Registered Nurses Leaving the Profession in the First Two Years

Nurses are leaving the profession. It is estimated that 33% leave before the second year of employment as a registered nurse (Robert Wood Johnson Foundation [RWJF], 2014). This is not a new phenomenon. Kramer (1974) first wrote about this exodus in 1970 when she published her research Reality Shock. At that time, Kramer believed that nurses were leaving due to inadequate education to prepare them for the reality of nursing. Since then, more research has examined nurse retention, but it has largely considered intention to leave the profession. Very few studies have focused on nurses who have actually left the profession.

It is estimated that 33% leave before the second year of employment as a registered nurse

While this may seem like semantics, i.e., “intention to leave and dissatisfaction” versus “actually leaving,” there is a distinction. Because someone is dissatisfied does not necessarily mean they will leave. In fact, one study done in Iran (Alilu et al., 2017) found that while many nurses were dissatisfied, they would not leave the profession because they had invested time and money. The research study reported in this article attempted to fill this gap in knowledge by interviewing individuals who have actually left nursing positions. The purpose of the study was to explore the reasons offered by these nurses who left the profession in the first two years of practice.

Background

Nursing Solutions Inc. (2021) recently reported that 24% of nurses are leaving the profession before the first year and an additional 19% are leaving before they finish their second year of practice; in January 2019, hospitals experienced the highest turnover rates in the last decade. MacKusick and Minick (2010) found that within the first three years of working, 30 to 50% of nurses either left their employers for another or left the profession entirely. The United States is already facing a nursing shortage due to retirement and an increase in the elder population. In fact, the American Association of Colleges of Nursing ([AACN], 2019) projected that 1.1 million registered nurses will be needed over the next ten years to replace those nurses who are retiring and to handle the increase in patient volume as the population increases in age. Predictions are that the shortage will be worse in the southern and western parts of the United Sates (AACN, 2019). The reason for this current and projected shortage is that the number of individuals who use healthcare will increase, while at the same time, the supply of nurses will decrease (AACN, 2019).

A priority for current research is a focus on those who have left the nursing profession to inform interventions to help to retain them.

Despite predictions of such high numbers, very little research has been done to discover the reasons for the departure of nurses beyond expected retirement. Most fairly recent literature considers intent to leave the profession (Alilu et al., 2017; Choi et al., 2013; Flinkman et al., 2013; Sabanciogullari & Dogan, 2014). "Intent to leave" means that the nurses are still working in the nursing profession, and are dissatisfied, but have not actually left their jobs (Rudman et al., 2014). A priority for current research is a focus on those who have left the nursing profession to inform interventions to help to retain them.

Study Methods

Design and Sampling
This study used a qualitative descriptive design. This design is best used when very little is known about a subject. It also allows participants to explain in their own words, which was the aim of this project (Kim et al., 2017). This study was approved by The University of Arizona Institutional Review Broad.

Inclusion criteria were individuals who started practicing as a registered nurse in a hospital setting for at least one year but left the profession within two years of that start time. Excluded was any registered nurse who had practiced longer than two years.

Participants were recruited through Research Match (2024), an online data base that contains a list of individuals throughout the United States who have agreed to be contacted about potential research studies. The description of the study was sent to potential participants. If they were interested in participating, they would review the consent, after which their information was sent to the researcher. For studies with a qualitative descriptive design, recruitment typically continues until data saturation (i.e., the point where information collected in interviews is consistently repeated) has been achieved (Kim et al., 2017). Data saturation for this study was met at 17 participants.

Data Collection and Interview Procedures
Interviews occurred online in real time via a face-to-face virtual platform. Interviewing in this situation offered the best option due to recommended social distancing practices at the time, and the geographical distance of participants who did not live close to the researcher.

The interviews started with the researcher reviewing the consent form and obtaining verbal consent for the participant to continue. Interviews were semi-structured and all participants were asked similar questions. To begin, the researcher asked participants to describe why they left the profession and then specifically inquired about bullying from co-workers, orientation training, COVID-19 pandemic impact, and whether they felt their education had prepared them for practice. Other questions explored what prompted them to become a nurse, their expectations of nursing, and their transition from nursing school.

