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European Journal of Applied Sciences – Vol. 11, No. 3
Publication Date: June 25, 2023
DOI:10.14738/aivp.113.14836.
Salminen-Tuomaala, M. (2023). Factors Associated with Attractiveness and Retention in Nursing. European Journal of Applied
Sciences, Vol - 11(3). 360-374.
Services for Science and Education – United Kingdom
Factors Associated with Attractiveness and Retention in Nursing
Mari Salminen-Tuomaala
Seinäjoki University of Applied Sciences, Finland
ABSTRACT
The study describes factors associated with the attractiveness and retention of
nursing, as experienced by registered nurses (n=24) upgrading their education to a
Master’s Degree at a University of Applied Sciences in Finland. The study aims at
producing knowledge that can be used to improve nurse retention and the
attractiveness of the clinical nursing profession. The 6-3-5 Brainwriting Method of
Rohrbach was used to collect data which was analysed using inductive content
analysis. The findings support previous international literature. Promotion of
appreciation, professional development and wellbeing at work through optimal
working conditions, increased influence and compassionate, supportive leadership
were among the most significant, recurrent themes in the participant contributions.
Further work is required to increase the appreciation of nursing in order to retain
nurses and attract new applicants. The measures suggested in this research include
the development of more compassionate leadership, professional development
options and optimal conditions to ensure wellbeing at work.
Keywords: Attractiveness, retention, career, nursing, wellbeing at work
INTRODUCTION
Millions of new nurses will be required globally by the year 2030; the pre COVIC-19 pandemic
world was already short of almost six million nurses [1,2]. Finland is also struggling to attract
and retain nursing staff; the shortage of staff is likely to persist and even intensify within the
next decade [3]. In this article, attractiveness refers to any force or means that helps
organizations recruit and retain staff and to promote work engagement [4]. Retention refers to
an organization’s ability to prevent staff leaving their work [5].
Health services across the world are facing the challenge of poor retention, as well as ageing
and retirement of the workforce. A significant part of the nursing workforce will retire or leave
the profession in the next few years, while the need for services is likely to increase in countries
with ageing populations [2]. It is important, both nationally and internationally, to explore what
kind of factors could promote nurse retention and help recruit new professionals [6, 7].
International research indicates that nurse retention and the attractiveness of the profession
can be promoted by nurses’ influence over their work, professional development and career
opportunities, a positive work atmosphere and well-functioning multiprofessional
collaboration [8, 9, 10, 11, 12, 13]. Open nurse-leader dialogue and mutual appreciation can
increase retention [14, 15, 16, 17]. Support and encouraging feedback, both in words and deeds
are called for [18]. It is recommended that leaders make an effort to listen to their employees
and to be more approachable and flexible to reduce turnover intention. [19, 20]. In other words,
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Salminen-Tuomaala, M. (2023). Factors Associated with Attractiveness and Retention in Nursing. European Journal of Applied Sciences, Vol - 11(3).
360-374.
URL: http://dx.doi.org/10.14738/aivp.113.14836.
more compassionate leadership might have a positive impact on the turnover rates [18]. Nurse
engagement - nurses’ commitment to and satisfaction with their jobs, and their level of
commitment to the nursing profession itself - has also been found to be associated with nurse
retention [21, 22, 23, 24, 25].
In contrast, a perceived heavy workload and stress have been found to decrease nurse retention
and the attractiveness of the profession [18, 26, 27, 28]. The same holds true when the work
requirements have been considered unreasonable, the working conditions inadequate [10]
and/or the professional development prospects poor. [11, 29]. Lack of leader support and
appreciation, a negative work atmosphere and poor management and leadership mar nurse
engagement [18, 27, 30, 31]. Experienced bullying early during the career can cause nurses to
leave their profession [11, 32].
In Finland, the attractiveness of the nursing profession has been studied recently from the
perspectives of nursing students [33], licensed practical nurses [34], and nurses [35, 36, 37].
