key: cord-0729160-sbp7k287
authors: BELL, Mary; Sheridan, Ann
title: How Organisational Commitment Influences Nurses’ Intention To Stay In Nursing Throughout Their Career
date: 2020-10-11
journal: Int J Nurs Stud Adv
DOI: 10.1016/j.ijnsa.2020.100007
sha: db378e72e0f0198dc981a8d43e7b21ddf6bcad79
doc_id: 729160
cord_uid: sbp7k287

BACKGROUND: : The current COVID 19 pandemic brings into sharp focus the global necessity of having sufficient numbers of nurses and the dire impacts of nursing shortages throughout health systems in many countries. In 2020 retaining skilled experienced nurses continues to be a major global challenge. The dominant and consistent concentration of workforce research to date has focused on attitudinal factors including job satisfaction and burnout and there is limited research on how organisational commitment in combination with job satisfaction and burnout may explain what keeps nurses in nursing. OBJECTIVES: : To measure how organisational commitment in combination with job satisfaction and burnout relate to the intention of Registered General Nurses’ staying in nursing (ITSN). DESIGN & METHODS: : A quantitative descriptive design using a cross-sectional survey was utilised. A national postal survey of a representative sample of registered general nurses employed within the Republic of Ireland (ROI) health services was undertaken in 2010. A number of established valid and reliable instruments were used to measure attitudinal factors and their relationship with intention to stay (ITSN). Data were analysed using IBM SPSS version 24.0 and descriptive, correlational and multiple regression analysis were undertaken. RESULTS: : A total of 756 registered nurses participated in this study. The strongest predictor of intention to stay in nursing was organisational commitment (β=.32, p=.000) while burnout and job satisfaction had a significant relationship with ITSN. CONCLUSION: : Results reveal the complex and multidimensional nature of ITSN with the majority of nurses having a strong intention to stay in nursing. Organisational commitment and low burnout represented predictors which are influential in nurses remaining in nursing throughout their career lifespan. These results remain relevant in 2020 particularly in light of the ongoing pandemic when retention and recruitment of skilled and experienced nurses to the workforce will be critical to the management of health care, considering the increased nurse vacancy rates in many countries and the evident lack of resolution of the issues raised from this study.

A quantitative descriptive design using a cross-sectional survey was utilised. A national postal survey of a representative sample of registered general nurses employed within the Republic of Ireland (ROI) health services was undertaken in 2010. A number of established valid and reliable instruments were used to measure attitudinal factors and their relationship with intention to stay (ITSN). Data were analysed using IBM SPSS version 24.0 and descriptive, correlational and multiple regression analysis were undertaken.

Results: A total of 756 registered nurses participated in this study. The strongest predictor of intention to stay in nursing was organisational commitment (β=.32, p=.000) while burnout and job satisfaction had a significant relationship with ITSN.

Results reveal the complex and multidimensional nature of ITSN with the majority of nurses having a strong intention to stay in nursing. Organisational commitment and low burnout represented predictors which are influential in nurses remaining in nursing throughout their career lifespan. These results remain relevant in 2020 particularly in light of the ongoing pandemic when retention and recruitment of skilled and experienced nurses to the workforce will be critical to the management of health care, considering the increased nurse vacancy rates in many countries and the evident lack of resolution of the issues raised from this study.

What is already known about the topic:

 Job satisfaction is associated with nurses staying in their job  Nurses are more likely to stay in the job if they are satisfied with the safety and quality of patient care they can deliver What this paper adds:

 Commitment to the organization is a stronger predictor of intention to stay in nursing throughout a career lifespan than job satisfaction  Nursing demographics influences intention to stay in nursing and in particular organization commitment  The combination of low burnout, supportive co-workers, facilitative scheduling and good effective social interaction influence nurses to stay in nursing throughout their career lifespan

