What is behind the high turnover intention among hospital nurses during the full liberalization of COVID-19 and the postpandemic era in China: a 2-wave multicentre cross-sectional comparison study

The COVID-19 pandemic has had a profound impact and poses a substantial threat to hospital nurses worldwide because of the exigency and uncertainty of the situation [1]. As the fight against the epidemic progresses, on December 27, 2022, the National Health Commission of the People’s Republic of China (NHCPR) released a circular regarding further optimization of COVID-19 prevention and control measures and abruptly implemented a full-liberalization policy, eliminating daily nucleic acid testing or temperature screening for patients with COVID-19 infection [2]. In an extremely short and rapid period, the vast majority of people, including medical workers and the general public, became infected. Nevertheless, hospital nurses were compelled to confront challenges and hardships, such as the massive surge in the number of critically ill COVID-19 patients, and had to continue working even when they themselves were infected.

On May 5, 2023, the World Health Organization (WHO) announced that COVID-19 is no longer a public health emergency of international concern (PHEIC). Concurrently, the COVID-19 situation in China has transitioned to a state of sporadic, localized transmission, with the normal functioning of medical services nationwide and no large-scale outbreaks reported; this is referred to as the postpandemic era [3]. The transition of COVID-19 control measures marked a critical turning point in health care delivery and workforce management. Research has indicated that nurses are especially susceptible to physical and psychological problems resulting from excessive, high-intensity workloads and prolonged use of personal protective equipment during the COVID-19 pandemic [4]. This, in turn, is associated with increased turnover intention [5].

Nurses constitute the largest proportion of hospital health care workers and play a vital role in the treatment, care, and management of patient disease progression during disease outbreaks, disasters, and emergency situations [4, 6]. Additionally, nurses have the closest contact with COVID-19 patients globally and spend more time attending to patients than other health care professionals do; thus, they are at risk of developing high-level stress and physical and psychological exhaustion [2]. Furthermore, evidence has indicated that nurses have experienced many deaths among critically ill COVID-19 patients, their relatives, and their colleagues, resulting in enormous psychological burdens [7]. During the COVID-19 pandemic, a meta-analysis revealed that the overall prevalence rates of burnout, depression, anxiety, insomnia and psychological distress among health care workers were 37.4%, 31.8%, 34.4%, 27.8% and 46.1%, respectively [8]. After the sudden full spread of COVID-19, nurses experienced acute and aggravated psychological problems. A multicentre cross-sectional analysis during the full liberalization period of COVID-19 revealed that frontline nurses experienced turnover intentions (37.66%), depressive symptoms (69.20%), anxiety (62.51%) and insomnia (76.78%) [2]. More importantly, poor psychological health among nurses is a crucial predictor of turnover intention [9]. Given the shortage of nurses, exploring the factors associated with nurses’ turnover intentions and reducing turnover are essential issues that nursing managers and scholars need to pay attention to.

Turnover intention, which pertains to employees’ propensity to withdraw from their current positions and explore new prospects, is a critical predictor of turnover; however, it does not invariably translate into actual turnover [10]. Nurses are more prone to having higher turnover intentions than those in other professions. Research has shown that the proportion of hospital nurses with turnover intentions ranges from 20.2–56.1% [11], indicating that the nursing group is unstable and is in constant flux. Previous public health emergencies, such as SARS in 2003 and the recent COVID-19 pandemic, have significantly impacted healthcare workers’ turnover intentions. During the SARS outbreak, studies reported increased turnover rates among nurses [12]. Similarly, the COVID-19 pandemic has created unprecedented challenges for healthcare systems worldwide, potentially affecting nurses’ career decisions [13]. A cross-sectional study conducted during the normalization of the COVID-19 epidemic (between September 2020 and May 2021) in Guangdong Province, China, revealed that 64.5% of nurses had high and very high turnover intentions [13]. Furthermore, the State of the World Nursing 2020 announced that the global shortage of hospital nurses will reach 5.7 million by 2030, indicating that the high turnover rate of nurses will undoubtedly pose a formidable challenge to the Chinese health care system [14]. Given these concerning trends and their potential implications for healthcare delivery, continuous monitoring of nurses’ turnover intentions in the post-pandemic era becomes increasingly critical for developing effective retention strategies and maintaining healthcare workforce stability.

