Purpose
This study was conducted to identify the factors influencing nurses’ intention to stay after coming back from parental leave.
Methods
This was a descriptive cross-sectional study. The participants were 175 female nurses working in hospitals with over 300 beds and returning after three months of parental leave. Data were analyzed using independent t-test, one-way ANOVA, Pearson’s correlation coefficient, and stepwise multiple regression.
Results
There were significant differences in intention to stay by age (t=2.65, p<.001) and position (t=-2.23, p=.027). Intention to stay was positively correlated with social support (r=.24, p<.001) and self-efficacy (r=.42, p<.001), and negatively correlated with work-family balance conflict (r=-.21, p=.004). Factors influencing intention to stay were self-efficacy (β=.94, p<.001) and work-family balance conflict (β=-.49, p=.005), with an explanatory power of 20%.
Conclusion
The findings allow for proposing that increasing nurses’ intention to stay may require self-efficacy improvements to enable nurses to adjust to their work environment, and hospitals should provide nurses with institutional support in order to reduce nurses’ work-family conflicts.
,1
and Jihyun Kim2
This is an open access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-
This study was conducted to identify the factors influencing nurses’ intention to stay after coming back from parental leave.
This was a descriptive cross-sectional study. The participants were 175 female nurses working in hospitals with over 300 beds and returning after three months of parental leave. Data were analyzed using independent t-test, one-way ANOVA, Pearson’s correlation coefficient, and stepwise multiple regression.
There were significant differences in intention to stay by age (t=2.65, p<.001) and position (t=-2.23, p=.027). Intention to stay was positively correlated with social support (r=.24, p<.001) and self-efficacy (r=.42, p<.001), and negatively correlated with work-family balance conflict (r=-.21, p=.004). Factors influencing intention to stay were self-efficacy (β=.94, p<.001) and work-family balance conflict (β=-.49, p=.005), with an explanatory power of 20%.
The findings allow for proposing that increasing nurses’ intention to stay may require self-efficacy improvements to enable nurses to adjust to their work environment, and hospitals should provide nurses with institutional support in order to reduce nurses’ work-family conflicts.
Nurses are the first and principal healthcare providers to interact with patients; specifically, they provide direct care to respond to their physical needs, treat their health problems, and prevent illness [1]. A chronic lack of nurses exacerbates difficulties in the clinical area of nursing, which deteriorates the quality of nursing care and threatens patient safety [2]. There are various factors influencing nurses' turnover intention, such as work overload, stress, shift work, childcare, and childbirth [3, 4]. Among these, work-family conflicts related to pregnancy and child rearing and family factors were identified as those influencing nurse turnover intention the most [5]. In Korea, 43.2% of experienced nurses cited pregnancy and child rearing as obstacles to re-employment, while 38.5% of those with children under the age of 6 years did not try to re-enter nursing [6]. Further, 19.2% of experienced nurses resigned even after re-employment [6].
After parental leave, nurses feel guilty about not being able to properly perform their roles as mothers and nurses [7]. In addition, it is said they face difficulties in parenting due to three-shift work, and there is a lot of pressure from the boss who is not generous with parenting [3, 4, 7]. This naturally results in resignation. Recognizing this, the parental leave system has been implemented globally. Moreover, various changes to full-time and part-time work, such as the implementation of a six-hour work day, have been brought to facilitate child care in Japan and the United States of America [8]. While Korea has implemented a "parental leave system," only 63.4% of nurses returned to work after parental leave [9]. As a result, it is necessary to study the reason for the continued decline in the number of nurses returning to work after parental leave.
The environmental factors influencing the intention to work, include organization commitment, organization culture, and organization socialization, and personal factors include professional identity, job satisfaction, resilience, burnout, and job stress [10, 11]. Low intention to stay significantly impacts nursing as a whole. If nurses have a low intention to stay, they will be more likely to leave their jobs when faced with economic losses, work burden, and low morale [5]. In addition, a low intention to stay can worsen the quality of nursing care and pose ongoing difficulties with hiring new nurses [12]. Therefore, it is imperative to increase the understanding regarding nurses’ intention to stay and, what other variables may affect it.
Many nurses returning from parental leave face work-family balance conflicts and consider quitting jobs to reduce them [13]. They find it difficult to simultaneously carry out their responsibilities as nurses, mothers, and wives [14]. Moreover, it is important to note that nurses experience a variety of health problems due to the intense physical activity and stress resulting from the nature of their work. In addition, the irregular hours involved in shift work can make it difficult for them to look after their children and complete household chores [13, 14]. These factors increase the conflict between work and family, leading to higher burnout and turnover intentions among nurses [4, 15], which negatively affect nursing work [16].
