A qualitative exploration of facilitators and inhibitors influencing nurses ’ intention to leave clinical nursing *

4 University of the West of Scotland, School of Nursing and Midwifery, Paisley, Scotland. ABSTRACT Objective: The aim of this study was to determine the barriers and facilitators shaping the development of an intent to leave the nursing profession, from the perspective of Iran’s clinical nurses. Method: The study was completed using qualitative content analysis And included 21 Participants who were clinical nurses with a variety of work experience across a range of clinical posts. Semi-structured interviews were used to collect data and data obtained from the interviews were analyzed and interpreted utilizing a content analysis method. Results: During data analysis, 2 main themes, 5 categories and 12 subcategories were extracted as follows. Facilitators include: (I) spoiled identity (weak social status and violation of dignity), (II) frustration (feeling subordinate including a lack of appreciation), and (III) experience of hard labor (job stress, hard work and shift work). Inhibitors include: (I) positive management behaviors (rewards and support systems), and (II) being valuable (spiritual satisfaction, the efficient presence and professional capabilities development). Conclusion: Based on the findings, it can be concluded that managers can prevent nurses from leaving clinical nursing by providing appropriate activities for them and increasing their motivation and satisfaction.


INTRODUCTION
In almost all of the countries in the world, nurse staffing constitutes the largest component of the health workforce (up to 80% in some centers).Now globally, the world is facing a workforce crisis within which one of the most striking features is the shortage of nurses (1) .Shortage of nurses and qualified nurses leaving the profession is a global problem in developing and developed countries (2) .In Iran there is no available official statistics on the shortage of nurses, but one report showed the Iranian population at 75 million people in 2013, and identified that only 100 thousand are currently available from the estimated 240 thousand nurses needed to adequately service such a number (3) .Even if the existing number of nurses is doubled, patients will still not receive care from adequately staffed teams.Moreover, according to normally accepted figures the ratio of nurses to beds is 1.5-2.An average of 2 nurses are therefore needed for each bed, but this factor is below 1 in Iran where there are 0.9 nurses per bed, again confirming that the number of qualified nurses should be at least doubled (3) .The relevance of this is highlighted by studies suggesting a relationship between nursing staff number and clinical outcomes for hospitalized patients within European hospitals (4) .
Difficulties in retaining nurses is a common concern across both developed and developing countries and has a negative impact on the provision and quality of health care, as well as impacting negatively on associated costs (5) .The number of qualified staff leaving nursing is increasing as is the volume of those voicing a reluctance to continue in the profession (6).This dissatisfaction often leading to subsequent departure from nursing (7) .A review of relevant literature confirms that the majority of nurses (71.42%) consider leaving the nursing profession on a daily basis (8) .Some researchers estimate that 30% -50% of newly graduated nurses decide to change their status or leave completely during the first 3 years of their clinical experience (9) .In Iran itself, a study of nurses suggested that the average rate of contemplation amongst practitioners to quit was high with only one-third of the nurses surveyed (34%) satisfied with their job (10).This dissatisfaction is likely to have a direct effect on their intention to leave nursing.Given the current shortage of nurses in the country and the projected worsening shortage in the future due to the impending retirement of large numbers of nurses, population growth and an aging population (11) , it is essential to assess the factors preventing and facilitating the development of an intention to leave clinical nursing practice in Iran.
Studies of nurses leaving their profession and the development of decision making around this process have been carried out mainly through the use of quantitative research methods and questionnaire surveys (12) .However, considerations required in order to fully investigate this phenomenon seem to require a multi-dimensional exploration beyond the scope of these original approaches.None of the available studies examined integrally both the factors related to turnover and the effect of these factors on turnover.It is apparent therefore that more studies need to be conducted.
There have been many studies investigating the causes of dissatisfaction and intention to leave clinical nursing (12) , however, very few nursing research papers have examined these variables in any depth through the use of qualitative research methods.Moreover, the scope of qualitative and quantitative research available on the subject could be further enhanced.As a result, the appropriateness of exploring this phenomenon through the use of qualitative research methods becomes clear within the search for a deeper understanding of the subject.Considering the interactive nature of the nursing profession and the differences in the unique understanding of each individual practitioner, it is unlikely that a full exploration of understanding can be reached through the use of questionnaires alone.Uncovering the lived experiences of people in respect to their social interactions are more amenable to the application of qualitative research and this is true for the search for a more comprehensive picture of turnover (13,14) .So, the aim of this study was to gain a deeper understanding of the barriers and facilitators of clinical nurses' intention to leave, so that programs and procedures would be developed and used to reduce the phenomenon of turnover.