Currently, abundant evidence has demonstrated that turnover intention is the direct antecedent of turnover behaviour, which strongly predicts actual turnover [15]. Turnover intention can significantly impede progress in one’s nursing career. Frequent nurse turnover has numerous negative effects on nursing work quality, patient outcomes, and medical organization stability, among other factors; this may give rise to emotional instability and slack conduct among other nurses within the organization and exacerbate the potentially high costs for hospitals in terms of new staff recruitment, hiring, and training [16], especially in the remote and poverty-stricken rural areas of China, where there is a shortage of hospital nursing staff [17]. The loss of experienced nurses, especially those with specialized skills, can detrimentally affect the provision and continuity of nursing services, potentially leading to higher incidences of nursing-related adverse events and patient mortality [18]. Consequently, a deeper understanding of turnover intention facilitates decision-makers in taking preventive measures to curtail or even eliminate nurses’ turnover intention prior to actual turnover, thereby saving costs for the organization [15].

During the COVID-19 pandemic, the prevalence of turnover intentions among hospital nurses and nursing assistants was already substantial [19]. Nevertheless, as far as we are aware, there is minimal knowledge regarding turnover intention and its changing trends among hospital nurses from the full liberalization of the pandemic to the postpandemic era. Moreover, a comparative study on the turnover intentions of Chinese hospital nurses in these two critical time periods has not been reported to date. This dearth of information may prevent nursing managers and policy-makers from devising preventive and promotive interventions to mitigate the adverse consequences of turnover intention.

Additionally, it remains unclear which potential factors might be associated with the turnover intention of nurses in different periods, and this lack of research may impede timely and effective interventions for turnover intention. To fill this gap, the current study conducted a 2-wave multicentre cross-sectional comparison study of Chinese hospital nurses during the full liberalization of COVID-19 (T1: 27 December 2022 to 7 January 2023) and the postpandemic era (T2: 11 May to 23 May 2023). The aim of this study was to determine the prevalence of turnover intention and identify its significantly associated factors among nurses in different periods of COVID-19 and in the postpandemic era. Consequently, our study will make a positive contribution to the literature, enabling nursing managers and policy-makers to closely monitor turnover intention, investigate its antecedents, and implement targeted strategies to reduce nurses’ turnover intention.

In this pioneering 2-wave, multicentre cross-sectional study examining nurse turnover intentions during the full liberalization of COVID-19 and postpandemic periods, we found consistently high prevalence rates, with no significant decline between the two time points. The prevalence rates were also higher than those reported in other studies conducted among hospital nurses at the onset of the COVID-19 outbreak [13, 32, 33]. Despite the return to normal operations in the postpandemic era, the persistently high turnover intention rates suggest enduring impacts of the pandemic on the nursing workforce, warranting continued vigilance and intervention. Continuous monitoring and tracking of turnover intention are necessary, along with the identification of appropriate response and intervention strategies, which are consistent with previous research.

The results indicated that mental health issues, including anxiety, depression, and insomnia, were positively correlated with turnover intention among nursing staff. Several studies have verified the significant positive associations between anxiety, depression, insomnia and turnover intention [34‐36]. Moreover, anxiety and depression have been consistently identified as predictors of turnover intention in previous studies [37]. Notably, after adjustments were made for other variables, anxiety and insomnia ceased to be predictors of turnover intention among nurses. Additionally, depression was not significantly associated with turnover intention during the initial stage of the full liberalization of COVID-19 (T1) but became significant during the postpandemic era (T2). However, Tabur et al. demonstrated that anxiety and depression were not predictors of turnover intention among health care professionals [38]. The result appears to be consistent with our study, and this finding can be largely attributed to the differences in the statistical analysis methods used [34]. Given the significant correlation between anxiety and depression scores, statistically significant results may vary when anxiety and depression are simultaneously incorporated into the same model [39]. On the other hand, the aforementioned results might be related to the numerous variables included in the prediction model [33]. Given that many variables are incorporated into the equation for joint prediction, the effect of depression could be weakened or interact with other factors [31].