Social support can be useful for nurses returning from parental leave and has been found to positively impact their intention to stay [17]. Here, “social support” refers to the perception and actuality that one is cared for, has assistance available from other people, and is part of a supportive social network [18]. It acts as a social and psychological protective factor [19]. Scholars have confirmed that support from colleagues, superiors, and family members positively impacts nurses' work-family balance conflicts [15]. Moreover, the support of colleagues and superiors positively affects job satisfaction [20] and nursing performance [21].
High self-efficacy may also increase nurses’ intention to stay. “Self-efficacy” reflects an individual’s belief that they have the motivation and abilities (e.g., cognitive resources) necessary to perform a task [22]. People with high self-efficacy have a stronger belief that they will be able to carry out a required behavior successfully. When a problematic situation—such as a work-family dispute—arises, individuals with higher levels of self-efficacy may be able to solve the problem more easily. Accordingly, the level of work-family balance conflict has been found to decrease as self-efficacy increases in work and family roles [23]. In addition, as previous studies have reported, self-efficacy decreases intention to leave [24, 25].
Previous studies have been conducted to identify the influencing factors related to intention to stay [10, 11], but few studies have been conducted on nurses returning after parental leave. Therefore, we tried to analyze the factors related to nurses' intention to stay after coming back from parental leave in consideration of existing knowledge. We hypothesized that work-family balance conflict, social support, and self-efficacy impacted intention to stay. The specific research objectives were as follows: i) identify the general characteristics of the participating nurses, their levels of intention to stay, and associated factors; ii) identify differences across intention to stay after parental leave according to the general characteristics of the nurses; iii) identify correlations between intention to stay, work-family conflict, social support and self-efficacy; and iv) identify the factors influencing the intention to stay including work-family balance conflict, social support, and self-efficacy.
We conducted empirical quantitative research using a descriptive and cross-sectional design to examine the factors affecting intentions to stay among nurses in South Korea.
The participants were recruited using availability sampling. The inclusion criteria were as follows: i) female nurses, ii) nurses who worked in hospitals with over 300 beds in the two largest cities (Busan and Ulsan) in South Korea, iii) nurses who have been working after returning to work from a parental leave lasting longer than 3 months, and iv) nurses with children under 8 years old. In Korea, parental leave can be taken “if there is a child under the age of 8 or if the child is in the 2nd grade of elementary school”, so this period was established. In addition, based on a previous study where the period for forming interpersonal relationships and organizational adaptation was determined after 3 months [26], nurses who had worked for more than 3 months after their leave were selected as participants. The exclusion criteria were as follows: i) nurses with children who had been treated for a chronic disease for at least 3 months and ii) nurses who refused to participate in this study. It was based on the fact that mothers who were raising chronically ill children aged 3 months or older had significantly higher parental stress than mothers who had normal children [27].
The G*Power 3.1.9.4 [28] was used to calculate the number of participants. The multiple regression power analysis with a level of significance of .05, statistical power of.90, effect size of .15, and a total 5 predictors, required a sample size of 116 as the minimum. For the effect size was estimated to the previous studies with design and variables similar to this study [10, 29]. As a result, a total of 175 questionnaires were used for the analysis, which met the minimum number of participants.
The questions about age, education, job position, working conditions, working department, and total clinical experience were obtained from the participants.
Social support was measured using the Social Support Scale originally developed by House [18] and modified by Son and Ko [30]. This scale consisted of two factors, including supervisor support (4 items) and co-worker support (4 items). Supervisor support consists of items such as “My supervisor is very interested in my relation to my work.” Co-worker support consists of items such as “I have colleagues who are very close.” Participants were asked to respond using a five-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree), with a higher total score indicating higher social support. Three of the eight questions were converted to negative questions. The Cronbach’s α of the scale in Son and Ko’ s [30] study was .79 for supervisor support and .74 for co-worker support; meanwhile, in this study, they were .80 and .65, respectively.
Self-efficacy was measured using the General Self Efficacy Scale developed by Chen et al.[22] and modified for human resource management aspects by Oh [31]. This scale consisted of single factor with a total of 8 items including “I can successfully overcome many barriers” and “I think I can do anything I have in mind.” Each question used a five-point Likert scale from 1 (strongly disagree) to 5 (strongly agree), with a higher total score indicating higher self-efficacy. Cronbach’s α for the reliability of this scale was .87 at the time of development [22], .80 in the previous study [31], and .89 in this study.