Data Management and Analysis
Content analysis was done using inductive coding, specifically as described by Thomas (2006) which provides a straightforward set of procedures to follow. The inductive approach derives codes from the data that are generated, whereas deductive coding uses a set of pre-determined codes that were already developed and are applied to the new set of data that were collected (Munhall, 2012). The first step in inductive analysis is to clean or prepare the data. Each interview was transcribed verbatim by the researcher after the session. The researcher reviewed each transcript carefully to ensure accurate transcription. Two copies of the data were saved, one to work with and the other as a back-up and original.

The next step is to familiarize oneself with the data by reading and re-reading the transcript. This reading and re-reading helps the researcher to begin the process to identify themes. The researcher examined each line of the interview transcription and started to separate data into similar clusters. For example, when asked why they left, some participants responded it was due to hours or management. These two responses went into separate sheets in a spreadsheet document. The semi-structured interview process using similar question topics informed the analysis process. Similar clusters were grouped and labeled. At this point, it was important to return to the data and ensure that as data were coded and re-arranged, the meaning of the data had not changed.

Each theme that emerged was listed in a codebook. The next interview transcription was then cleaned, the data separated and added to the existing themes as appropriate. If data emerged with the second interview that were different from the first, new themes were added to the codebook. Data collection continued until no new themes emerged from new data (i.e., data saturation), at which point data collection stopped after interview 17.

Trustworthiness
Trustworthiness in qualitative studies helps to establish that the results are accurate and reliable (Lincoln & Guba, 1985; Munhall, 2012). Lincoln and Guba (1985) established four criteria of trustworthiness: credibility, transferability, dependability, and confirmability.

Credibility is how confident the researcher is in the “truth” of the findings and ensures the findings are true and accurate. For this project, peer debriefing was used. The purpose of this debriefing is to uncover what the researcher may be taking for granted, such as researcher biases, perspectives, and assumptions (Lincoln & Guba, 1985). Peer debriefing was completed by discussing findings from the analysis with external peers with expertise in leadership and qualitative research methods.

Transferability considers how the study findings may apply to other similar situations, populations, or phenomena (Lincoln & Guba, 1985; Munhall, 2012). One way to accomplish transferability is thick descriptions or detailed accounts. To accomplish this, the researcher used direct quotes from participant interviews and provided as much detail as possible regarding the participants and their reasons for deciding to leave the nursing profession. As such, readers can draw their own conclusions or transfer the results to other similar situations.

Dependability is the extent to which the study could be repeated by someone else, with consistent processes and results (Lincoln & Guba, 1985; Munhall, 2012). An inquiry audit involves inviting a researcher who is not involved in the study to examine both the process and the product of the research, evaluating it for accuracy and whether or not the findings, interpretation, and conclusion are supported by the data (Lincoln & Guba, 1985, Shenton, 2004). Throughout this study, the researcher kept an audit trail and discussed discussions with outside experts.

Confirmability involves making sure that researcher bias did not change the interpretation of what the participants said (Lincoln & Guba, 1985; Shenton, 2004). To establish confirmability, I used an audit trail to highlight every step of the data analysis process. This included a rationale for decisions made, which helped to establish an accurate portrayal of participants' responses.

Findings

Demographics
The 17 participants lived in three different states, with 14 nurses from New York, two from Illinois, and one from Colorado. Interviews ranged from 11 to 37 minutes; the average interview time was 17 minutes. Of the 17 participants, 12 were females and five were males. The length of time they spent working as a nurse ranged from 12 to 23 months. All of nurses worked in a hospital setting: one worked in a pediatric hospital; three in the emergency room; six on inpatient medical- surgical floors; and seven in the intensive care unit (ICU).