Analogous to the outcomes of prior studies, psychological factors such as life satisfaction are crucial elements in relation to turnover intention. Life satisfaction can be gauged by general well-being. In the present study, life satisfaction was negatively correlated with turnover intention among nursing staff, and these results paralleled those of previous studies [40,41], indicating that enhancing nurses’ well-being can mitigate their turnover intentions and turnover rates. According to the literature, a favourable sense of well-being can significantly augment nurses’ psychological resilience and mental health and is associated with lower absenteeism and turnover intention [42]. Consequently, preventive and promotive interventions as well as positive psychology interventions should be implemented to the fullest extent possible to curtail the occurrence of turnover intention among nurses.

In this study, nurses’ turnover intentions were significantly affected by their job satisfaction. Nurses who are dissatisfied with their nursing work are more prone to leave their workplace, which is consistent with the results of previous studies [43]. A cross-sectional study in Ethiopia indicated that hospital nurses who were unsatisfied with their job autonomy were 2.55 times more likely to intend to quit their jobs than those who reported satisfaction [43]. Turnover theory emphasizes that turnover intention stems from workers’ dissatisfaction, and our study supports this theory [44]. To alleviate nurses’ turnover intentions, effective intervention measures should be implemented in a timely manner to increase their job satisfaction. Another significant predictor of turnover intention in hospitals was nurses’ interest in their nursing work. Specifically, nurses who lack interest in their job usually lack clear career goals and planning; more seriously, they may even question their competence in the job. Ultimately, such nursing staff may have greater turnover intentions. Some prior studies have suggested that professional nurses in emergency or critical care medicine are more likely to experience greater overwork and stress than those in other departments are, which could lead to greater turnover intentions [45]. However, no such associations were found in the current study. Because the nurses in the 2-wave multicentre survey were mostly medical, surgical, and outpatient nurses, with a low number of nurses from the emergency department and ICU, the results of our study differed from those of previous studies. Therefore, the working department may not be a factor influencing turnover intention among chinese nursing staff, and further studies are needed to clarify this issue.

Furthermore, our findings demonstrated that contemporary contract nursing staff, compared with no fixed-time contract staff and administrative nurses versus clinical nurses, presented a higher turnover intention rate at T2. The primary reason might be that the proportion of contemporary contract nurses (81.99% at TI and 85.19% at T2 in the present study) was greater than that reported by Cao [46] (65.72%) and Chen [47] (69.46%), potentially contributing to greater turnover intention. Because the 2-wave multicentre survey was conducted during different special times, the above results were not significant at T1, which also verified that the factors associated with high turnover intention during different periods were not uniform. Specifically, the Chinese nursing employment system has two parallel types of employment for nursing staff: no fixed-time contract nurses and contemporary contract nurses. Although both types of nurses perform the same work, contemporary contract nurses receive lower salaries and fewer benefits than no fixed-time contract nurses do [48]. Consequently, contemporary contract nurses are more inclined to leave their positions. To reduce nurse turnover, the Chinese government should prioritize the formulation of rational policies to eliminate the disparities between no fixed-time contract nurses and contemporary contract nurses and increase development opportunities for hospital nursing staff [49]. Our study revealed that administrative nurses had an elevated risk of turnover intention compared with clinical nurses. Although these administrative nurses had relatively successful professional careers, more work experience, better positions, and higher salaries, turnover intentions did not tend to decrease. It is possible that these nurses were engaged in more nursing management, quality and safety work. Moreover, the appointment of administrative nurses is relatively conservative in chinese hospitals, as most administrative nurses are selected from those with excellent clinical skills and rich nursing knowledge [50], regardless of their management abilities and without further administrative training. Thus, administrative nurses have few standards to guide their work [51] and may feel inadequately qualified for their position, especially during special periods of public emergency.

