Journal of Clinical Nursing, 25, 1336–1345D Hayward et al.literature about experienced nurses and turnover (e.g.Shacklock & Brunetto 2012) and our combined clinicaland research experiences in nursing, we determined thatnurses who met the following inclusion criteria could beable to provide rich information about their decision toleave: minimum five years experience in an acute care setting; had worked in a previous setting for a minimum oftwo years, and had left that workplace for another nursingposition within the last two years. The two year requirements were based on assumptions that this was sufficienttime to allow nurses to develop knowledge of their workplace environment and culture. As English fluency is arequirement for registration with the College of Nurses inour province, we also identified fluency in English as inclusion criteria. As key informants, participants were selectedwho also exhibited a willingness to engage and shareinsights about their experiences related to the topic ofinvestigation (Thorne 2008). The sample was obtainedfrom one urban and one rural acute care facility in BritishColumbia, Canada; nurse managers approved the onsiteresearch. The first author (DH) recruited participants byattending staff meetings to describe the study and throughposters distributed in the work settings.The 12 participants were female and their mean agewas 44 years (range 35–55). Their years in nursingranged between 5–26 years, on average 16 years. Six participants practiced at the point-of-care; two held pointof-care leadership positions and four were clinical nurseeducators. Eight participants worked full time and fourworked part time. The participants were employed in critical care or medical-surgical units. Four held a master’sdegree and the others were prepared at baccalaureate ordiploma levels.Data collectionConversational-style individual interviews were conductedby the first author at a place of the participant’s choice andconvenience. The participants were asked to describe theirprevious work setting and perspectives about the decisionto leave the position. Sessions ranged from 30–60 minuteswith ample opportunity for the interviewer to probe intonurses’ experiences and insights during the dialogue. Allinterviews were digitally recorded and transcribed verbatimby an independent transcriptionist. After each interview,the first author recorded observations as well as the participant’s expressions and inflections during the session. Reflexive, ongoing journaling was used to permit her to reflect onher experiences and learning in the interview and thoughtsduring coding and analysis.Data analysisThis study adhered to an inductive analytic approach, basedon Thorne’s approach (2008), by which we sought to findpatterns in the participants’ experiences and better understand the phenomenon unique to their social and personalcontext within the clinical practice setting (Thorne 2008).Data analysis was employed throughout the data collectionprocess to watch for emerging themes, patterns, dependenton the participant’s responses that spoke to their experiences and reflections on leaving their previous job (Thorneet al. 2004). Participant stories were compared and contrasted within and between transcripts to verify if emergentpatterns or associations matched the data collected fromprior interviews and transcripts. Patterns in the data werecompared and contrasted to test whether they reflected ourunderstanding of the nurses’ experiences, or discredited ourinterpretation of that occurring (Thorne et al. 2004). Toestablish rigour, the findings were compared with audiotaped interviews, journal notes and transcriptions to verifyauthenticity of the data by the primary investigator.ResultsThe decision to leave their previous practice settings wasnot easy for these resilient and determined experiencednurse-participants. All participants expressed some degreeof guilt and sadness as a result of their decision, despiteexperiencing considerable stress in their previous role. Theirdecisions to leave were not spontaneous; rather, all participants required an extended time frame to make the finaldecision, spanning six months to two years. Although somevariations existed within their stories, we identified threeinter-related factors that influenced participants’ decision toleave practice settings: challenging workplace environments;limited leadership support; and personal health issues.Challenging workplace environmentsWorkplace environments (e.g. the tone of the setting and/ororganisation, Duffield et al. 2011) were a substantial factorin the participants’ decisions to leave their previous workplace. High patient acuity, increased workloads and ineffective professional relationships were the subthemes of theircommentary on workplace environments.Patient acuityParticipants unanimously stated that patient demographicshad changed over their years of practice and they nowcared for sicker patients. The substantial increase in patient© 2016 John Wiley & Sons LtdJournal of Clinical Nursing, 25, 1336–1345 1339Original article Experienced nurses and turnoveracuity had resulted in more complex patient health challenges and medical needs. In providing care to thesepatients, many participants described the pressures to workfaster, more efficiently, acquire more knowledge andexpand their assessment skills for earlier recognition ofpatient deterioration. All participants reported feeling overwhelmed by higher patient acuity levels and this stress wasa key aspect influencing their decision to leave. A nursewith 11 years of experience on a surgical unit stated:I look back on it, I was burnt out, because you know your patientassignment stays the same, but patients are sicker, they requiremore interventions, more tests, not doing so well, but