Nurses retention: the impact of transformational leadership, career growth, work well-being, and work-life Balance

The retention of nurses has emerged as a significant concern, given the alarming costs associated with nurse shortages [1, 2]. Retaining nurses has proven to be a challenge due to the potential for burnout among nursing staff, the adoption of various leadership styles by modern managers, and the misplacement of priorities, with an excessive focus on cost reduction rather than prioritizing the well-being of staff for long-term success [3‐5]. Addressing this issue necessitates transformational leadership that is not solely focused on performance outputs but also demonstrates a genuine concern for nurse well-being—additionally, offering clear pathways for career growth that can contribute to an improved work-life balance [6, 7].

However, the health sector mainly needs help with human capital shortages, making it even more challenging to retain nurses in hospitals [8]. As a result, hospital managers are focusing on maintaining job satisfaction, improving job performance, and increasing nursing resources through strategies such as work-life balance to address the current shortage of human resources [9‐11].

The round-the-clock nature of hospital operations has long been challenging for nursing staff, balancing work and family life. High workloads, sleep deprivation, and exhaustion can strain personal relationships with family and friends [12, 13]. Healthcare organizations need to prioritize the development of a work environment conducive to nurse retention, as this directly impacts the financial stability and quality of care provided [14‐16]. The issue of nurse retention is a significant concern, with the definition evolving from simply maintaining staff levels to addressing staff retention issues, implementing long-term staffing strategies, and now expanding to include future employment and work design [17, 18].

Leadership impacts the ability to carry out tasks, influence subordinates, and enhance job satisfaction, and is also connected to the standard of patient care [19, 20]. Transformational leadership centers on an individual who, through motivation, empowers other subordinates to collaborate in building the team. It encompasses idealized influence, inspirational motivation, intellectual stimulation, and individualized consideration [21, 22]. In the healthcare setting, transformational leadership fosters group progression and attainment of higher levels of competence and capability. Multiple studies have found that the antecedents of transformational leadership are strongly linked to job satisfaction for nursing staff, including nurses and nurse assistants [23‐25].

Transformational leadership helps reduce burnout in nursing staff by promoting overall health, improving motivation, reducing job stress, and enhancing well-being [26‐28]. Transformational leadership creates a collaborative team environment where nursing staff can develop satisfying, supportive relationships and directly engage with their leaders and colleagues [29]. Transformational leadership can foster career growth through mentorship programs, professional development opportunities, and continuous education to deepen their expertise and incorporate strategic financial management into their operational roles [30, 31].

Furthermore, leaders are inclined to provide more opportunities for career growth to their subordinates [32]. The opportunity for career growth has been identified as a critical factor in retaining nurses. This growth opportunity includes work-related learning, development of potential, the chance for advancement, and opportunities for increased influence and authority [17, 33].

Career growth encourages exchanging experiences across different job domains within project teams, and training sessions demonstrate the organization's commitment to continuous change, learning, and career and personal development. Furthermore, effectively managing nurses' development in competitive career advancement planning is essential to leadership [34, 35].

Nursing well-being encompasses mental, physical, and social health while on the job [36]. Nursing is widely recognized as one of the most high-pressure occupations compared to other careers [37, 38]. The scarcity of nurses has increased work hours, placing significant strain on nurses [39]. The heightened work pressure has been found to reduce nurses' job fulfillment, leading to a decline in their commitment to their roles, ultimately resulting in consistently high turnover rates [40‐42].

Nurses frequently express worries about their employers' lack of consideration for their requests to improve work-life balance through reduced hours, flexible schedules, and a supportive work environment [43]. The challenge of balancing personal and professional life in the nursing field can result in decreased job satisfaction. More research on work-life balance in the nursing profession needs to be conducted, which has recently gained attention from researchers [44]. Studies have verified a strong connection between work-life balance, intention to leave, and staff retention, underscoring the importance for healthcare organizations to address nurses' work-life issues to enhance their overall well-being [45]. A satisfactory work-life balance contributes to a better work attitude, a strong sense of belonging, and job satisfaction. It increases the likelihood of nurses staying in their roles to support an optimal work environment [46, 47].