The findings of this study are potentially beneficial in guiding hospital administrators to comprehensively understand nurses’ responses regarding turnover intentions during the pre- and postpandemic eras and further facilitating the provision of preventive and promotive interventions to mitigate turnover intentions and enhance the mental health of this particular group. This study has clarified the factors associated with the turnover intentions the nursing profession during the full liberalization of the COVID-19 period and during the postpandemic era.

There are several limitations to this current study concerning the sample size and sampling approach. First, the convenience sampling method might not be representative or applicable in a generalizable manner to hospital nurses in China. The impact of the COVID-19 epidemic on nursing staff turnover intentions could have been either overestimated or underestimated. We were unable to determine the prevalence of turnover intention among hospital nurses who did not participate in our research. Second, given the constraints associated with using correlation scales for turnover intention, intolerance of uncertainty, life satisfaction and mental health, this 2-wave cross-sectional design restricts the explanation of causal relationships. Future longitudinal research is needed to accurately track alterations in turnover intention and mental health among nursing staff.

In conclusion, the current study initially depicted the prevalence of turnover intentions among chinese hospital nurses during the two crucial periods, namely, the full liberalization of COVID-19 and the postpandemic era. Despite the return to normal in the postpandemic era, the COVID-19 pandemic has had a long-term and profound negative impact on nursing work, leading to increased turnover intention and workforce shortages. Moreover, we discovered that turnover intention among hospital nurses was associated with multiple factors, such as dissatisfaction with nursing work, lack of interest in nursing, life satisfaction, depression, employment type and job duties. These findings facilitate a more comprehensive understanding of hospital management regarding the prevalence of turnover intentions among nursing staff since the full liberalization of COVID-19 and offer guidance and targeted, practical policy-making recommendations within nursing human resources departments. There is an urgent need for longitudinal studies, qualitative studies, or even mixed methods to provide further evidence concerning the development of nursing careers and the mental health of nurses. The chinese adaptations of the standardized questionnaires utilized in the current study are reliable and valid, and they can assist health care managers in identifying areas of concern within their institution and implementing effective interventions to prevent nurses from resigning and promoting their career success.

Our study recommends continuous monitoring of turnover intention among hospital nurses, implementing measures to increase nursing job satisfaction and nurse care, cultivating nurses’ interest in nursing work and providing targeted psychological intervention services. Hospital managers should fully utilize the advantages of job duties when distributing work based on the capabilities of administrative nurses to improve their management skills and guide clinical nurses to engage in nursing work with enthusiasm and initiative. According to the requirements of nurses at different levels, it is crucial to offer diverse opportunities and support to assist nurses in pursuing further education and career development, allocate human resources rationally to keep them active in fulfilling their tasks, and reduce turnover rates. Moreover, the selection and training of specialized nurses constitute a highly significant career development direction. The development of specialized nursing enables specialized nurses to intensify their work in the field they are proficient in or fond of, thereby attaining a sense of professional value and accomplishment.

Simultaneously, we propose various forms of stress-reduction activities for nurses, including psychological counselling, mindfulness-based stress reduction, and sandplay, with the aim of improving their general well-being and emotional intelligence. We advocate for an increase in night-shift allowances and salaries for nurses, as well as the expansion of rewards and rest time for night-shift nurses. This ensures that nurses obtain sufficient rest after night shifts and enhances their professional satisfaction. In most developed countries, the income level of nurses typically exceeds the average social income. Under the precondition of guaranteeing the quality of nursing care and patient safety, we encourage the rational appointment and scheduling of nurses. Moreover, head nurses should endeavour to meet the individual needs of nurses while ensuring normal work operations. Only through these measures can we reduce turnover intention among nurses, enhance career satisfaction, and optimize the structure of nursing teams not only in China but also potentially in other countries.