you still. . .have to provide safe care.Many participants reported that as experienced nursesthey were assigned more acute patients than their less experienced counterparts, and their workload increased in conjunction with the number of acutely ill patients. They werealso called upon to problem-solving complex patient situations or assist during critical events such as deterioratingpatient status. Participants admitted to ‘burnout,’ identifying how the growing complexity in their patients’ needs ledto increased workload demands, which they believed theycould no longer manage, despite the resourcefulness developed through years of nursing experience.Workload demandsThe substantial increase in patient acuity combined withmore complex patient needs contributed to increased workload demands on their nursing care associated with agreater number of significantly ill patients requiring simultaneous care, and conflicting patient and administrative(e.g. charting) demands on their time. Increased workloaddemands were also associated with operational features ofthe participants’ work setting, including chronic understaffing, perceived high patient-to-nurse ratios, overpopulated units that required caring for patients in hallways andother nonprivate spaces, and conflicting and competingdemands on their time and role. A few participantsexpressed deep regret when they believed patients did notreceive the care they deserved and when the nursing carethey could provide was incongruent with personal and professional standards. For example, some expressed remorsefor being unable to provide privacy when caring for dyingpatients who were located in hallway beds; participantswere frustrated by circumstances that lacked the provisionof dignity for life altering events.Many participants expressed what they described as ‘aninability to keep up’ over time, which resulted in feeling‘exhausted’ and ‘burnt out.’ The inability to manageincreased workloads was not isolated to participants whoworked at point-of-care. Those in point-of-care leadershiproles also expressed dissatisfaction with juggling multipledemands and conflicting priorities over patient clinicalissues, staff issues and responsibilities to attend meetings onand off site. A nurse in her mid-40s described how competing workplace demands led her to leave a position:I felt pulled between time spent on the floor and time spent doingother duties. I found it difficult . . . there was not the time to doboth. . . .Unless I could clone myself I couldn’t do both, . . . I foundit difficult when I was asked to attend so many meetings, and Icouldn’t be attending to things I felt I should be doing on the unit.The stressful demands of the nurses’ workloads wereeither ameliorated or increased by the nature and quality ofprofessional relationships in the work place.Professional relationshipsProfessional relationships were an integral aspect of theenvironmental factors influencing participants’ decisions toleave. Participants defined their working relationships bythe manner in which nurses helped one another providepatient care and address practice issues in a timely manner.The degree of collaboration and cohesiveness among teammembers was identified as contributing to positive workplace environments and job satisfaction.The nature of working relationships was influenced byattitudes and behaviours among team members, a staffingmodel that mixed RNs and licensed practical nurses(LPNs), and the support provided by team members in thementoring and integration of new graduates and nurses.Some participants described working with supportive andcollegial peers, attributing healthy morale on the unit tothe strong sense of teamwork and a supportive environment. Collegiality in teamwork had kept participants intheir previous positions for long periods of time, despiteincreased workloads and high patient acuity. Participantswho experienced less cohesive working relationships orexclusionary work environments reported these experiencesas contributing to their initial consideration to leave theirwork place.The lack of supportive working relationships played outin diverse ways for practice and patient care. For instance,some participants reported their peers refused or madeexcuses when requested to help transfer heavy patients orassist with heavy workloads. Other participants reportedpatients’ call lights going unanswered by nurses if thesepatients were not assigned to them; although later, it wasdiscovered those same peers engaged in nonwork-relatedactivities at a nursing station. A nurse of nine years© 2016 John Wiley & Sons Ltd1340 Journal of Clinical Nursing, 25, 1336–1345D Hayward et al.described her frustration with this lack of teamwork andexplained how it ultimately affected her decision to leave:And then the staff morale over the years was so poor, everyonewas unhappy. No one seem[ed] to really want to help anyone else.. . . like when someone rings a call bell, ‘Oh, sorry, I’m not yournurse . . . you have to wait,’ and then that person needs to get overthe bathroom. You had to search for people, and then people weren’t overly willing to help, so you’re doing unsafe maneuvers.Some participants noted that role and scope of practiceconfusion between the team of RNs and LPNs led to ineffective collaboration among staff, especially in the care ofvery complex patients. Uncertainty in roles and responsibilities led to inflexibility and lack of team work in adjustingpatient assignments as patient acuity fluctuated; forinstance, failing to rapidly reassign patients to RNs formore complex care or support LPNs as patient status deteriorated. The participants expressed fatigue and stress aboutpoor working relationships and its effects on reduced quality of patient care, a factor ultimately influencing their