The concept of work-life balance involves nurses effectively managing a flexible work schedule to ensure proper time distribution between work and personal life [48, 49]. This study holds significant value as it sheds light on the essential factors influencing nurse retention, particularly the impact of transformational leadership and work-life balance. By pinpointing these critical predictors, the research offers practical guidance for healthcare organizations aiming to enhance nurse retention rates, which is crucial for maintaining high-quality patient care and minimizing costs associated with turnover. Furthermore, decreasing staff turnover and absenteeism markedly enhances nursing staff's well-being and overall health, ultimately leading to improved and more effective healthcare delivery. This, in turn, boosts the efficiency and productivity of healthcare facilities in addressing societal demands.

Moreover, the findings advance the literature on nurse retention, underscoring the necessity for targeted strategies prioritizing leadership practices and work-life balance. This research also paves the way for future investigations into additional factors, such as career growth and work well-being, which could further refine retention strategies. Our research has provided valuable insights for nurses and leaders to address to improve career growth and nursing staff retention within the nursing profession. Therefore, this study examines the impact of transformational leadership, career growth opportunities, work well-being, and work-life balance on nurse retention.

Table 1 reveals that more than half of the participants (58.9%) were between 25 and 30 years old, with a mean age of 29.8 (3.9) years, 68.4% were females, and most of them were married (68.7%). Participants' positions within their units showed that nearly half (50.2%) were nurses, while nursing technicians accounted for 18.5%. Educational qualifications indicated that a significant majority (63.6%) hold a Bachelor of Nursing degree, with secondary nursing technicians at 21.5% and nursing diploma holders at 12.5%. Experience levels vary among participants, with the largest group (42.8%) having between six and ten years of experience at their current place of employment.

Table 2 presents the total WLB score of 43.7 with a standard deviation (SD) of 6.3. The three subscales yielded the following average scores: the work interference with personal life had a mean of 22.6 (SD = 5.1), the work/personal life enhancement aspect scored an average of 11.4 (SD = 3.0), and personal life interference with work had a mean score of 9.7 (SD = 2.9). The GTL Scale revealed a total score of 18.9 (SD = 6.9). The idealized influence and inspirational motivation dimensions scored 5.4 (SD = 2.1 and SD = 2.3, respectively). Individual consideration scored 5.3 (SD = 2.1), while intellectual stimulation scored 2.7 (SD = 1.2). For the CGS, the total score was 48.2 (SD = 11.1). Within this, career goals averaged 13.3 (SD = 3.4), career capacity was at 14.6 (SD = 3.4), and career opportunities scored an average of 20.3 (SD = 5.7). The WBWS indicated a total score of 48.2 (SD = 11.1). The average scores for expressiveness and fulfillment at work were 21.9 (SD = 7.4), and positive affect was 23.5 (SD = 6.4). However, the negative affect had a mean score of 34.2 (SD = 12.5). Finally, NRIS indicated an average score of 30.8 (SD = 6.6).

Figure 2 illustrates the distribution of the NRI within healthcare settings. It showed that 43.4% of the participants had a moderate intent to retain, 32.0% had a high level, and only 24.60 had a low intention to retain within their settings.

Table 3 shows that age significantly impacted the WLBS and CGS scores. Participants aged 25 to 30 reported the highest mean WLBS score of 44.5 (SD = 6.4), with a statistically significant difference (F = 2.830, P = 0.039). For CGS, participants aged 35 to 40 showed the highest mean score of 54.4 (SD = 10.5), indicating significant differences (F = 3.630, P = 0.013). Additionally, there was a strong association between age and WBWS scores, with younger participants reporting higher scores (F = 6.578, P < 0.001). Marital status significantly influenced WLBS and NRIS scores. Single participants had the highest WLBS mean score of 44.8 (SD = 6.1), with a notable difference (F = 6.521, P = 0.002). For NRIS, divorced or widowed participants had lower retention scores (29.3 ± 4.4) compared to married individuals (31.5 ± 6.3), indicating a significant relationship (F = 3.652, P = 0.027). The educational qualification also showed substantial associations with WLBS and GTLS scores; those with a Master’s or PhD reported the highest GTLS mean score of 26.3 (SD = 7.7) and a CGS mean score of 53.6 (SD = 12.2) compared to other educational levels (F = 3.029, P = 0.030 for GTLS and F = 4.060, P = 0.008 for WLBS). Lastly, years of experience at the current place of employment affected WLBS and NRIS scores significantly; those with one to five years reported the highest WLBS mean score of 44.8 (SD = 6.1), (F = 4.261, P = 0.006). For NRIS, participants with sixteen years or more had higher retention scores than those with fewer years of experience (34.6 ± 5.0), with significance noted at F = 3.778, P = 0.011.