The results are similar to international research. According to the nursing students, the role
and appreciation of nursing should be advanced at the level of individual nurses, organizations
and society [33]. Increasing the appreciation of nursing is essential for licensed practical nurses
as well [34]. Nurses agree that the attractiveness of their profession has deteriorated. Their
wishes include adequate human resources, better professional development opportunities and
salaries to match the responsibilities [35, 36, 37].
RESEARCH PURPOSE AND RESEARCH QUESTIONS
This study describes factors associated with the attractiveness and retention of nursing, as
perceived by experienced nurses undertaking a Master Programme in Advanced Practice
Nursing. The study aims at producing knowledge that can be used to improve nurse retention
and the attractiveness of the clinical nursing profession. The research problems are:
1. What kind of factors are associated with improving the attractiveness of nursing?
2. What kind of factors are associated with improving retention in nursing?
DATA AND METHOD
Data Collection
A qualitative approach was selected to explore experienced nurses’ views of factors associated
with the attractiveness of nursing and retention of nursing professionals. The participants
(n=24, including 22 women and 2 men) were registered nurses with 5-25 years’ experience
across a diverse range of clinical specialities. They were upgrading their education to a Master’s
Degree in Advanced Practice Nursing at a University of Applied Sciences. The participants were
employed as nurses in various locations across Finland.
The 6-3-5 Brainwriting Method of Rohrbach (1968) was used to bring together participants’
individual experiences and associations yielded by the shared ideation process [38]. The
method is suitable for collecting qualitative experiential expert knowledge. The participants
worked in groups of six persons. Two groups were allocated the topic of “Factors that increase
the attractiveness of nursing”, whereas the other two groups were given the topic of ”Factors
that increase the retention of nursing professionals”. All participants were given a piece of
paper and five minutes time to write down three ideas on how to improve the attractiveness of
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nursing/ retention of nursing professionals. After the five minutes were over, all participants
were instructed to pass their paper to the next participant sitting on their right side. During the
following five minutes, each participant read the existing ideas and added three new ideas. The
process continued, using five-minute intervals, until the participants received their original
papers. Rich material involving fresh associations was produced in each of the four groups
during the 30 minutes [39, 40].
Data Analysis
The 6-3-5 Brainwriting Method yielded clauses and sentences, which were analysed using
inductive content analysis [41]. The original clauses and sentences were reduced into 198
meaningful units, which were grouped into sub-categories according to content. Last, the sub- categories were combined into more generic categories, which were collapsed into the two
main categories.
Ethics and Trustworthiness
Owing to the deteriorating staff shortage in nursing, the topic can be considered to be
significant from the perspective of the nursing profession and society. The Research and
Development Manager at the University of Applied Sciences granted permission for the
research. The Finnish National Board on Research Integrity Guidelines (2023) were followed
[42]. Participation was voluntary. All participants gave verbal consent to have the material used
as research data. Their anonymity was protected throughout the research process.
The criteria of credibility, confirmability, transferability and reflexivity were used to ensure
research trustworthiness. [43]. Credibility means that the findings reflect participants’
conceptions of the phenomenon under study. The method used, 6-3-5 Brainwriting, and the fact
that participants were nurses with a long work history either in primary health care or
specialized medical services across Finland, can be claimed to ensure an authentic picture of
the topic. Confirmability means that the findings are based on research data, not on
investigators’ ideas of the phenomenon. The description of the data collection and analysis,
together with tables, make it possible for readers to see how the research process took place.
Transferability is about the possibility that similarity could be found in other research contexts.
The findings of this study are likely to be transferable at least nationally, and they may provide
useful insights to international readers as well. Last, reflexivity means that the investigators
acknowledge the effect their pre-conceptions may have on the study. In this study, both
researchers’ long history of nursing may have influenced their interpretation of the data.