Work-family balance conflict was assessed using the Korean version of the work-family balance conflict scale [32] originally developed by Netemeyer et al. [33]. It was examined from two dimensions a total of 10 items: work toward family conflict (5 items), and family toward work conflict (5 items). An example of an item for work toward family conflict is “Work stresses and strains negatively impact my family life.” An example of an item for family toward work conflict is “There are times when I make mistakes in dealing with my work due to household or personal work.” This scale uses a five-point Likert scale from 1 (strongly disagree) to 5 (strongly agree). A higher score indicates more work-family balance conflicts. Cronbach’s α for overall scale was .90, work toward family conflict was .90 and family toward work conflict was .86 in the previous study [32], while it was .83 for overall scale, .79 for work toward family conflict, .82 for family toward work conflict in this study.
Intention to stay was measured using the Nurses’ Retention Index (NRI) originally developed by Cowin [12] and secured validity and reliability in Korean by Kim [34]. This scale consisted of a single factor with a total of 6 items, including “I intend to continue being a nurse for a period of time in the future” and “I'm looking for a job other than a nurse.” Two of the six questions were converted in reverse as negative questions. Participants were asked to respond using an eight-point Likert scale from 1 (strongly disagree) to 8 (strongly agree), with higher scores indicating a higher intention to stay. Cronbach’s α for the scale was .97 at the time of development, .88 in the previous study [34], and .92 in this study.
The data collection was collected between January 10 and February 10, 2021. After obtaining approval from IRB and the chief nursing officers of the 11 hospitals over 300 beds, the researcher directly explained the purpose and process of the study to the unit manager and the participants. Each department's nursing explained the study to each department, followed by providing the list of subjects who voluntarily indicated their intention to participate in the study. The research director explained the purpose and procedure of this study over the phone to each subject on the list, verbally confirmed their willingness to participate, and whether they met the inclusion criteria. Next, after distributing questionnaires and consent forms through each unit manager, the research subjects were allowed to fill out the questionnaires and insert them into sealed envelopes that were placed in a designated location and picked up by the researcher directly. The time required to complete the questionnaire was 10 to 20 minutes. The consent form included information on the purpose of the study, confidentiality of data, and withdrawal from the research. The collected questionnaires were kept by the researcher in a case with a padlock.
Data were analyzed using IBM SPSS (v.25.0). A descriptive analysis was performed on the general characteristics of participants, social support, self-efficacy, work-family balance conflict, and intentions to stay. Independent t-tests and a one-way ANOVA were conducted to check the differences in the intentions to stay. The post hoc test was performed with the Scheffé test. Relations among variables were analyzed using Pearson’s correlation coefficient. The normality of the variables was confirmed using Kolmogorov- Smirnov test. To check the multicollinearity and autocorrelation of variables, it was confirmed whether the Variation Inflation Factor value was less than 10 and the Durbin-Watson value was less than 2. To identify the factors impacting intention to stay, a stepwise multiple regression analysis was performed.
This study was approved by the Institutional Bioethics Committee of Choonhae College (IRB No. 1044386-A-2020-018). The participants’ responses to the survey were sealed and kept anonymous. Informed consent was obtained from all the participants. The participants were explained about the purpose and progress of the study, that they could withdraw from the research at any time, and the collected data would not be used for any purpose other than research. After completing the questionnaire, gifticons worth 5,000 were given to the research participants.
To protect personal information, all data of research subjects were treated anonymously. Data were stored in a locked cabinet, and computer files were protected from unauthorized access by setting a double password. The collected data will be destroyed after 3 years.
The average age of the participants was 35.2 years, and those with undergraduate degrees comprised the highest proportion at 57.1%(n=100). More than half (62.3%) of the participants were staff nurses, and 46.9% had 3 shifts works. The largest proportion of the nurses were working in patient wards (48.0%), and their average clinical experience was 135 months (11 years and 3 months). The majority of participants—56.0%(n=98)—had one child and 44.0% (n=77) had taken parental leave for more than 12 months. The average working period after returning was 23 months (1 year 9 months), and 53.1% (n=93) of the nurses had moved to their current department after returning to work. During working hours, most children were cared for by child care institutions (60.0%), and husbands (44.6%) mainly helped with child care after work (Table 1).
Table 1
Intention to Stay by Participants’ General Characteristics (N=175)
The average of social support was 3.23±0.54 points, within which supervisor support comprised 3.20±0.69 points and peer support 3.26±0.64 points. The average of self-efficacy was 3.51±0.59 points. The average of work-family balance conflict was 3.44±0.61 points. The average of the sub-factors of work toward family conflict was 3.80±0.64 points and family toward work conflict was 3.07±0.80 points. The average of intention to stay was 5.38±1.45 points (Table 2).