decision to leave.Participants in direct patient care and point-of-care leadership roles reported harassment (e.g. nurses bullying peersat work) in their previous workplaces which furtheraffected their thoughts about leaving. Whether observed orpersonally experienced, harassment distracted participants’focus and redirected their energies to diffusing or managingnegative behaviours, which impacted their ability to attendto the duties of their job. Those who witnessed or experienced harassment also reported the destructive impact ithad on them personally and noted the harmful effects thisbehaviour had on workplace environment, resulting in poorworking relationships and reduced unit morale.In addition to undefined roles and harassment, ineffectivecommunication with colleagues also influenced nurses’ decisions to leave. Poor communication contributed to job dissatisfaction, reduced quality of patient care, and negativepatient outcomes. A nurse in her mid-40s described the barriers to productive communication from managers and colleagues in her workplace:There’s intimidation; you don’t want to voice your opinion. Youdon’t want to step on anybody’s toes, and you don’t want to angeranybody, so I think that inhibits some of the communication . . .both laterally and up and down.Participants also reported poor communication and a lackof respect in their working relationships with physiciansincluding verbal abuse. Overall, participants perceived disrespectful and ineffectual working relationships promoted asense of powerlessness in the workplace environment,decreased the quality of patient care and negatively affectedunit morale. These factors were identified as unacceptableworking conditions that led nurses to leave their jobs.Limited leadership supportAll the participants spoke about leadership as a factor thatinfluenced them to ultimately leave their previous job.Leadership support was not discussed dichotomously aspresent or absent, but as a series of practices that varieddepending on the context. Participants identified leaders atthe point-of-care, primarily nurse managers, patient carecoordinators or clinical nurse leaders (e.g. charge nurses)and in some instances, leadership extended to the interprofessional team, particularly physicians. The nurses describedtheir perception of supportive leadership behaviours: providing guidance and direction for autonomous decisionmaking, acknowledging nurses’ contributions, using openand transparent communication to explain the rationale fordenied requests or changes in unit policy, being present onthe clinical unit during challenging situations, employingcollaborative problem solving through difficult clinical orpatient decisions, and encouraging professional development for expanded nursing practice. Ultimately, whataffected participants’ decisions to leave, however, was thedegree to which these behaviours contributed to challengesin communication and teamwork, and consequentlyreduced excellence in patient care.Some participants, for example, admitted feeling hesitantto voice concerns with point-of-care nurses in charge roleswho they described as ‘unapproachable,’ which impededresolving patient concerns or clinical challenges. Beingunapproachable meant that the nurse risked being penalisedin some manner (e.g. ridiculed or dismissed) for approaching the leader or the leader became unavailable when support was required. Participants provided numerousexamples of how they hesitated to voice concerns to pointof-care leaders, and observed less experienced nurses beingfrightened to approach charge nurses due to anticipatednegative responses.Participants also described gaps in leadership supportamong managers who were physically absent in the clinicalsetting, refused to listen to nurses and failed to validate oracknowledge nurses’ contributions to patient care and unitfunctioning. A mid 40-year-old nurse described the lack ofvalidation she experienced:Sometimes you just want people to say that you did the best youcould do with the circumstances and not be told, ‘You could havedone this, [and] you should have done this,’ But then you have© 2016 John Wiley & Sons LtdJournal of Clinical Nursing, 25, 1336–1345 1341Original article Experienced nurses and turnoversomeone in management tell you that you still didn’t do it goodenough. That’s a big thing, always being questioned, and knowingI give 100%. . . because that’s my work ethic. I don’t slack off. Ialways do the most I can, . . . so it was a long time coming but Ihad to leave.The participants stated that unsupportive and disrespectful leadership practices negatively affected their sense ofself-worth as nurses. In some instances, the participantsnoted that they wished they had left their positions muchsooner, because they had experienced a loss of self-confidence and self-esteem.Personal health issuesThe participants talked about how their previous positionsnegatively affected their health and well-being, ultimatelyinfluencing their decision to leave and seek alternate work.The nurses described experiencing anxiety attacks, insomnia, gastrointestinal disorders, skin inflammation and cardiovascular symptoms; these health concerns weresignificant enough to force participants to stop and considerthe impact their jobs were having on their personal healthand well-being.As the participants’ health deteriorated, psychological andphysical symptoms were significant enough for many torequire prescription medication to cope and manage workresponsibilities. In some cases, their symptoms escalated tothe extent they were incapable of performing their previousjob duties and stated that they ‘had to find a different job.’Furthermore, health issues were often discussed in relation to working conditions for nurses more generally. Forsome participants, for example, nightshifts were identifiedas a major source of health issues, causing physical fatigue,exhaustion, sleeping disorders and digestive problems.Nonetheless, participants who worked day shifts also experienced health complications that persisted over time. Someparticipants suffered catastrophic health consequences thatthey attributed to their work as noted in the followingnarrative:I eat well, I exercise, but it was a real shocker, I wasn’t expectingthat [life threatening illness]. And at that point, I decided to jettison all the stress in my [work] life and do an about-face. I decidedI needed to get off shift work. . .I think really it was the stress ofthe job and the night shifts that was the deciding factor.