Table 4 presents that the WLBS had a significant positive correlation with the GTLS, CGS, and NRIS with coefficients of r = 0.154, 0.130, and 0.288, respectively (p = 0.003, 0.025, 0.001). Additionally, GTLS significantly correlated with CGS, NRIS, and WBWS (r = 0.590, 0.247, and 0.209, p < 0.001). CGS demonstrated a strong positive correlation with NRIS (r = 0.456, p < 0.001) and with the WBWS (r = 0.268, p < 0.001). Lastly, NRIS and WBWS were significantly positively correlated (r = 0.257, p < 0.001).

Table 5 reveals that the WLBS was a significant predictor of nurse retention, with an unstandardized coefficient of 0.255 (p < 0.001), indicating that the retention index increases by approximately 0.255 units for every unit increase in work-life balance. A standardized coefficient (Beta) of 0.426 further supported this positive relationship. GTLS also emerges as a significant predictor, with an unstandardized coefficient of 0.082 (p = 0.002) and a standardized coefficient of 0.171. In contrast, the CGS and WBWS did not significantly predict retention; CGS had an unstandardized coefficient of -0.082 (p = 0.154), while WBWS showed an unstandardized coefficient of -0.042 (p = 0.482). The overall model demonstrated an R-squared value of 0.234, meaning that approximately 23.4% of the variance in nurse retention can be explained by the independent variables included in the analysis with significant F-statistic (F = 22.294, p < 0.001), indicating that the model is statistically significant.

Egypt's healthcare sector is experiencing a significant shortage of qualified nurses, threatening the quality and accessibility of healthcare services. High turnover rates, driven by low wages, heavy workloads, and limited professional development, exacerbate this issue. Addressing nurse retention is essential with rising healthcare demands due to Egypt's growing population. This study investigated the impact of transformational leadership, career growth, work well-being, and work-life balance on nurse retention.

Our findings revealed that the NRIS recorded an average score of 30.8 (SD = 6.6), indicating moderate retention among most nurses. Participants experienced a balanced yet moderately variable relationship between work and personal life, with a total Work-Life Balance (WLB) score of 43.7 (SD = 6.3). Work interference with personal life had a mean score of 22.6 (SD = 5.1), while personal life interference with work averaged 9.7 (SD = 2.9). Leadership perceptions were moderate, with a total GTL score of 18.9 (SD = 6.9), and career aspirations were well-balanced, with a total CGS score of 48.2 (SD = 11.1). Emotional well-being showed variation, reflected by a WBWS total score of 48.2 (SD = 11.1), highlighting a mix of positive and negative experiences.

This could be that salary benefits, staffing numbers, administrative workloads, and the accessibility of necessary supplies are some variables that influence nurse retention. The quality of relationships with patients, their families, and co-workers significantly impacts retention, as does the extent to which nurses feel independent and empowered in their decision-making regarding patient care. Nurses are more likely to stay in their positions when they have decision-making authority because it increases their professional fulfilment and job satisfaction. Similarly, a 2018 cohort study involving 21,050 newly hired nurses from 304 hospitals in South Korea tracked turnover rates and risk factors over 18 months. The study revealed that 26.4% of nurses left within their first year, with 20.1% resigning in the first 6 months and 6.3% between 7 and 12 months. The turnover risk was higher with an increased bed-to-nurse ratio, suggesting that staffing levels and workload significantly influence nurse retention [68]. These findings contrast with previous research conducted at Menoufia University Hospital in Shebin-ELkom, which involved 400 nurses. The results demonstrated that more than half of the nurses exhibited low levels of work engagement and held a negative perception of talent management. Furthermore, the majority of nurses experienced poor retention rates. Overall, the study established a strong positive relationship between nurses' retention, work engagement, and perceptions of talent management [69].

