Nurses’ and midwives’ job satisfaction and retention during COVID-19: a scoping review

The search terms for this review were developed using the PCC mnemonic: Population, Concept and Context. The Population, Concept, and Context (PCC) mnemonic was applied in the early stages of developing the research question, which together with the review’s inclusion and exclusion criteria, directed the scope of search terms used in the process of searching and screening the literature [13, 15] (Table 1).

Population comprised registered nurses and midwives employed in frontline bedside roles, or in education, administration, research, or leadership. Health care workers, licensed practical nurses, enrolled nurses, nursing and midwifery students, and assistants in nursing and midwifery were excluded, due to their different scopes of practice. Concept is defined as the intrinsic and extrinsic factors shaped by the COVID-19 pandemic that have impacted job satisfaction and career intentions of registered nurses and midwives. Specifically, this review prioritised studies that explored how these pandemic-influenced factors might drive nurses and midwives to either continue in their current professions, contemplate departure, or even consider entirely different career pathways. Intrinsic factors are characterised by specific attributes including age, sex, marital status, educational attainment, psychological capital (self-efficacy, hope, and optimism), perceived readiness, mindfulness, coping methods, and resilience, among others [16, 17]. Alternatively, extrinsic factors are external constructs that directly influence the practical environment in which care is delivered. They encompass organisational concepts such as key policies and procedures, and broader system management which includes staffing, workload modelling, human resources, management structures, logistics, workplace culture, and support services [18, 19].

An initial series of searches was conducted by the first author to ascertain the breadth and depth of the topic. The following electronic databases were searched for relevant studies from 2019 to 2023: the Cumulative Index of Nursing and Allied Health Literature (CINAHL), PubMed, MEDLINE (Ovid), and PsychINFO, integrative reviews and individual studies. Once the initial exploratory search had been conducted, a comprehensive search strategy of keywords and MeSH terms was developed for Ovid. The nomenclature identified in the titles and abstracts of relevant articles, as well as the index terms used for their description, were utilised to develop the search strategy. Consistent with the PCC criteria, MeSH headings related to job satisfaction, retention, COVID-19, nurses, midwives, and health settings were included in the search. An example of some of the keywords and terms is presented below in Table 2. The Search Strategy is detailed in Appendix A.

The search strategy, keywords and index terms were peer-reviewed by the university librarian and three other authors. Key terms and index phrases were modified to suit each specific database. Additionally, the reference lists of all chosen sources were examined to identify any further relevant studies. Initially, the focus of this scoping review was on identifying research conducted in Australia and New Zealand, with the aim of uncovering existing or ongoing work relevant to the field within these specific regions. However, as the search progressed, it became evident that the lack of research available within Australia and New Zealand was insufficient to provide a comprehensive understanding of the topic. As a result, the scope of the review was intentionally broadened to include global research, ensuring a more robust and inclusive analysis of the subject matter.

The review was limited to studies written in English that were published between 2019 and December 2023. Studies before 2019 were excluded since COVID-19 was not prevalent or widespread before this period. The pandemic was officially declared by the WHO to no longer be a “public health emergency of international concern” [20] in May 2023; however, the search dates for papers included the whole of 2023, to take advantage of any studies conducted immediately post-pandemic. A range of study designs, including quantitative, qualitative, and mixed methods approaches, are included in this review. Sources that did not align with the study objective were excluded.

A total of 1833 articles were discovered, as shown in Fig. 1. The principal literature search identified articles from MEDLINE, CINAHL, and PsychINFO. All identified citations were collated and exported into the citation management software EndNote, where the first author removed 462 duplicates. This reduced the number of articles eligible for title and abstract review to 1,371. All citations, titles and abstracts of the remaining articles were screened and assessed against the eligibility criteria to identify relevant studies for inclusion. From this subset, 44 articles were deemed to meet the eligibility criteria. The full texts of the selected articles were then examined in detail to assess eligibility. Seventeen of these articles met the inclusion criteria for this scoping review. In cases of uncertainty or inconsistency related to inclusion, the articles were discussed with three of the other authors so that a successful consensus could be reached. Reasons for exclusion of full text papers are recorded in Fig. 1: PRISMA Flow Diagram. The findings from the database search and the process of selecting studies are illustrated in the flow diagram below (Fig. 1). The flow diagram adheres to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) format [13].

The data extraction process in this scoping review is defined as 'charting', in which a descriptive summary of the results was generated [13], and a data charting form was developed by identifying variables that corresponded with the research question. No prior protocol was developed for this scoping review. The data that was charted included the authors, the journal, country, date of publication, study design, sample size and key findings (Table 3). The variables were determined independently by the first author and discussed with three of the other authors.

The following specific intrinsic factors influenced job satisfaction and retention during the pandemic: Personal Characteristics and Nursing and Midwifery Wellbeing.

Studies in this review analysed demographic factors such as age, gender, marital status, years in nursing or midwifery, years in the current job, clinical unit, and education level to assess their impact on job satisfaction and retention.

In examining the gender role, De los Santos and Labrague [26] determined that female participants displayed heightened apprehension related to the pandemic in comparison to males. This intensified anxiety arose from female participants' concerns about contracting COVID-19 and potentially transmitting the infection to their families. Building on this, Astin et al. [22] indicated a correlation between intent to resign during the pandemic and factors such as gender, marital status, and seniority. Females who were married and those individuals in senior roles were more inclined to consider resignation during this period [22].