RESULTS
This section presents experienced nurses’ views of factors associated with the retention of
nursing professionals (4.1) and of factors associated with the attractiveness of nursing as a
profession (4.2). Direct participant quotes are provided to support the findings.
Professionalization and Appreciation as Factors Increasing Nurse Retention
The first research question dealt with research participants’ ideas of factors that make it more
likely for nurses to remain in their current positions. Table 1 shows the seven generic
categories (4.1.1 - 4.1.7) and the sub-categories that emerged in the analysis
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Salminen-Tuomaala, M. (2023). Factors Associated with Attractiveness and Retention in Nursing. European Journal of Applied Sciences, Vol - 11(3).
360-374.
URL: http://dx.doi.org/10.14738/aivp.113.14836.
Table 1. Professionalization and Appreciation as Factors Increasing Nurse Retention
Sub-category Generic category Main category
Interesting duties
Meaningful work that
promotes and makes use of
expertise
Professionalization and
Appreciation as Factors
Increasing Nurse Retention
Meaningful projects
Advanced practice nurses as
educators
Allocating advanced practice
nurses’ duties that match their
qualification and competence
Career advancement
Making use of nurses’ expertise
Influence over the development of
one’s job description
Training opportunities
Being appreciated in society
Appreciation and promotion
of the value of nursing
Being appreciated in the
organisation
Being appreciated by the employer
Having one’s competence
appreciated
Support and appreciation from
leaders
Appreciation of one’s own work
Making clinical expertise visible
Making the work/profession visible
Flexible working hours
Ensuring optimal working
conditions
Adequate resources
Lunch benefits
A pool of substitutes
Visible networking
Developing leadership
Adequate support staff (IT,
secretarial)
Remote work
Work rotation
Chance to attend to patients
without interruptions
Fully functioning equipment
Safe working facilities
Appropriate uniforms
Adequate salary
Ensuring optimal salaries
Match between salary and
contribution
Salary bonuses
Influence over one’s salary
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Extensive occupational health
services
Promotion of wellbeing at
work
Support for wellbeing at work
Rehabilitation during work career
Preventive occupational health care
Provision of sports vouchers
Employer support for work
wellbeing
Leader support for employee family
life
Silent retreats to counterbalance
the interactive nature of the work
Workplace wellbeing activities
Better work ergonomics
Work supervision
Regular shared time with
colleagues
Promotion of collaboration
Enabling collaboration
Listening to and involving
professionals
Promoting multiprofessional
collaboration
Promoting collaboration with
colleagues
Promoting work in pairs
Training leaders to understand
grassroots work
Development of
compassionate leadership
Developing leaders’ emotional
intelligence skills
Developing leaders’ empathy skills
and compassion
Ensuring that staff are being heard
Promoting open dialogue between
staff and leaders
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Salminen-Tuomaala, M. (2023). Factors Associated with Attractiveness and Retention in Nursing. European Journal of Applied Sciences, Vol - 11(3).
360-374.
URL: http://dx.doi.org/10.14738/aivp.113.14836.
Meaningful Work that Promoted and Made Use of The Nurses’ Expertise:
First The participants agreed that meaningful work that promoted and made use of the nurses’
expertise could make nurses remain in the profession. It was important that the work involved
interesting assignments that corresponded to the nurses’ qualifications, competence and
expert knowledge. Career prospects, training opportunities and influence over the
development of one’s job description were further factors likely to increase nurse retention. To
quote a participant,” You can achieve retention by increasing career advancement options”.
Appreciation and Promotion of The Value of Nursing:
Appreciation and Promotion of The Value of Nursing was another factor that could help retain
nurses, according to the study participants. The appreciation should take place at many levels;
nurses appreciating their own work; immediate supervisors supporting their staff and
appreciating their competence; the employer, the organization and society appreciating the
work. The study participants suggested that nursing professions and clinical expertise should
be made more visible in society, for example in the social media. They said, for example,”
Appreciation; nurses are not maids to doctors”, and” More visibility on national news channels
about real nursing work”.