METHOD
Participating were selected through the process of purposive sampling from the nursing workforce of several teaching hospitals affiliated to Tabriz and Uremia Universities of Medical Sciences in Iran.The sample selection process was based on the following criteria: 1) having a baccalaureate degree or higher, 2) having at least one year of work experience in clinical nursing practice, 3) being willing to participate in the study, and 4) having the ability to discuss t phenomenon from a nursing perspective.A total of 21 nurses met the inclusion criteria and agreed to enroll in the study.
Between May 2014 to July 2015, a period of 14 months, semi-structured interviews were used to explore the participants understanding of the phenomenon.This involved the use of open-ended questions to investigate the facilitators and inhibitors influencing nurses' intention to leave clinical nursing.Researchers interviewed each participant individually for 40 to 60 minutes at either the participants work setting (n=16), or outside of their work environment (n=5).The interview commenced with a general question about facilitators and inhibitors influencing nurses' intention to leave clinical nursing and then moved to more specific, detailed questions as the interview advanced.Such focused questions included "How does the status and image of nurses in the hospital and community affect you?" and "Is there a situation in which you have taken the decision to leave the profession, if so then explain this situation?"Interviews were recorded with permission and later transcribed.The raw data were coded verbatim using MAXQDA10 (version 10 R 160410 by udo kuckartz, Berlin, Germany), before analysis.
The 21 participants were comprised of 19 women and 3 men, were aged between 24 and 45 years, had an average age of 32 years and an average work experience of 6 years www.ee.usp.br/reeuspA qualitative exploration of facilitators and inhibitors influencing nurses' intention to leave clinical nursing (1.5 to 18 years).The educational profile of the group saw 13 of them holding a BSN and 8 having an MSN.Study participants were working in different parts of governmental teaching hospitals in Iran and 11 of them were married and 10 single.
The content analysis method as described by Hsieh and Shannon (15) was applied for its suitability to meet the objectives of this study.Through an inductive process, data were coded and categorized (16) .Data analysis continued simultaneously after the first interview until saturation was reached.Researchers encrypted the copied text, and discussed coding refinement for each emerging theme.Classified codes were categorized, compared and interpreted within the context of general transcripts.
During the study, specific methods were used to ensure rigor and trustworthiness of data collection and analysis.For reporting of qualitative study findings trustworthiness of methods instead of validity and reliability are widely expected (16) and for this study, four supporting processes of trustworthiness; conformability, dependability, credibility and transferability were applied.Credibility was confirmed by selecting the appropriate data collection method of interviews.Researchers interviewed participants for their views and experiences in their practice environment.Moreover, member check was used in addition to prolonged involvement of the researcher to increase the credibility of the data.Also, after encoding, the interview transcripts were returned to the participants to ensure the accuracy of the codes and the relevant interpretations.Dependability was established by detailed and descriptive data analysis and direct references to individual professional experiences.Raw data were translated by a professional translator from Farsi (Persian) into English and back translated to preserve maximum accuracy of participant communication within the context used.Conformability and consistency of analysis were maintained through research team meetings to discuss and dissect the preliminary findings.Thematic analysis and coding process occurred through consensus, and to increase the transferability of the findings, a description of context, participants' selection demographic, data collection and analysis process was presented so that the reader is able to determine if the results are transferable to other contexts (17) .
The present study was approved by the Ethics Committee of Tabriz University of Medical Sciences (Grant code: 5/4/3861), Iran.Before data collection, researchers obtained written, informed consent to ensure anonymity, privacy and confidentiality for participants, and emphasized their voluntary enrollment.Information on the study objectives and goals were detailed and contact information for the principal investigator was offered to answer participants' questions.

