A Grounded theory study of the intention of nurses to leave the profession 1

ABSTRACT Objective: this study explores the process of the development of an intention to leave bedside nursing. Method: the process was studied from the perspective of 21 nurses using the grounded theory method. Data were collected using semi-structured interviews and the constant comparative method of Corbin and Strauss was used for data analysis. Results: according to the participants, the two main categories, "social image of nursing", and "culture and structure of the bedside", were the contextual factors that influence why nurses are leaving bedside care provision. Disappointment with a perceived lack of progress or improvement in the clinical experience formed primary psychosocial concerns for the participants. Competence and a process of self-control were steps taken by the participants. These, associated with interventional conditions produced the outcomes of the loss of professional commitment and desire to leave bedside nursing. "Failure to integrate personal expectations with organizational expectations: in search of escape" was the central category of the study that linked the categories together. Conclusion: the findings of this study provide useful information about the needs of nurses for overcoming the intention to leave bedside care. The identification of this process can help in recognizing emerging problems and providing solutions for them.


Introduction
Turnover is a critical issue for the nursing workforce (1) , negatively affecting the health system regarding both disease prevention and the health and quality of the nursing services (2) . The shortage of nurses is a global problem (3) and the turnover of nurses is very high in comparison to other healthcare professions (4) . The Council of Europe has estimated that the nursing workforce will face a shortfall of 590,000 people by the year 2020 and the intention to leave the nursing profession varies from 4% to 54% of nurses surveyed (5) . In addition, almost 72% of nurses have thoughts of leaving the nursing profession everyday (6) . In Iran, official figures on the shortage of nurses are not available, however, with a population of 75 million in 2013, it is considered that approximately 240,000 nurses are needed to service this size of population, whereas there are currently only 100,000 nurses. Even by doubling that number, the population would still have minimal access to health care (7) . In other studies with Iranian nurses the levels of intent to leave nursing are high (8) and only one third of nurses (34%) reported satisfaction with their jobs (9) . Lack of job satisfaction is likely to have a direct impact on the intent to leave the career. Given the current shortage of nurses in the country, and considering the severe shortage of nurses expected in the future due to the retirement of existing nurses, population growth, and an aging population profile (10) , it is of extreme importance to assess the extent of this problem in Iran.
A shortage of nurses and high staff turnover are recognized as detrimental to patient care (11) , quality of care (12) , and healthcare costs (13) . Costs associated with staff turnover including recruitment, financial and training issues contribute towards organizational dysfunction (14) .
To understand the decision making process through which individual nurses are influenced towards the consideration of leaving their profession requires application of a research methodology that is sensitive to individual decision making, set against the context of wider social interaction (15) . Such a depth of understanding cannot be achieved meaningfully through the use of questionnaires and closed questions.
For this reason, the present study utilized a qualitative methodology in the form of grounded theory.

It is recognized that nurses working within
Iran may face unique influences on their decision making, regarding decisions to leave nursing, or may make decisions in different ways, indeed one study identified quite different results in comparison to nurses studied elsewhere. This study found that although the nurses in Iran were not entirely happy in their work, they did not want to leave it. The author of the study was testing a model to explain this decision making process and, as a consequence of the results obtained, suggested it as an additional dimension in the development model. He proposed that other researchers investigate this concept in Iran, carrying out studies to explore the role of factors such as the labor market and employment status in this field (16) . This paper discusses the reasons that lead to an intention to leave the nursing profession, it reviews the context of decision making with regard to leaving bedside care, and studies the conditions influencing this. It is hoped that by understanding these processes, the relevant authorities will be able to formulate a strategy to retain nurses within the clinical practice. The aim of this study was to explore the developmental process of the generation of a desire to leave bedside nursing.

Method
The nurses who participated in this study were selected from several teaching hospitals affiliated to

Tabriz and Urmia Universities of Medical Sciences in
Iran. The sample selection process was based on the following criteria: 1) having a high school diploma or higher, 2) having at least one year of work experience in the clinical nursing practice, and 3) acceptance of the invitation to participate in the study. A total of 21 nurses employed in different wards of a governmental teaching hospital met the inclusion criteria and agreed to participate in the study.
Selection of the participants was initiated using purposive sampling and after the eighth interview continued through theoretical sampling (In order to complete the categories and concepts created from previous interviews) until saturation was achieved.
The study subjects took part in semi-structured Data collection and analysis in the research process occurred simultaneously (17) and the emerging theory was proposed based on the data. 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 the general transcripts.
For reporting of the qualitative study findings, the trustworthiness of methods are widely considered applicable in place of the validity and reliability associated with quantitative research (18) . In the present study four supporting processes of trustworthiness were applied, namely conformability, dependability, The conformability and consistency of the analysis were maintained through research team meetings to discuss and dissect the preliminary findings. Thematic analysis and the coding process occurred through consensus, and to increase the transferability of the findings, a description of the context, selection and demographic data of the participants, data collection and the analysis process was presented so that the reader would be able to determine whether the results are transferable to other environments (19) . The study was approved by the Ethics Committee