Optimal Working Conditions:
Third The study participants stressed the importance of having nurse leaders ensure optimal
working conditions, including adequate resources, support staff, facilities and equipment. The
participants felt that flexible working hours, work rotation and remote work, when feasible,
could be helpful in retaining nurses. An adequate pool of substitutes was needed, according to
the participants. They also said that nurses would appreciate a chance to take time to attend to
their patients without being constantly interrupted. Good working conditions would affect the
daily routines, patient safety, and retention positively. To quote,” Enough time and resources,
so you can do your work as well as you would like to”.
Optimal Salaries:
In addition, optimal salaries were considered very important in the effort to retain nursing
professionals. The salaries should correspond to the qualifications and work requirements.
Assignments that require special competencies or increased responsibility should be
compensated for.
Promotion of Wellbeing at Work:
Promotion of wellbeing at work was also considered important for nurse retention. The study
participants mentioned extensive occupational health services, including preventive health
care and rehabilitation. They also proposed measures to improve both physical and cognitive
ergonomics, to “shape up the work ergonomics”. An opportunity to have clinical supervision
and having one’s family life taken into consideration (work-life balance) were seen as effective
means of retaining nurses in the profession.
Promoting Collaboration:
According to the study participants, employers could increase nurse retention by actively
promoting collaboration at the workplace. This could involve better listening to employees and
involving them in planning and decision-making. Nurse leaders could arrange those employees
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meet and share time regularly. Other aspects of collaboration suggested included multi- professional teamwork, improved collaboration among peers and sharing of knowledge and
skills.
Development of Compassionate Leadership:
The last suggestion to emerge was related to the development of compassionate leadership.
The participants indicated that nurse retention could be increased if nurses were heard and
supported effectively. This would require the development of leaders’ emotional intelligence,
empathy and situational awareness. The promotion of open dialogue between leaders and staff,
especially, was seen as a factor that could increase the retention rate. The participants said, for
example,” Leadership should be equal and competent. The employees should be trusted, they
should be listened to and encouraged”, and” Compassionate leadership, empathy and genuine
dialogue instead of bureaucracy.”
Professional Development and Wellbeing as Factors Increasing the Attractiveness of the
Nursing Profession
The second research question dealt with research participants’ ideas of factors associated with
the attractiveness of nursing as a profession. Table 2 shows the nine generic categories (4.2.1 -
4.2.9) and the sub-categories that emerged in the analysis.
Table 2. Professional Development and Wellbeing as Factors Increasing the
Attractiveness of the Nursing Profession
Sub-category Generic category Main category
Positions for advanced practice
nurses
Advancement of
professional development
Professional Development and
Wellbeing as Factors Increasing the
Attractiveness of the Nursing
Profession
Chance to combine work and
studies and being allocated duties
that correspond one’s education
Designing a career path model
Equal educational opportunities
Enabling work rotation
Good orientation
Developing student supervision Development of students’
Improving the condition in work clinical practice
practice
Appreciation students as equals
A mentoring model for graduates
Enabling work during studies
More practically oriented education Attention given to the
needs of practice in
education
Giving attention to worklife
challenges during education
Developing combined study
programmes
Enabling further training
Improving peer relations among
nurses
Increasing the appreciation
of nursing professionals
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Salminen-Tuomaala, M. (2023). Factors Associated with Attractiveness and Retention in Nursing. European Journal of Applied Sciences, Vol - 11(3).
360-374.
URL: http://dx.doi.org/10.14738/aivp.113.14836.