Concerning socio-demographic factors, our outcomes indicate that age, marital status, education, and years of experience influenced WLBS scores and CGS. Younger nurses reported higher WLBS and CGS scores. Single nurses had better WLBS scores, while divorced or widowed nurses showed lower retention. Higher education levels, particularly Master's or Doctorate degrees, were linked to better WLBS and career growth. Nurses with 16 or more years of experience at their current workplace also had higher retention. These findings may be due to higher education enhancing knowledge, skills, and career advancement opportunities. Nurses with advanced degrees, such as a Master's or Doctorate, often experience greater job satisfaction, confidence, and work-life balance. Their qualifications offer more career flexibility, leading to higher advancement opportunities and a more manageable workload. These findings align with Garside's (2023) [70] systematic review, which emphasized that work-life balance is crucial for nurses at all career stages. Nurses consistently seek flexibility, family-friendly policies, fair compensation, and opportunities for professional development. Notably, the most satisfied nurses tend to have more experience and have recently taken on new roles. This highlights the importance of retaining nurses in the profession and suggests that keeping them in the same position when dissatisfied can be counterproductive if they feel disengaged. Similarly, de Vries et al. (2023) [71] found that nurses with more experience are likelier to remain in their roles, with retention being incredibly high among older nurses, particularly those in middle age or beyond.

The study found that better WLBS is positively linked to favourable leadership perceptions GTLS, career growth CGS, retention NRIS, and well-being WBWS. Effective leadership GTLS was positively linked to career growth and retention, while CGS positively correlates with higher retention and job satisfaction. Additionally, higher retention of NRIS is associated with improved well-being of WBWS. This can be attributed to leadership styles, coping abilities, and personal traits influencing nurses' retention. Transformational leadership is vital in improving retention by empowering, supporting, and inspiring nurses. It creates an encouraging work environment that enhances long-term commitment, reduces burnout, and boosts job satisfaction. Variations in nurses' retention rates across hospitals can often be attributed to the leadership style employed by hospital administrators. Transformational leaders address individual needs, build trust, and help reduce turnover, resulting in a more stable and committed nursing workforce.

Numerous studies supported these findings, including Farahani et al. (2024) [72], which identified six key factors influencing nurse retention: personal traits, job needs, employment services, working conditions, workplace relationships, and organizational culture. Work-life balance, career advancement, and job satisfaction were the primary factors affecting retention. While there are similarities, there are differences between retention factors in European and non-European countries, highlighting the need for multifactorial approaches to develop effective retention strategies. Thirty-four studies found that nurses stay because they are satisfied with their jobs and devoted to their organizations. The factors that permeate these notions weigh differently across generations. While not a perfect explanation, they show substantial disparities in workplace needs by age, influencing intention to stay, job satisfaction, organizational commitment, and, ultimately, nurse turnover [70]. Rony et al. (2023) [73] studied the factors affecting work-life balance in 656 nurses in Dhaka, Bangladesh, finding a positive link between work-life imbalance, unhappiness, and adverse effects on family life. They concluded that supporting work-life balance is crucial for improving healthcare productivity, patient care, and clinical outcomes. Marufu et al. (2021) [17] identified nine domains impacting staff turnover in 47 studies, including leadership, career advancement, organizational environment, staffing, and compensation. De Vries et al. (2023) [71] identified six determinants influencing job retention: organizational culture, working environment, relationships, job demands, employment services, and personal traits. Career advancement, WLB, and job satisfaction significantly influence retention. While European and non-European countries share some similarities, they also show differences in retention factors. According to Sani & Adisa (2024), leadership, mainly through transactional and transformational styles, is crucial for WLB, fostering trust-based, reciprocal exchanges [74].

Similarly, Hashish & Ashour (2020) [75] found that non-monetary strategies by nursing leaders in Egypt are essential for reducing brain drain, with economic and workplace conditions being the most impactful. Yarbrough et al. (2016) [76] highlighted that career growth and professional values are strongly linked to retention and positively correlated with career development and job satisfaction. The integrative review emphasizes that effective leadership cultivates a positive safety culture, eliminating barriers to care, and is crucial for patient safety. Leadership, a positive work environment, job satisfaction, and fewer unpleasant work experiences are all crucial factors in nurse retention. Nurse supervisors foster motivation by creating supportive environments, and specific leadership approaches have been shown to reduce psychological stress, absenteeism, and turnover, ultimately enhancing job satisfaction [77]. The multidimensional theory of commitment highlights that employee commitment, including affective, continuance, and normative components, strongly correlates with retention. Notably, normative commitment (staying out of obligation) has a more significant impact on retention than affective commitment (emotional attachment). Therefore, management should foster affective and normative commitment, providing essential tools and a supportive work environment to enhance employee engagement and retention [78].