RESULTS
During data analysis, 2 main themes, 5 categories and 12 subcategories were extracted as follows and presented in Chart 1.The two main themes are the nurses' facilitators of turnover and inhibitors of turnover.

Factors Facilitating nursing turnover
Participants in this study identified that a number of factors influenced intent to leave the profession or bedside care.These factors include: (I) spoiled identity (weak social status and violation of dignity), (II) frustration (being subordinate and the lack of appreciation), and (III) hard labor experiences (job stress, hard work and working shifts).

I: SpoIled IdentIty
A positive and flexible professional identity is considered important to perform multiple roles in the qualified care of patients and reduce stress in the workplace.

Weak social situation
Nurses stated that unrealistic images of nursing in society, including negative attitudes toward clinical nurses, lack of understanding of the nursing profession and low social status are the concerning aspects of the social status of nursing, and all of these negative experiences have been reasons why participants considered leaving the bedside care of the patients.A participant (P.6) says: Apart from my family, our family believed that nursing is so much small and worthless field or at least they told me, why do you choose nursing?You should have been a doctor.

Another nurse stated:
I feel that I am looked at as an Infusion therapist in the part… (P.3)

Trampled dignity
In this study, trampled dignity presents in the forms of aggression, disrespect and contempt.Nurses stated that being subjected to these unethical behaviors spur their desire to leave bedside care.One of the nurses had this to say about how a head nurse disrespects clinical nurses: Head nurse has a good rapport with doctors and medical stu-

II: FruStratIon
A major theme emerging from this study arose from the following three subclasses: being subordinate, a lack of appreciation and the experience of hard labor.

The experience of being subordinate
Some of the participants in this study were of the opinion that the experience of being subordinate frustrated them and spurred their desire to leave bedside care.One of the nurses said: Sometimes when you feel you have enough knowledge about any nursing activity, you observe there is need to call a doctor… (P.9) In many cases, the experience of being subordinate made participants feel their role was as a person required to perform only menial tasks and as a result contributed to intention to leave the profession.Here is a statement by one of the participants in this case: I observed that physicians see nurses as only a subordinate and use you as a caretaker (P.13)

Lack of appreciation and encouragement:
Participants expressed that ignoring the role of the nurse and the importance of nursing care and an associated lack of positive feedback by the health system are the other factors that frustrate them from remaining at the bedside.They say in this case: One night we had two critically ill patients in addition to having another critically ill patient.We had also an intubated patient and until morning we two nurses work on 17 patients.At morning, the supervisor came to deliver the sector.Rather than say thank you, you work all the night until morning and did not want any auxiliary force, he found vein phlebitis and noted it.The nursing is very worthless… (P.14)  Another nurse stated: I told the head nurse that the supervisor came to the sector and complained about why I did not perform a certain action and write down the objections.What we needed was for the supervisor to come and say thanks that night for working with many critically ill patients, instead she only punishes and does not encourage us at all.All objections deter us from staying at the bedside.If she encourages one nurse, I am encouraged and I say that she attends to me (P.19).

III: the experIence oF hard labor
The experience of Hard labor was another facet of this theme.For many nurses, involvement in this profession comes with many difficulties generating associated problems including problems derived from the essence of the profession that cannot be controlled.This included dealing with infectious diseases, the requirement to work different shifts, work conditions considered unsuitable and resultant stress and work stress.