Emerging Themes
A total of five themes were identified: 1) Overworked, 2) Family Obligations, 3) Management, 4) Not Completely Gone [from nursing], and 5) Additional Factors. Each theme, along with the relevant codes that were included in that theme, is discussed below and presented in the Table.

Table. Brief Description of Emerging Themes

Theme #1: Overworked
The first theme that emerged was feeling overworked. This is a term that many participants used when asked why they left their nursing position. They described this as feeling as though they were working too many hours or days in a week. They felt they never had a say in what schedule they worked or how much they worked. Codes that supported this theme were hours and no control over their schedule, with supporting quotes offered below.

They felt they never had a say in what schedule they worked or how much they worked.

Hours. Participants reported that they were working an extreme number of hours each day and for many days within the week. Their shift was typically 10-12 hours a day and they worked 5 or 6 days a week. Extreme number of hours was the most frequent reason given for leaving the nursing profession. Many were also required to work swing shift, where they worked dayshift hours one day and then had to work night shift for the next day. Participant 1 stated, “Management they really over-working us, the working hours made it difficult to get a life out. You couldn't get a small holiday, so it was horrible. The management was much…. not really looking at our needs.” Not only was time off around holidays an issue, but even from week to week the number of hours that the participants worked made life outside of work difficult for them. Participant 2 stated “Yeah, 10 hours per day. I was working 10 hours per day five days a week.” Almost all of the other participants worked similar hours.

Extreme number of hours was the most frequent reason given for leaving the nursing profession.

No Control Over Schedule. Nurses described situations where leaders in management would make the schedule with no input from them, so they were unable to request time off for family events. They were also not able to reduce the number of hours or days that they were working. For example, participant 8 stated “Yeah, for a day off, you must apply more than a week before and it was not a guarantee that you can …that you are given the day off. So, it was quite harsh.” Many participants described this as a reason for leaving.

Theme #2: Family Obligations
Another theme that emerged was family obligations. This theme was closely related to the theme of being overworked and working long hours. But for this theme these concerns specifically and consistently interfered with family time. Participants felt that the number of hours that they were working interfered with the amount of time they were able to spend with their families. Leaving nursing provided them with more of this family time. Participant 15 stated “The working hours were so long, and I was not able to have time for my family at all, so it was causing some issues.” Similarly, Participant 4 stated “it limited my time, I used to spend with my family, my wife, my kids.” Most participants felt that the work schedule and long hours were interfering with family time.

Leaving nursing provided them with more of this family time.

Theme #3: Management
Management also emerged as a theme. This was defined from the data as not providing the support or equipment that the participants felt they needed to perform their jobs. In relation to support this aligned with the themes of overwork and family obligations; participants went to management to request time off for family or a reduction in the hours that they were working. Participants felt that management was not open to these requests and would often pressure them into working more hours. Participant 1 said “management they really over-worked us, the working hours were difficult to get a life out of. You couldn’t get a small holiday so it was horrible.”

Another code to emerge within management was the fact that many managers were not nurses or other members of the healthcare team. The researcher asked, “Were your managers other nurses or individuals trained in management?” Most participants indicated that their managers (i.e., the individuals making schedules, hiring, training) were not ever educated or employed as nurses, but had degrees and a background in management. Participant 5 stated, “management, they were just other people, they ever never trained or worked as a nurse.”

...many managers were not nurses or other members of the healthcare team.

In addition to concerns about the work schedule and qualifications of managers, pay was also included in this theme. Many participants mentioned that they were not paid on time due to management concerns. For example, they were asked by management to wait for their pay and/or had to take pay cuts. Participant 3 stated “Well, they didn’t quite pay us for some months.”

Theme #4: Not Completely Gone
A fourth theme to arise was the idea that many of these nurses are not yet completely gone from the profession. This theme was thus defined as a willingness to return to the nursing profession if circumstances change. The codes that were identified were both staying and returning to nursing.