Table 2
Level of Social Support, Self-efficacy, Work-family Balance Conflict, and Intention to Stay (N=175)
The results regarding the average intentions to stay according to the general characteristics of the participants showed that there were significant differences in age (t=-2.65, p<.001) and position (t=-2.23, p=.027). Nurses over 35 years of age had a higher intention to stay than those under 35, and it was confirmed that the nurse in charge and the unit manager had higher intentions to stay than the staff nurses (Table 1).
Intention to stay was positively correlated with social support (r=.24, p<.001), and self-efficacy (r=.42, p<.001). However, a negative correlation was observed between intention to stay and work-family balance conflicts (r=-.21, p=.004) (Table 3).
Table 3
Correlations among Social Support, Self-efficacy, Work-family Balance Conflict, and Intention to Stay (N=175)
In order to identify the factors affecting intention to stay, age and job position, which were significant among the general characteristics, were used as inputs. Age was input as a continuous variable, and position was treated as a dummy variable (1=staff nurse, 0=unit manager and charge nurse) for analysis. In addition, social support, self-efficacy, and work-family balance conflict, which were significantly correlated to intention to stay, were analyzed using stepwise multiple regression as major variables. Before regression analysis, normality of the data was tested using Kolmogorov-Smirnov test, the Durbin-Watson value of 1.90 ensured the independence of the residuals, and the variance inflation factor of 1.019 confirmed that there was no multi-collinearity. An analysis of the regression model revealed that self-efficacy (β=.38, p<.001) and work-family conflict (β=-.21, p=.005) influenced intention to stay. The regression model’s explanatory power was 20%(Adjusted R2=.20, F=20.52, p<.001) (Table 4).
Table 4
Factors Influencing Intention to Stay (N=175)
There is a need for an environment in which professional experienced nurses can serve for a long time. Identifying and strengthening factors that can increase their intention to stay can reduce economic losses caused by nurse turnover and increase the effectiveness of healthcare organizations [10, 11, 29]. This study sought to offer insights into how to increase nurses’ intention to return to work after parental leave by identifying the factors affecting their willingness to work.
This study confirmed that the older the nurse and the higher the position, the higher the intention to stay. In Park and Lee’s [11] meta-analysis study examining the factors influencing the Korean nurses’ intention to stay, 13 out of 14 analysis papers (92.9%) showed the same results as in this study. A systematic review study of overseas nurses' intention to stay at work stated that nurses in their 30s and older tend to stay at the hospital for a long time while maintaining their intention to stay [35]. A study that examined social workers’ intention to stay after parental leave found that the higher the position, the higher the intention to stay [36]. However, there is a difference between the subjects of previous studies and this study. In general, it is speculated that the higher the age, the higher the job position and work proficiency, the more familiar and comfortable the existing ward, and the higher the promotion and work compensation [10, 11, 35, 36]. Based on a previous study [11] in which nurses with more than six years of clinical experience had a significantly higher intention to stay, it is necessary to view older and experienced nurses as resources to be actively utilized. However, various environmental and personal factors affect intention to stay. Future studies should analyze the personal characteristics that might influence nurses’ intention to stay of nurses after parental leave in consideration of various environments such as various hospital sizes and work wards. Therefore, it is necessary to develop an adaptation program that can restore confidence along with providing a sense of belonging and the latest information about the workplace even during parental leave. As a result, it can lead that nurses can adapt well and lead to higher intention to stay even after returning to work. In addition, policy support and support programs are required for nurses of relatively low age to adapt to work and raise children.
In this study, the factor that had the greatest influence on intention to stay was self-efficacy, consistent with the results of Han and Choi [37] and Alrasheedi et al.[24]. As noted above, “self-efficacy” refers to judgments and beliefs about one's own ability to overcome a particular situation and perform various behavioral processes or patterns [22]. High self-efficacy improves an individual’s sense of accomplishment at home and workplace, improves quality of life, and plays a positive role in overcoming negative emotions caused by stress [38]. Accordingly, self-efficacy is an important positive predictor of performance and can serve as an important means of increasing and adapting productivity to make hospitals more competitive [39]. Accordingly, self-efficacy can be improved by facilitating a sense of belonging in the workplace and providing nurses with the most up-to-date nursing information, especially for nurses returning from leaves. In addition, psychological support through counseling and the development and education of personalized return adjustment programs are essential for building self-efficacy.