Our regression analysis demonstrated that work-life balance and transformational leadership are significant predictors of nurse retention. Specifically, work-life balance had a strong positive influence, with a 0.255 increase in retention for each unit improvement and a high standardized coefficient (Beta = 0.426), highlighting its substantial role in predicting nurses' decisions to remain in their positions. Transformational leadership also positively impacted retention, although to a lesser extent, with a 0.082 increase in retention for each unit increase (p = 0.002). Conversely, caregiver Group Support and Workplace Bullying Witnessed did not significantly affect retention statistically. Overall, the model accounted for 23.4% of the variance in nurse retention, suggesting that enhancing work-life balance and leadership practices represents a promising strategy for improving nurse retention rates. The supportive work-life balance might explain how these findings reduce stress and burnout, increasing job satisfaction and retention. Transformational leadership also plays a crucial role in fostering support, inspiration, and professional development. Leaders who communicate well, encourage collaboration, and recognize staff contributions boost job satisfaction, empowerment, and commitment, ultimately enhancing nurse retention and strengthening the healthcare system. A cross-sectional study at King Faisal University's Hospital in Al-Khobar, Saudi Arabia, with 499 nurses, revealed that leadership styles and the availability of challenging opportunities significantly influenced retention, as indicated by ordinal regression analysis. These findings highlight the critical role of leadership and career development in enhancing nurse retention [79].

In this regard, Abdul Salam et al., [80] found a moderate correlation between resilience scores and perceptions of transformational leadership, with leadership perceptions explaining 29% of the variance in resilience. Transformational leadership emerged as a significant predictor of resilience among nurses. Additionally, Sitompul et al., (2024) [81] confirmed a positive linear relationship between work-life balance, work participation, and innovative work behavior [81]. The regression analysis showed that this relationship was significant, with an R² value of 0.291. This emphasizes the importance of supporting work-life balance and employee engagement to foster innovation.

While the study presents valuable insights, it is not without its limitations. Firstly, the reliance on hard copies may hinder the generalizability of the findings, as it restricts participation to specific care units and introduces logistical challenges. However, this method does ensure direct verification of respondents' identities, reducing the risk of duplicate responses. Additionally, online questionnaires may limit participation from individuals who lack internet access or are less familiar with digital tools, potentially skewing the sample.

Secondly, the cross-sectional design constrains the ability to establish causal relationships between the variables; a longitudinal approach could provide deeper insights into how these factors influence retention over time. Furthermore, the data relies on self-reported measures, which may introduce bias from participants' subjective perceptions and the possibility of social desirability bias. The study employed simple sampling methods, which could lead to researcher bias and may overlook certain variables related to work circumstances and leadership styles across diverse healthcare settings, ultimately limiting the generalizability of the results to other nursing contexts. Consequently, further research is warranted to address these limitations and enhance our understanding of the dynamics of nurse retention.

The results reveal moderate work-life balance challenges for participants, with work demands often interfering with personal life. Transformational leadership is positively perceived, though intellectual stimulation is lower. Participants feel they have promising career opportunities but moderate motivation for advancement. Emotional experiences indicate high levels of workplace stress. Younger, single, and highly educated individuals report better work-life balance and retention intentions. Correlations suggest that work-life solid balance and transformational leadership positively influence retention and well-being. Regression analysis confirms that work-life balance and transformational leadership are significant predictors of nurse retention.

Transformational leadership is viewed positively, yet there is a noted deficiency in intellectual stimulation, suggesting that leadership styles could be enhanced to better support staff. While nurses recognize promising career opportunities, their motivation for advancement remains moderate, indicating a need for targeted interventions to boost engagement and career development. The high levels of workplace stress reported by participants underscore the necessity for effective stress management strategies within the nursing environment. Interestingly, younger, single, highly educated nurses report better work-life balance and retention intentions, suggesting that demographic factors affect how work-life balance is perceived and managed. The positive correlations between work-life balance, transformational leadership, and nurse retention emphasize the importance of fostering a supportive workplace culture prioritizing employee well-being. To improve retention rates and overall job satisfaction among nurses, healthcare organizations should consider implementing policies that promote work-life balance, such as flexible scheduling and opportunities for professional development. Training programs focused on transformational leadership could also enhance managerial support and create a more stimulating work environment.