Staying. Nurses were asked if they would have stayed if the hours were reduced or if management would have been more supportive. Many responded that they would have stayed in their positions as nurses. For example, in a follow-up question the researcher asked, “Do you think that if your managers would have been more receptive to you working fewer hours that you would have stayed at your job?” Participant 16 replied “I definitely would have stayed.”

This theme was thus defined as a willingness to return to the nursing profession if circumstances change.

Return to Nursing. Many participants have found employment in other professions or jobs, but many also stated that they would be open to returning to nursing if the hours were reduced or increased support from leaders in management. In one example of this, the researcher reflected back to a participant response by asking this follow-up question, “And you said that you might go back to nursing one day?” Participant 17 replied, “Yeah, I get a job at a place where they are understanding, I can go back.”

Theme #5: Additional Factors
After the initial request from the researcher for participants to describe why they left the profession, they were all asked more specific questions about bullying from co-workers, educational preparation, training/orientation upon hiring, and the potential impact of the COVID-19 pandemic. The literature has suggested that nurses may be leaving the profession due to some of these factors (AACN, 2019; Flinkman et al., 2013; Rudman et al, 2014). This provided the rationale to ask participants these specific follow-up questions within the interviews. However, when asked, all participants stated that these factors did not play a role in their decision to leave.

Bullying from Coworkers. This was defined for this study as the way that co-workers treated and responded to nurses who eventually left the profession. All participants were asked about interaction between themselves and their co-workers. Almost all of them stated that their co-workers were supportive and helpful. For example, participant 15 stated “They were very supportive and, whenever I was unable to do anything, they would ask me, and they would do it.”

Educational Preparation. The literature has suggested that nursing school and educational preparation could be a reason for leaving the profession (Rudman et al, 2014). All participants were asked whether they believed their education prepared them to be a nurse. While many participants felt that their education could have provided them with more “hands on” experience, none felt that it was not adequate or gave this as a reason for leaving the profession. The researcher specifically asked, “Was there anything about your nursing school training that you would have changed or that you thought maybe you needed more or less of?” Participant 16 replied “Not at all. Everything was perfect.”

Training/Orientation. This was defined for this study as nurses receiving training during the transition from school to staff nurse (i.e., orientation). In recent years, the idea of a nurse residency program has begun to materialize in the literature (Flinkman et al., 2013). This suggests that having a nurse residency programs or offering nurses extensive training in their first year as a nurse can aid in the transition, which in turn may retain more nurses. All participants were asked if they received training and what the training entailed. The length of the training program ranged from “a few weeks” to two years.

While some participants still did not feel completely comfortable after the training program ended, none listed this as a reason for leaving the profession of nursing. Participant 10 stated “Yeah, we went through a training program. Um, the program was for two years. We were paired with other nurses, senior nurses, who also had been there before us. So, that’s how the training program went.” Later in the interview, the researcher asked, “Did you feel comfortable when you started working on your own?” Participant 10 replied “Umm. I can’t really say I was comfortable. I had doubts in there, but I always had the nurse that I was paired with, so I went to ask questions and clarifications from the partner.” Despite having these training programs, all the nurses in the study still left the nursing profession.

While some participants still did not feel completely comfortable after the training program ended, none listed this as a reason for leaving the profession of nursing.

COVID-19 Pandemic. This was defined for the purpose of the interviews as the extent to which the COVID-19 pandemic may have affected the nurse’s decision to leave the profession. All nurses left the profession in the last 3 months to a year, which was during the COVID-19 epidemic. Participants were specifically asked if the COVID-19 pandemic was a reason for them to leave the profession. All of them answered no. Participant 12 stated:

No, I enjoyed helping patients. I really enjoyed it. Even those who came in with the COVID problems and all of that. I really enjoyed it. But the hours were too long for working and the pay was … in fact the pay was reduced during the COVID season.

The responses affirmed that the COVID-19 pandemic, at least from the perspective of risk of the spread of infection, was not the reason for them to leaving the profession.