The second factor influencing intention to stay was the work-family balance conflict. This is consistent with the results of a study by Jeon and Lee [40] on the effect of work-family balance conflicts on intention to stay among married female nurses. In other countries, it has been consistently reported that work-family balance conflict is the most important antecedent factor in nurse turnover intentions [41, 42]. In addition, considering that a meta-analysis confirmed a strong correlation between work-family balance conflict and turnover intentions [4], it is clear that work-family balance conflict is related to the work lives of women with children. It is difficult for married nurses to meet the demands of both their home and work lives while maintaining a balance, but if management for nurses’ return after parental leave is carried out at the organizational level, this conflict can be resolved. To support this shift, an atmosphere that emphasizes balance between work and family should be created systematically, and efforts should be made to alleviate the conflict between work and family by introducing flexible working hours, an alternative work force, and related systems.
In this study, work toward family conflict (3.80±0.64 points) was higher than family toward work conflict (3.07±0.80 points). This suggests that a woman returning from parental leave faces many difficulties balancing work and family life [13, 14]; unsurprisingly, scholars argue that women are still expected to fulfill traditional gender roles in their family lives [42]. Work-family balance conflict, which causes many problems for shift nurses [43] impacts job satisfaction and relates to intention to work [17]. Accordingly, there is a need for institutional supports that nurture work-family balance and flexible adjustments of work hours. In Korea, research on work-family balance conflict has mostly been conducted in the fields of business administration and women's policy, and research on this topic in nursing is limited. Since the number of women in nursing is absolute, research on work-family balance conflicts in the field of nursing sciences is also needed.
We hypothesized that social support would positively influence intention to stay; however, this variable was not significant in this study. Social support can be classified into various types, such as family support, co-worker support, and friend support [18]. Previous studies confirm that support from co-workers and superiors has the strongest impact on intention to stay [11, 44]. A meta-analysis study on intention to stay among Korean hospital nurses found that support from colleagues increased intention to stay [11]. In addition, an examination of the factors that influence the intention to stay among nurses in Japan, China, and Korea confirmed that organizational support can positively affect intention to stay [44]. High levels of support at work still significantly influence nurses' intention to stay. For example, Sanner-Stiehr et al.[45] found that nursing leadership still positively impacts nurses’ intention to stay, especially when leaders respond to their situational needs and present them with coherent messages and resources at work.
On the contrary, this study confirmed that social support, which was a previously expected variable, did not influence intention to stay. This was because our subjects held positions above the nurse in charge (37.7%) and their average age was over 30 years. As a result, it is thought that the support of supervisors and colleagues was limited compared to staff nurses. Experienced nurses working in hospitals experience lower levels of stress and exhaustion and higher levels of job satisfaction than amateur nurses [46]; hence, their need for peer support tends to be low [46]. In addition, social support scale used in this study had a limitation in that it was not a tool for nurses. Thus, the nurse's perception of social support may be somewhat incorrect. Hence, future research on social support with reliable instruments and intention to stay among parental leave nurses, should be carried out between different age groups and the workplace.
This study involved some limitations. Since it was conducted by recruiting nurses from general hospitals in only two regions of Korea using the availability sampling method, it may be difficult to generalize the results of the research for all nurses returning after parental leave. Furthermore, there may have been a few differences in the introduction and use of parental leave systems across the hospitals, so caution is needed in interpreting the findings. Additionally, since a self-reported questionnaire was used, it is possible that subjects responded in a socially desirable way. Future research should identify further variables that affect intention to stay by incorporating different perspectives using a mixed methods approach. In addition, there is a limitation that some of the scales used in this study were not developed for studies conducted on nurses. In the future, the use of a tool that has ensured the reliability and validity of data with respect to nurses will need further study. Furthermore, given that various parenting settings may affect the nurses’ intention to stay after returning from parental leave, further analysis will be required. Nevertheless, this study’s findings still offer insights useful for developing strategies to increase intention to stay after parental leave among nurses by identifying factors affecting their intention to stay.
This study found that self-efficacy and work-family balance conflicts significantly influence nurses’ intention to stay after returning from parental leave. These results can inspire strategies for increasing nurses’ intention to continue working in a hospital after coming back from parental leave. First, it is important to increase nurses’ self-efficacy at the individual level. Psychological supports—such as counseling, personalized programs, and administrative support—are needed to decrease nurses’ anxiety about their work performance after a parental leave. Second, policy support within the organization is needed to reduce work-family balance conflict such as, provision of flexible working hours and availability of childcare facilities in workplace. Furthermore, efforts should also be made to positively establish awareness about maternal protection system and parental leave. Responsibility for raising children is not only a problem facing individuals and families, but also a social problem; accordingly, institutional systems are needed to improve work-family balance.