Work stress
All participants reported a wish to have fewer shifts and to spend less time in direct patient care.A tense atmosphere prevails within the clinical setting and generates stress for participants.One of the participants said: Most of the patients of the infectious sector are infected; when I work on them I always have stress.I fear they are needle stick, then I do not think I have any objective or purpose to continue life or to work and I prefer to stay out of the bedside.Because I am constrained at work here, I feel when I came here I had TB… (P.7) Another nurse state: Always I have stress in the sector.For instance, I seat in the station, always I have stress that one comes in the agitated state and … but in this sector there is no such thing … there is stress too, I am with stress (P.15)

Hard work
Nurses were forced to work in harsh environments with high work expectations and a great deal of responsibility as an undergraduate nurse.In some shifts, they were forced to deliver all patient care with only the help of a novice nurse.Staff numbers were often low though patient care still needed to be delivered.Some of the shifts were recognized as having a heavy workload and were extremely busy.Nursing work is very hard and there is no work as hard as it in any profession.Nursing is the hardest thing (P.12)

Working shifts
The requirement to undertake a high frequency of variance in shifts including double shifts and night shifts is one of the most common complaints by nurses, considered causative in generating intent to leave bedside care.They even expressed fraught memories of night shifts worked; feeling the resulting work pressure was too extensive.The main and most important factor of my dissatisfaction is work shift, where we have no holidays…we do not have a fixed schedule and our shifts are changing… (P.2) Another nurse stated: Sometimes I get tired of work, I announce colleagues, when they say come to night shift, it is like telling me to go and die.There I will die, it is so hard for me..our shifts are very compact (P.8) It was apparent that profession related facilitators generating an intent to leave the nursing profession were triggered by many factors, however nurses who were well motivated and who were clearly aware of the working conditions required within the nursing sector often continued working within the profession.The nurses were however often concerned by the poor support offered by their their managers, at times they were extremely frustrated by a lack of recognition from their managers, especially in cases where the nurse saw themselves as efficiently delivering good quality care.This often generated an intention to leave bedside care.

Deterrent Factors preventing nurses leaving
The theme is established from the two main categories of positive and valuable management behavior.These include: (I) positive management behaviors (rewards and support systems), and (II) being valuable (spiritual satisfaction, the efficient presence and professional capabilities development).

I: poSItIve management behavIorS
One of the important factors affecting nurses quitting their job is the style of management employed by managers.

The reward system
Financial incentives and other rewards, including both verbal, nonverbal and written encouragement had occasionally created a new energy and spirit in the lives of tired nurses.While this encouragement was not always received for aspects considered important and the amount of encouragement was often low, even a low amount was felt a great help for removing physical and mental fatigue, and prevented thoughts of quitting nursing… But we had good supervisors.For example, the manpower was few, extra beds were announced at night…we had critical patients in the sector…it was true that they could not send force us, because other sectors had problems, too…but supervisors recorded a fairly good report for us…(P.1)

Support
It seems that by considering the differences between individual staff abilities and additional support requirements related to shift work and working within team, managers are able to create a positive impact on job satisfaction and intentions to leave within their staff.

When I was studying MSN at the university, I set my work schedule so that I can participate in my classes without stress. My manager that wrote programs for me and really supported me. Moreover, he accepted my program. One day I was in the dorm he called me and said I know you leave at evenings and nights but I need you for one evening and night, please accept if it is
possible…the manager did a lot of things for me that attracted me so that his concerns were my worries and I agreed… (P.17)

II: beIng valuable
Nurses, who see nursing as a valuable profession, show more interest and desire to leave the bedside and is harnessed in them.