Results
Data were presented using the framework The nurses said they had no power at the bedside, and they felt there was no improvement or progress in the healthcare system. Their clinical skills were ignored and neglected by their managers; meanwhile any minor flaws they exhibited were magnified and blown out of proportion. Due to the fact that bedside care did not fully satisfy their needs, they were seeking other opportunities to satisfy their needs related to ways to progress in the system. Therefore, their main concern was the lack of opportunity for professional development.

Interventional Conditions
The coping strategies of the participants were also affected by the interventional conditions (conditions prohibiting nurses from leaving bedside care) "having a role in society" and "having a job and income".

Having a role in society
Some participants stated that they tolerated the poor clinical conditions because it gave them a role in the family and society. This is because when they work, they are considered part of the community and thereby have a role to fulfill. Participant

Employment and income
The majority of the participants believed that having a permanent job was a good thing as it allowed them control in their lives, however, they were also sure that they did not want to spend all of their time
included self-control shaped by the conditions generating concern. Describing characteristics of this class include "avoiding," "tolerance" and "routinecentered performance".

Outcomes
The participants used active and passive strategies to overcome perceived social and psychological problems, leading to subsequent consequences. These consequences were located in a spectrum ranging from being forced to leave bedside care through to persevering with it.

Loss of effective professional commitment
The participants continue providing bedside care,  of the nurses identified that, due to the difficulties related to the profession, such as low pay, irregular working hours etc., they would not be satisfied if their children chose the nursing profession as a career (20) .
If the relationship between doctors and nurses is not based on participation, equality, trust and respect and doctors look upon nurses as worthless and incompetent people, nurses will feel uncomfortable in their work and will not progress due to feelings of www.eerp.usp.br/rlae 7 Alilu L, Zamanzadeh V, Valizadeh L, Habibzadeh H, Gillespie M.
inferiority (21) . This shows that nursing professionals need to be valued and acknowledged for their work (22) .
According to the findings of this study, the culture and practice of bedside care is the main factor causing participants to leave this setting. A literature review showed that excessive workload, lack of facilities and support services, manpower shortages and insufficient ratios of nurses to patients were considered to contribute to the generation of the intention to leave nursing (23) .
Constant comparison analysis of the data indicated that the main psychosocial problem, that is the main concern identified by the nurses participating in this study, was the lack of opportunities for advancement and promotion. Studies have shown that there is a relationship between individual performance and turnover. The imbalance between personal effort and the reward gained is directly related to the intention of nurses to leave (24) . This is what the participants referred to as 'weakness' in this study.
The study participants faced limited opportunities for development and used strategies to overcome this, following the specified processes including the two steps of competence and self-control. The results of this study present differences and similarities with some national and international studies. An interesting finding of this study, contrary to similar research (25) , is that the coping strategies applied to overcome any intent to leave bedside care were more evident in person-oriented actions, while the role of the management and organization was weak. Another difference between this study and other studies (26)(27) is that the nurses here did not experience fatigue from the exposure to problems, even though they showed some degree of wanting to leave the bedside.
The results of the investigation (28) showed that empowerment is a predictor of job satisfaction and a factor supporting the retention of employees in the workplace and in determining whether they will avoid leaving the profession.
In this study it was found that the participants generally experienced an intention to leave bedside care. This finding is consistent with the findings of other researchers who revealed that the intention to leave is one of the most realistic predictors of real staff turnover (29) .
It should be noted that employee turnover is not only a financial burden for organizations, but also generates pressures leading to other staff considering leaving clinical care. In addition, because of the loss of manpower and the inability of organizations to rapidly employ replacements there is a subsequent reduction in the quality of the service delivered, with the consequence of reduction in service efficacy and increased patient dissatisfaction (30) .

Limitations
The

Conclusion
The findings of this study provide useful information about the needs of nurses for overcoming intentions to leave bedside care. The identification of this process can help us to recognize emerging problems and offer solutions for them.