‘Mental fatigue’ and ‘burnout’ were the phrases nursesoften used to describe how they felt immediately prior tothe decision to leave a practice setting. Physical and mentalhealth issues were often ‘the final event’ that pushed themto leave.DiscussionThis is among the first qualitative studies to investigatenursing turnover in acute care settings from the perspectiveof experienced nurses who have left nursing positions. Thefindings contribute to our understandings of nursing turnover across three interrelated topics: healthy workplaceenvironments, the role of leadership and nurses’ health andwell-being. Moreover, this study affords empirical insightsfor understanding and creatively thinking about how tobest support and aid in the retention of experienced nursesin acute care settings. For instance, the findings that nursestook extended periods of time to leave a position speaks tothe complexity of nurses’ decision making and suggests possible points of intervention to address concerns. This periodof contemplation may be an opportune time for experienced nurses to undertake professional development activities to expand their coping strategies and to equipthemselves in challenging situations. It is also a pivotalpoint for nursing leadership to intervene by providing supportive leadership, acknowledge nurses’ value and strive toretain their expertise in practice settings.In our Canadian study, workplace environment factorssuch as negative working relationships with peers, managers and physicians aggravated the nurses’ discontent andprovoked thoughts of leaving; findings that were similarlyreported in survey research in Italy (Galletta et al. 2013)and across 10 European countries (Heinen et al. 2013). Theperceived lack of cohesive working relationships also contributed to lower unit morale with negative consequencesfor teamwork and patient care. Furthermore, the importance of leadership more generally in nurses’ decision making warrants further consideration. The current findingscorroborate previous evidence for instance, that leadershippractice that fosters collaborative practice environmentsand provided support for nurses promoted a sense of confidence in their abilities to manage the inevitable workplacestress and job demands (O’Brien-Pallas et al. 2006,Erenstein & McCaffrey 2007, Zeytinoglu et al. 2007, Sherman & Pross 2010). Positive leadership, despite other environmental factors, was noted to promote staying in a joblonger even though they had thoughts of leaving.Our study adds to the existing research by illustrating thecomplex interrelationships between leadership, turnoverand nurses’ well-being. Leadership was elucidated as a process or series of practices that varied depending on contextual features of the environment vs. as a dichotomy ofpresent or absent. In addition, the degree of influence ofleadership practices on nurses leaving a position was ultimately determined by how leadership impacted a nurse’s© 2016 John Wiley & Sons Ltd1342 Journal of Clinical Nursing, 25, 1336–1345D Hayward et al.ability to provide quality patient care, a finding noted inother research (e.g. van der Heijden et al. 2010). Leadership practices that inhibited quality care left nurses feelinga negative sense of accomplishment, a loss of self-confidence and self-esteem, powerlessness and distress over theinability to provide what constitutes ethical nursing care –all factors associated with moral distress and burnout (Leiter & Maslach 2009, Epstein & Delgado 2010). Somescholars (e.g. Epstein & Delgado 2010) have also arguedthat the more experienced the nurse, the greater the degreeof moral distress they may experience as a result of cumulative experiences in distressing situations. The relationshipbetween moral distress, burnout, leadership and turnovertherefore, raises an important issue for consideration ineffective leadership practices to retain experienced nurses inpractice settings.It is vital to acknowledge the impact ineffective workingrelationships and leadership practices have on nurses’empowerment and job satisfaction if we wish to retainthese valuable resources (Laschinger et al. 2009a,b, Gallettaet al. 2013). Addressing and improving the nature of professional relationships in practice settings may be a keyintervention by which managers can enhance nurses’empowerment and ability to manage increased workdemands (Erenstein & McCaffrey 2007, Roche et al.2015). Healthy work environments along with leaders whopromote a culture of openness in communication, groupcohesion, acknowledgement and support for nurses contribute to satisfying and fulfilling nursing practices, whichcan positively impact nurse retention (Erenstein & McCaffrey 2007, Laschinger et al. 2009a,b, Sherman & Pross2010). To alleviate nurses’ distress and to address their concerns, healthcare leaders must recognise the importance ofthe workplace environment and the impact these factorshave on declining job satisfaction and subsequent turnover.Although healthcare leaders cannot alter the growingdemands of patient populations, they can