Spiritual satisfaction
This is one of the most important subcategories within this theme.Some participants believe that religious beliefs are so effective that they had been able to withstand what would have been more intolerable problems in nursing.In this case, it can be pointed out: I always treat my patients as if they are my family, and I do everything I can.For instance the patient who is not conscious and does not know what I did for him, like to suction him each quarter.So, I can don't suctioning and say I did suction, because there will be no one to prove that I did it or not… (P.4)  In many cases, participants have noted receiving the blessing of patients as a factor supporting their satisfaction.For example, another nurse speaks of her experience of this kind of patients' blessing: Hence my work is very heavy, instead when I give the drug the patient blesses me and this blessing is very valuable for me (P.16)  The participants report bearing hard labors, encountered via superiors, patients or caregivers, a lack of management support, injustice and through the hope associated with reward, encouragement and spiritual development.A participant suggests: Finally, the things we do will be seen by God even if colleagues don't see (P.18)

The efficient presence
Feeling they were an efficient presence within the nursing profession and especially participating effectively in moments of crisis which help save the lives of other human beings makes clinical nurses value their presence in the nursing profession and reduces their desire to leave the profession.One participant in this context, said: For example, there was a situation that saved the patient in the very bad condition…I went beside the patient and saw he is not good and had nausea and vomiting, I fast took blood pressure and saw he had high pressure.It was about 17, I started my actions immediately (P.5)

Development of professional abilities
Trying to learn more and to pursue a graduate degree were other issues that were identified by the participants as supportive.The possibility of growth and professional development of nurses gives a good feeling and increases their confidence in remaining at the bedside of the patients.One of the participants said: When I came to the clinic, I did not have even power to say to an assistant to do anything and or do your task properly, then I decided to go for my PhD to hold this power when I came back to the bedside with a PhD degree (P.11)

DISCUSSION
The experience of nurses in this study showed that spoiled identity with subcategories "violation of dignity" and "weak social status" facilitates the desire to leave bedside care.Given that respect is an important element of dignity some organizations have developed guidelines for prevention against and protection from occupational harassment (18) .Negative attitudes of the public towards nursing and inaccurate imaging of the field within society are important factors reducing the incentive for nurses to remain in the delivery of bedside care.Previous research has shown that that the nature of Nursing has not always been clear and nurses continue to suffer because of the stereotyped public image of nursing.These public stereotypes could create a onerous and troublesome environment within the health care system (19) .Therefore, making it difficult for nurses to work within such environments.Sometimes there is a tendency for nurses to separate themselves from the profession as a result of the facilitator forces generated by their managers and nurse executives.The frustration caused by the lack of appreciation received was the main issue raised by participants in this study.This sense of frustration was sometimes associated with more serious reactions including the desire for separation from the nursing profession.Other studies have also shown that the public are often unaware of the independence and knowledge base underpinning nursing.In addition, in many studies most participants feel the public think that nurses are subordinates of doctors (20) .Although the nursing profession is undergoing a progressive evolution in Iran, there is ongoing need for people with higher degrees to remain within the nursing field in order to keep pace with the educational requirements of the wider world.The professional development of nurses in this country has not progressed far and clinical nurses still imagine themselves as performers of doctors orders in addition to carrying out a few basic tasks.Such a view discourages the nurses from applying the extent of their knowledge and decision-making abilities directing them towards only obeying instructions (21) .In addition, most physicians in Iran are of the view that nurses are just following their commands and consequently are helpful, but are not seen as specialists in the delivery of patient care.Such a view creates dissatisfaction in nurses, increasing their consideration of leaving the profession (22) .
In cases where the activities and efforts of nurses were ignored and the smallest defects criticized, including cases where they were severely reprimanded, they report feeling so bad and believed that, despite the many efforts they have shown in their duties, nobody appreciated them.Other studies have shown that over-emphasis on failure leads to dissatisfaction, low productivity and poor outcomes in patient care and is a primary reason for nurses leaving the profession and nurses' dissatisfaction with the profession (23) .
Hard labor experience is one of the most significant experiences of Iranian nurses.Participants in this study all considered their nursing career as continuously stressful.In another study (24) , high workload and strenuous workplace circumstances, were also identified as the main factors responsible for nurses leaving bedside care.
The experience of the nurses in this study showed that positive management behaviors with sub-categories of providing appropriate feedback through a reward system and support are the basis of enhancing the spirit of nursing staff, and are seen as one of the inhibitor guidelines preventing thoughts of leaving bedside care.Providing positive feedback appropriately is a role available to nurses which leads to a culture that is not only productive, but is also focused on promoting positive outcomes (25) .Results of a study conducted in Australia showed that a positive work environment and important attributes of nursing managers such as availability, appreciation and support of staff and consultation with them could increase the levels of job satisfaction in the system (26) .Research related to job stress, appreciation and desire to continue to work involving nurses in Jordanian hospitals, came to the conclusion that appreciation shown to the nurses has a moderate though direct effect on job stress and the intent for the nurses to remain within the profession (27) .In another study with the aim of investigating the reasons why Iranian nurses left service over a ten-year period, the researchers concluded that the nurses believed that lack of attention of their employers to their comments and a corresponding lack of support by managers and supervisors when needed, are the most important influence on turnover within the nursing workforce (28) .
Participants in this study expressed that the sense of worth, with sub categories of spiritual satisfaction, being an efficient presence and the development of professional capabilities were the other concepts that inhibit the development of an intention within nurses to leave clinical care.The general importance of spirituality and subsequent attention to moral aspects of the job among the Iranian population has brought about consideration of a broader perspective beyond the material and formal aspects of nursing considered in other locations.In another qualitative study, it was also found that clinical nurses in Iran attributed much of their motivation to their spiritual beliefs (29) .In any profession when a person feels in a position where a major responsibility rests with them, they generally exhibit a more positive focus toward their career.Yet in many hospitals in our country due to the shortage of nurses, the division of labor in the public sector is unfolds in a way that sees high patient to staff ratios and nurses who are frequently overworked.Nurses frequently do not have enough time to spend with patients.This has led nurses to feel less engaged with patients and thus carry out their duties as a series of mechanical tasks without actually seeing the patient.This approach reduces the development of a sense of belonging to the profession.This is despite many studies showing that working conditions wherein staff are praised and rewarded forms the basis for creating a positive professional environment that will lead to increased job satisfaction for nurses.Progressive management initiatives such as shared information, staff support, access to resources necessary for work and access to the opportunity to learn and grow can be used to reinforce employee performance (30) .
The experience of the nurses who participated in this study and who were working in teaching hospitals of Medical Sciences cannot be predicted to be identical to that of nurses who work in different contexts of health care delivery.Since it is recognized that features of private hospitals are different from features of public hospitals, more studies should be done to explain the experiences of nurses who work in the private sector.In addition, human experience is dynamic and the nurses' job and work environment are changed by educational, political, economic and social conditions and local expectations of health care.So it would be beneficial to carry out a longitudinal study to investigate the effects of various changes on nurses' perceptions of their work environment and job requirements.