Involving leaders in clinical nursing
Bringing leaders closer to
employees
Support and encouragement from
leaders
Appreciation from leaders to all
employees
Concrete acknowledgement for a
job well done from the employer
Listening to employees
Taking employee opinion into
account
Matching the salary with work
requirements
Aligning salaries with
education and work
Rewarding competence requirements
Higher salary
Personal bonus for competence and
education
Reward for a job well done
Reward for special competence
required in the job description
Compensation for extra
assignments
Developing the compensation
system for extra hours
More humane working conditions Improvement of working
Chance to influence working hours conditions
More attention to employees’ rota
wishes
Increasing permanent positions
Stopping consecutive short
contracts
Better treatment of substitutes
Increasing the availability of
substitutes
Better care of equipment
Increasing equipment, technology
and robotics to facilitate work
Providing shared activities to
promote coping
Work supervision
Providing physical exercise
opportunities
Shared sports and cultural activities Promotion of Work Ability
Work supervision
Vouchers to support staff wellbeing
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Empowering reflection after
stressful situations
Influence over one’s working hours Increasing employee
Influence over one’s duties influence
Influence over one’s working
conditions
Chance to develop one’s
competence
Improving the image of nursing Increasing appreciation of
nursing through positive
communication
Positive marketing
Improving the reputation of nursing
together
Sharing positive experiences of
daily nursing work
Advertising nursing in media
Increasing leaders’ appreciation of
nursing
Increasing the government’s
appreciation of nursing
Positive descriptions of hospital and
health centre operation
Use of celebrities in recruitment
Use of grassroots employees in
recruitment
Visiting school to inform pupils of
nursing
Advancement of Professional:
According to the study participants, advancement of professional development was one of the
factors that could make the nursing profession more attractive to potential candidates. In
concrete terms, this would involve high quality orientation, work rotation and equal
educational opportunities. A participant wrote, “A proper orientation period, time to learn the
practices, not just going into the lion’s den”. Being allocated duties that corresponded to one’s
education, for example in advance practice nursing, could increase interest in the profession,
according to the participants.
Students’ Clinical Practice Periods Should Be Developed:
Nursing students’ clinical practice periods should be developed to achieve positive learning
experiences and to make the profession more appealing. In the opinion of the study
participants, the working conditions and supervision of students in clinical practice should be
improved. Students should be encountered and appreciated as equals. At graduation, they
would benefit from mentoring. To quote,” A mentoring model, a promise that when you arrive
as a fledgling you are not left alone”.
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Salminen-Tuomaala, M. (2023). Factors Associated with Attractiveness and Retention in Nursing. European Journal of Applied Sciences, Vol - 11(3).
360-374.
URL: http://dx.doi.org/10.14738/aivp.113.14836.
Nursing Education Should Be Based on The Needs of Nursing Practice:
The study participants suggested more practically oriented education starting from current
real-life challenges. Combined study programmes and various further training opportunities
could be provided to create specific expertise tailored to the needs of practice.
Increasing The Appreciation of The Nursing Profession:
emerged as an important mission in the study participants’ contributions. This could be
achieved through leaders’ presence in practical nursing work, where they should express
interest in how the staff were coping and provide support and encouragement. The staff would
thrive if they felt that all employees’ experiences were equally interesting to the leaders. Equal
appreciation and concrete acknowledgement of good performance were mentioned. In the
words of one participant,” Leaders should be seen in the field sometimes, many of them are
estranged from everyday life. Appreciating grassroots level workers, seeing that nurses are
more than just names on the rota”.
Aligning Salaries with Education and Work Requirements:
The study participants further suggested aligning salaries with education and work
requirements to improve the attractiveness of the nursing profession. Special competence,
special work requirements and good performance should be rewarded. The job descriptions of
some employees involved special assignments requiring specific competence, and personal
bonuses should be paid for extra training and expertise. As one of the participants said, ”When
the salary matches the requirements, the profession will become a potential option alongside
other, better paid professions”.
Improvement of Working Conditions:
According to the participants, improvement of working conditions would make nursing a more
interesting choice to students. The working conditions should be more humane, with the
opportunity to influence one’s working hours and to gain a permanent position sooner, instead
of consecutive work contracts. Better treatment of nurse substitutes would make them more
readily available. One of the study participants wrote,” Optimal nurse-to-patient ratio; if the
number of nurses were expanded, nursing would become more appealing, with less stress and
better coping”. Furthermore, it was mentioned that the development of working conditions
through fully functioning equipment, technology and robotics was linked with improved
patient safety and occupational safety.