address staffingand education concerns by providing ongoing informationto promote nurses’ capacity to recognise the signs of deteriorating patient conditions, to practice evidence-based interventions that address changing needs of patients, and toeffectively work with teams composed of mixed skills.Finally, the mental health deterioration of nurses in practice is a concern gaining increased attention in the nursingliterature (Epstein & Delgado 2010). Most participants inthis study reported feeling overwhelmed and overextendedin their daily workload and expressed distress about thequality of their work with patients or in their leadershiproles, which parallels other research findings (O’Brien-Pallaset al. 2006, Sherman & Pross 2010, Duffield et al. 2011).There is evidence that nurses who report more job strainand psychological distress are more likely to report fair orpoor health (Shields &Wilkins 2006). In addition, chronicstress and related syndromes such as burnout have beenidentified as the most important factors influencing nurses’decisions to leave the profession (Zeytinoglu et al. 2006).This points to an important and understudied link betweenjob stress, psychological health and nurse turnover. Assuch, there is an urgent need for further study to limit thedevastating effects of negative or stressful workplace environments, their relationship with nurses’ health and importance in planning retention programs.ConclusionAll participants experienced stress in their previous jobs dueto factors within their workplace environment, leadershipsupport and personal health. Participants described howthese stressors affected their sense of security, ability to dotheir jobs and levels of confidence. Most participants experienced health challenges as a direct result of trying to manageworkplace stress which many identified as ultimately affecting their decision to leave. It is not a single factor that causesnurses to leave; turnover is a complex, dynamic process thatunfolds over time diminishing the capacity of the nurse tofunction effectively in the practice setting.Strengths and limitationsThis study was limited to one region and a small numberof nurses. The strength of this approach, however, was thedetailed perspectives of experienced nurses who left theirjob. Qualitative descriptive analysis facilitates a betterunderstanding of the processes and factors that may be useful to consider in planning organisational retention programs. Unlike the vast majority of turnover research thathighlights turnover intention (e.g. Roche et al. 2015), theparticipants in this study had already engaged in voluntaryturnover and left one position for another. This researchbegins to address an important gap in the methodsemployed to study nursing turnover (Hayes et al. 2012).Relevance to clinical practicePromoting strong working relationships, in which, staffmembers openly communicate and support each other is akey component to building and sustaining a healthy workenvironment (Sherman & Pross 2010). One way this can beachieved is by supporting individuals at the point-of-care toshare the responsibility and authority to address practice© 2016 John Wiley & Sons LtdJournal of Clinical Nursing, 25, 1336–1345 1343Original article Experienced nurses and turnoverissues. Point-of-care managers’ immediate attention to problems and a daily presence in the practice setting could provide opportunities to coach nurses through challengingsituations, mentor collaborative practice with frontline leadership teams and address daily issues. Daily expectations forcollaborative practice at all levels of staff could create ashared organisational style making everyone accountable andresponsible for contributing to a cohesive and collaborativeteam, thereby positively influencing organisational culture.Nurses could use existing employer reporting systems toreport harassment or lack of physician or nurse leaderresponse in critical patient situations. These processes are ameans to address potential or actual errors, learn from mistakes and prevent future mistakes. Evaluation of currentretention strategies is needed to ensure they target theunique complexity of the experienced nurse in clinicalsettings and address daily practice issues (e.g. professionalworking relationships). In the light of the research illustrating the long-term effects of work stress on nurses’ personalhealth, it is timely and important to develop more effectiveinterventions to assist health care leaders in addressing theorganisational impact on experienced nurses in the currenthealthcare climate.ContributionsDH completed this study as part of her Master of Sciencein Nursing Program and actively led the study design, datacollection and analysis and manuscript preparation. VBVM and AW all contributed to the study design, data analysis and were involved in all stages of manuscript preparation.FundingFunding for this project was provided by the Lyle CreelmanEndowment Fund.ReferencesCollini S, Guidroz A & Perez L (2015)Turnover in health care: the mediatingeffects of employee engagement. Journal of Nursing Management 23, 169–178.Duffield C & Franks H (2002) Careerpaths beyond nursing and the contribution of nursing experience and skillsin attaining these positions. International Journal of Nursing Studies 39,601–609.Duffield C, Roche M, Blay N & Stasa H(2011) Nursing unit managers, staffretention and the work environment.Journal of Clinical Nursing 20, 23–33.El-Jardali F, Merh M, Jamal D, Dumit N& Mouro G (2009) Assessment ofnurse retention challenges and strategies in Lebanese hospitals: the perspective of nursing directors. Journalof Nursing Management 17, 453–462.Epstein EG & Delgado S (2010) Understanding and addressing moral distress. 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