Discussion

In sum, this study found that the reasons for registered nurses leaving the profession included imbalances between life and work (e.g., being overworked, time working interfering with time with family, and issues with management). Some factors of potential dissatisfaction as discussed in the literature (e.g., bullying, inadequate educational preparation or orientation, the pandemic) may have been a part of their experiences but were not the reasons that these nurses described for leaving the profession. Finally, there is potential for nurses to be retained and/or to return to the profession. These three key findings are discussed below.

In sum, this study found that the reasons for registered nurses leaving the profession included imbalances between life and work...

Work-Life Imbalance
This study found that one of the biggest reasons for nurses leaving the profession was that they had little to no control over their schedules and the hours that they worked were extremely long. Both of these factors interfered with their family time and/or family obligations. Their perceptions were that leaders in management were not supportive of any input from them into these schedules and were unwilling to reduce the number of hours that the nurses were working.

The findings of this qualitative study support previous research from Finland. Flinkman et al. (2013) found that nurses were also leaving the profession due to what they termed the “work environment” made up of long shifts and low salaries. Low pay was a reason for nurses leaving the profession in Turkey as well (Masum et al., 2016). The RN Work Project, completed in the United States, also found that the work environment (described as the hours, length of shift, access to supplies, and nurse to patient ratio) were all reasons that nurses were leaving (Djukic et al., 2014; RWJF, 2014).

...one of the biggest reasons for nurses leaving the profession was that they had little to no control over their schedules and the hours that they worked...

Another finding from the above study (Djukic et al., 2014) was that management plays a role in nurses wanting to leave the profession. Flinkman et al. (2013) also described poor managers as not being approachable, not addressing issues on the unit, and not supporting the nurses; all of these factors were reasons that nurses in this study described for leaving. Other studies have also found that lack of support from leaders in management is a reason for nurses to leave (Choi et al, 2013; Cortelyou-Ward et al., 2010). While Simon et al. (2010) found that management practices were a reason for nurses to leave the organization and not necessarily the profession, many of the participants in this study felt that leaving and going to another employer would be the same, so leaving the profession was the only way to address these needs.

One idea that did emerge in this study is the description by many participants that most of their managers were never trained, nor had worked as nurses. Rather, their managers held degrees in business. This is a gap in knowledge that has not been previously addressed in the literature. It is unclear what effect, if any, the use of managers who are not nurses may contribute to nurses leaving the profession. This question would be helpful to explore in future research.

Other studies have also found that lack of support from leaders in management is a reason for nurses to leave

All of the participants in the study felt that some of their basic workplace needs were not met, causing them to leave the nursing profession. For example, they described that they were not able to work reasonable hours, were not paid on time, and felt that managers did not support them. Most of the participants stated that if these needs had been met, they would have stayed in the nursing profession.

Reasons for Dissatisfaction Noted in Literature
Another key finding was the lack of support for the existing literature related to the intention to leave the profession. It is important to note that most of the research in the current literature reflected a sample of nurses who were still working in the profession (rather than those who had already left) and had an intention to leave the profession.

It is unclear what effect, if any, the use of managers who are not nurses may contribute to nurses leaving the profession.

Literature that discusses intent to leave the profession has suggested that nurses want to leave due to bullying that they experience from co-workers; inadequate training when they enter the profession and/or inadequate educational preparation by nursing schools; and during 2020, the widely held belief that the COVID-19 pandemic was the reason for nurses to leave their positions (Falatah, 2021, Ishihara et al., 2014; Laschinger, 2012; Rudman et al, 2014). None of these reasons were described by the nurses in this study. The main reason for this discrepancy could be that what is causing dissatisfaction in nurses that are thinking of leaving the profession is different from what causes them to actually leave.

Most of the participants stated that if these needs had been met, they would have stayed in the nursing profession.

Retaining and Returning Nurses
The last key finding of the study was that it may be possible to not only retain nurses but also to have nurses rejoin the workforce. Many nurses in this study indicated that had they been able to reduce their work hours or had input into their schedule, they would not have left their nursing position. Many also indicated that if these two elements were to change, they would re-enter the profession.