CONCLUSION
The process of leaving bedside care was found in this study to be a dynamic concept influenced by a number of variables.Influences included individual and contextual factors such as spoiled identity, frustration, the experience of difficult working conditions, feelings of worth and managerial practices.Nurses participating in this study have identified factors influencing their retention in clinical practice, and these conditions have strong significance for the profession in Iran.Difficult working conditions and working different shifts can be tolerated if they are matched by appreciation from an understanding community and supportive administrators and nurse managers.
In order to reduce staff turnover it is necessary to focus on increasing job satisfaction and career development opportunities for nurses.Improvements must be made in the organizational climate of Iranian healthcare, including a matching of individual performance with rewards sufficient to generate increased commitment this not only leads to the development of the professions image within society but also protects against reduced performance and prevents talented and hardworking nurses from leaving the profession.
www.ee.usp.br/reeuspA qualitative exploration of facilitators and inhibitors influencing nurses' intention to leave clinical nursing Chart 1 -Themes, categories and subcategories -From May 2014 to July 2015, North West (Tabriz and Urmia), Iran.
www.ee.usp.br/reeuspRev Esc Enferm USP • 2016;50(6):980-987 dents, but does not have a good rapport with the nurses that are his colleagues.Well, this whole situation makes the nurses have no desire of doing anything; of course, I look for an excuse to run away from the bedside (P.21)