Promotion of Work Ability:
More systematic promotion of work ability was suggested the increase the attractiveness of
nursing. This could include various shared activities, for example sports and cultural events.
The participants proposed returning the earlier practice of handing out vouchers, which could
be used for cultural events or services (massage, gym etc). Work supervision and shared,
empowering reflection sessions after stressful situations were considered important for the
promotion of employees’ work ability. Leaders, psychologists or psychotherapists could
assume the role of facilitators in such sessions. To quote, “Supporting wellbeing at work,
investing in coping and resilience building”.
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Increasing Employee Influence:
Increasing employee influence was also suggested by the study participants to promote the
attractiveness of nursing. Optimally, nurses should have more influence over their working
hours, duties and working conditions. The opportunity to develop further professionally was
considered essential.
Increasing The Appreciation of Nursing Through Positive Communication:
Finally, the study participants proposed increasing the appreciation of nursing through positive
communication. A better image and reputation of nursing was required through positive
marketing and advertising. The public should learn about successes in daily nursing practice,
and nursing organizations should be described in more positive terms, possibly with help of
grateful patients or celebrities. Besides media publicity, visits of nursing professionals in
educational institutions could be useful in promotion the appreciation of the profession. Words
of appreciation from higher authorities, for example the government, were also needed.
DISCUSSION
This qualitative study presents experienced registered nurses’ ideas on how nurse retention
and the attractiveness of the nursing profession could be improved. The participants provided
extensive and varied suggestions. The findings were similar to recent international literature
[8, 33, 44]. As might be expected, the factors that were thought to increase nurse retention and
the attractiveness of the profession were mostly the same or similar. What was different was
that, iin the section on attractiveness, the topics of more practice-driven nursing education and
improved clinical practice experiences were brought up from the perspective of potential
nursing students.
The results reveal a need to improve the attractiveness and retention both at the level of
individuals (nurses and students) and in society, politics and social media through promoting
the general appreciation of the profession. Appreciation from leaders has been shown to
motivate staff and to promote engagement and wellbeing at work [14, 45, 46]. Support from
colleagues also affects job satisfaction positively [19, 47].
According to the results, the appreciation of the profession should be reflected in employee
influence, working conditions and remuneration. The study participants found, in agreement
with earlier studies, that flexible work arrangements and employees’ influence over their work
content and work conditions affected autonomy, motivation and wellbeing positively,
increasing retention and making the profession more appealing. As in previous studies,
professional development and career paths were considered essential [6, 33, 35, 48].
The promotion of work wellbeing, collaboration and supportive (compassionate) leadership
were further significant themes that emerged in the results. Although nurses in Finland seem
to find their work meaningful, thousands of nurses have left their profession due to experienced
stress and coping problems [35, 36]. Positive communication and feedback and encouragement
can help nurses cope better [49], and an ethical and supportive work climate may decrease
turnover intention [7]. A significant relationship has been established between ethical climate
and job satisfaction, with implications for nurse retention [50]. Similarly, leader support and a
collaborative climate have been found to shape nurses’ perception of the attractiveness of their
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360-374.
URL: http://dx.doi.org/10.14738/aivp.113.14836.
organization [12]. Open communication and nurse-leader dialogue was emphasised by the
participants in this study.
CONCLUSION
Further work is required to increase the appreciation of nursing in order to retain nurses and
attract new applicants. Professionalization, or establishing nursing as an independent and
appreciated profession still needs to be promoted, despite the decades of efforts to achieve this.
The measures suggested in this research include professional development options and optimal
conditions to ensure wellbeing at work. Nurses also appreciate supportive, compassionate
leadership, educational and career opportunities and influence over their work.
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