These nurses are part of what has been known for some time as the “shadow workforce” (McIntosh et al., 2006). A shadow workforce is individuals who are no longer working in a specific profession but have the necessary training and skills to rejoin that profession. All participants in this study had the training and experience of being a registered nurse but are no longer working in the nursing profession. All of the formerly employed nurses who were part of this study indicated that if conditions changed, meaning that they were paid on time and could work reasonable hours, they would return to the profession. All of these changes could reasonably be made. Thus, not only could nurses be retained, but nurses who have already left could return to help with predicted shortages.

A shadow workforce is individuals who are no longer working in a specific profession but have the necessary training and skills to rejoin that profession.

One change important to nurses that could be made is allowing them to self-schedule. Koning (2014), reported that allowing nurses to self-schedule is one of the main ways to increase work satisfaction. Koning also identified challenges with self-scheduling, one of which is balancing the nurses needs with those of the organization. However, 10 years after Koning’s report, we have more sophisticated computer systems that can help with achieving this balance, but little evidence that self-scheduling is in place for most nurses. When self-scheduling is implemented, nurses feel they have more flexibility and control.

Strengths and Limitations

A strength of this study is that the findings fill a gap in the literature. Reasons that nurses leave the profession has not been widely studied, and even fewer studies have considered those nurses who leave in the first two years. The main reason for this gap is that this population is not easy to find. Once nurses leave the profession, it is difficult to locate them. This may be why most studies that have considered retention of nurses have sampled nurses intending to leave the profession versus those who have already left.

One limitation with this study was that all participants worked in a hospital. Therefore, the findings do not represent nurses who work in other settings, such as in the community, who may have left their profession within the first two years. The sample size was small, but appropriate to the study design and aim. Qualitative findings are inherently not statistically generalizable due to the primary research goal of seeking rich descriptions of participants’ experiences. While these findings are not statistically generalizable to the wider population, it is hoped that the incorporation of well-established measures of trustworthiness (Lincoln & Guba, 1985), especially related to thick description, will allow readers to consider other settings in which the findings may be similarly applicable.

Implications for Research and Practice

Potential areas for future research should include study of registered nurses working outside the hospital setting to discover if similarities exist in this population, or if they are leaving for different reasons, or even at all. Nurses leaving the profession is a problem throughout the world. Similar studies in other countries would also be beneficial.

Because a key finding of this study was that managers play a role in the decision of nurses to leave the profession, future research could explore training for managers or what changes could be made within management processes to retain nurses. Additional research could also focus on the potential effect of non-nurse managers in the hospital environment on retention of nurses. Finally, development and testing of an intervention whereby nurses are allowed control over their schedule, combined with appropriate training for support by managers, could explore the impact of these changes (desired by nurses) and on retention within the profession of nursing.

Thus far, efforts to address the shortage have focused heavily on recruiting more nurses into the profession.

Conclusion

The findings from this study are important considering the shortage of nurses both in the United States and globally. Thus far, efforts to address the shortage have focused heavily on recruiting more nurses into the profession. While this is an appropriate strategy, it is critical to retain these novice nurses who are entering the profession. This study explored reasons why registered nurses have left the profession in the first two years. The findings describe their perceived concerns and may inform changes that can address the frustrations that led to their decision. Input into their schedules, reasonable work hours, and time off for family activities and obligations are areas managers can consider in an effort to respond to these needs. Many individuals who have left employment might be willing to return to the profession if changes can be made, offering a source of immediate relief as we face the ongoing nursing shortage.

Author

Stephanie Tate, PhD, RN
Email: s.tate88@csuohio.edu

Stephanie Tate completed a PhD at The University of Arizona. Nurse retention was the focus of her dissertation. She also has an MSN in leadership from Capital University and has earned Family Nurse Practitioner certification at Chamberlain University. She currently is an instructor at Cleveland State University in Cleveland, Ohio.