Said and El-Shafei [33] compared the experiences of nurses at two hospitals, one general hospital and another hospital in the same city that was converted to a designated COVID-19 Triage Hospital. Nurses at the general hospital had significantly longer professional tenure. The contrast in tenure and location of work notably impacted job satisfaction levels. Participants with less than ten years of experience showed a greater intention to leave compared to those with over ten years’ experience [33]. In a different study, Zaghini et al. [37] compared the differences in work hours. In the early stages of the pandemic, participants faced significantly extended work hours and responsibilities that went far beyond their usual duties and scope of practice. This, combined with the unfamiliarity, unpredictability, and stress associated with COVID-19, exacerbated workplace incivilities and led to deteriorated working conditions, thus adversely impacting job satisfaction [37].

Educational background has also emerged as a significant personal characteristic affecting nurses and midwives during the pandemic. A key theme within the study by Alameddine et al. [21] was the significance of educational background on resilience. Nurses with a Master of Science in Nursing demonstrated greater resilience than those with a Bachelor of Science in Nursing. Such findings are consistent with prior research [38, 39], which suggest a positive association between higher educational qualifications and resilience. Interestingly however, Cornish et al. [23] demonstrated that among participants working in a specific specialty area, there was no significant difference in the intention to leave emergency department nursing between nurses with advanced postgraduate qualifications and those without.

Despite the apparent correlation between educational level and resilience, Alameddine et al. [21], found that the decision to remain in the profession was often more heavily influenced by the financial and familial obligations. In this study 38.3% of participants no longer wished to maintain their roles in nursing profession, but obligations to meet family financial needs required them to continue working in the field. This was echoed by Crowe et al. [24], who reported despair among participants as they felt trapped in their nursing roles because of familial responsibilities. Several participants openly acknowledged their desire to transition to a different career but felt impeded by financial obligations [24].

Most studies included in this review demonstrated an association between individual psychological, emotional, and physiological health and well-being, and variations in job satisfaction and retention. Alameddine et al. [21] found that 86% of participants noted a substantial rise in stress and anxiety levels compared with pre-pandemic working conditions. Zaghini et al. [37] highlighted the shock and significant surge in work-related following the transformation of the participants’ hospital into a COVID-19 Triage Hospital. In that longitudinal study, some likened their unpreparedness for the pandemic to “going to war without any weapons” [37].

In the study conducted by Sungbun et al. [34], a comparative analysis was made between participants in the most affected pandemic areas, known as the dark red zones, and those in areas less impacted by the pandemic, referred to as non-red zones. There was an inverse correlation between motivation and intention to resign in the dark-red zones, which highlights a crucial aspect of resilience. Higher motivation in demanding environments may have buffered against resignation, highlighting the need to foster engagement. Enhanced organisational support could further reduce the intention to quit. In a study by by De Cordova et al. [25], participants who doubted their organisation’s ability to provide adequate Personal Protective Equipment (PPE) for their safety were more likely to experience burnout than participants who were confident in the organisation’s ability to provide vital resources.

In circumstances where an organisation demonstrated insufficient capability to adequately address and mitigate the complexities introduced by a pandemic, the individual resilience of the nursing and midwifery workforce was paramount. Alameddine et al. [21] found that resilience acts as a mediator to compassion fatigue, and high levels of personal, work-related, and client-related burnout did not contribute to turnover rates. Participants who reported the intention to quit their job demonstrated lower resilience scores [21]. This finding aligns with the observations of Labrague et al. [30], who noted that increased psychological resilience was associated with improved mental health outcomes and lower intention to resign. Resilience has been found to act as a buffer against the negative impacts of work-related stressors, suggesting that interventions aimed at strengthening resilience could be key in improving overall job satisfaction, reducing burnout, and lowering turnover intentions [27, 31, 40‐42].

Sungbun et al. [34] revealed that both exhaustion and cognitive impairment significantly predicted consideration of resignation. Notably, these effects were reported as being more pronounced in high-stress COVID-19, dark-red zone areas [34]. In the study by Fronda and Labrague [27], more than half of the frontline nurses surveyed experienced fear of contracting COVID-19, with over 25% of nurses expressing a desire to leave their job, and over one fifth wanting to leave nursing entirely. When physical health and psychological resilience are severely strained, post-traumatic stress disorder (PTSD), depression, anxiety, and stress may result [24]. In Crowe’s et al. study [24], every participant reported experiencing moderate to severe burnout, and 87.1% showed signs of secondary traumatic stress at the time of the survey.

This study highlights the impact of stress, burnout, and health challenges on nurses' and midwives' well-being and job retention during the pandemic. Strengthening job satisfaction requires fostering autonomy, meaningful work, and personal growth while addressing common stressors to support retention.

Extrinsic factors have profound impact on job satisfaction and retention. Extrinsic factors can be broadly defined as those elements external to the individual, such as the work environment. Key areas of focus include patient acuity, staff skill mix, staffing challenges, and the availability of PPE. These factors have been grouped together under the heading of Working Environment.