Despite two decades of extensive focused nursing workforce research, quick fix solutions to resolve the increasing global nursing shortage have yet to be found. It is estimated that there is currently a global shortage of 7.2 million nurses while shortages of at least 12.9 million nurses by 2035 are predicted (WHO,2018) . Indeed, the current COVID 19 pandemic has highlighted the global necessity of having sufficient numbers of nurses and shines a light on the catastrophic impacts of nursing shortages throughout health systems in many countries. While nurses remain the largest group of health service employees accounting for 60% of the healthcare workforce globally and delivering an estimated 90% of primary healthcare services (WHO 2020), a recent report on nurse staffing trends indicates clearly that the problem of retaining nurses will not be resolved anytime soon (Buchan et al.,2019) . How to retain nurses remains contentious with the predominant singular solution of adequate nurse staffing levels as a panacea for increasing patient safety outcomes and consequently increasing nurse retention (Aiken, Sloane et al. 2012) . However, the bulk of reported workforce research focusses on nurses working in acute hospitals and frequently concludes that multiple additional factors influence nurses' intention to stay reflecting both the reality and the complexity of the problem. Yet, there is a limited understanding of how nurses try to stay in nursing throughout their career (whether in tertiary, secondary or primary care) and what the factors are that contribute to this.

This paper reports on a component of a larger study that explored nurses' intention to stay in nursing throughout their career lifespan. Informed by a conceptual framework of intention to stay in nursing (ITSN), previously identified factors including job satisfaction, stress/burnout and organizational commitment were investigated on general nurses working throughout the health services in the Republic of Ireland (ROI). This study sought to ascertain how these factors work together to influence nurses' ITSN and to gather an insight at one point in time of nurses working in many different areas throughout the country. The results of this study continue to be as relevant in 2020 as they were when data collection was conducted, and this is particularly so given the continued high turnover rates reported which challenge retention (INMO 2019), coupled with the absence of any evident resolution of the issues raised from this study to promote ITSN. Moreover, the data gathered for this study was at the start of the global recession whereby funding for health services in ROI and throughout the world resulted in contraction of services and reduction in nursing workforce levels which still have not recovered. The global economic impact of COVID-19 with the global shutdown of production, travel and construction is likely to result in similar recessionary outcomes compounded by the need to invest significant amounts of additional funding in health care to mitigate the large-scale impact of the pandemic.

Intention to stay is an attitude and a behaviour that has not yet occurred (Al-Hamdan, Nussera et al. 2016 ) and is a strong statistically direct cognitive antecedent of retention (Price and Mueller 1981) .

While intention to stay has been interpreted and investigated in a number of ways within the workforce literature, there remains a lack of clear discrimination between this concept and similar constructs adding to the confusion and the inability to clearly compare results (Efendi, Kurniati et al. 2019) . For example there is a lack of clarity as to whether the nurse's intention to stay is within the current position (Cowden and Cummings 2012) , the current organisation (Krausz, Koslowsky et al. 1995 , Zeytinoglu, Denton et al. 2006 or within the nursing profession (Flinkman, Leino-Kilpi et al. 2010) . In this paper, intention to stay in nursing (ITSN) is defined as the nurse's perceived likelihood of staying within the nursing profession or leaving to find non-nursing work (Cowin 2001) . Three key factors are consistently related to intention to stay within the literature and include: job satisfaction, burnout and organisational commitment.

Job satisfaction is universally accepted since the 1930s as a significant predictor of employees staying or leaving their employment. Despite the abundance of research conducted on nurses' job satisfaction, the level of knowledge still remains limited (Lu, Zhao et al. 2019) . Job satisfaction is defined globally as an affective response an individual has to the job and/or to aspects of the job (Dilig-Ruiz, MacDonald et al.

). There is considerable evidence indicating the direct effect of many factors such as stress or burnout on job satisfaction but there are still many indirect effects of job satisfaction that remain unknown (Lu, Zhao et al. 2019) . Numerous theoretical models, pathways and mediators in the literature (Lu, Zhao et al. 2019) with the predominant focus being on how healthy, safe work environments effect nurses' job satisfaction and retention (Wei, Sewell et al. 2018 ) are being used to identify such effects. Factors such as the importance of workplace relationships (Lin, Viscardi et al. 2014 , Olsen, Bjaalid et al. 2017 , Wei, Sewell et al. 2018 , Yasin, Kerr et al. 2020 ), scheduling (Dall'Ora, Ball et al. 2016 , Ferri, Guadi et al. 2016 , Dilig-Ruiz, MacDonald et al. 2018 , leadership (Ulrich, Lavandero et al. 2014 , Wei, Sewell et al. 2018 , nurse-patient ratios (Aiken, Sloane et al. 2014 )and the connection between nurses' job satisfaction and better patient satisfaction (Chang and Zhang 2012, Lu, Zhao et al. 2019 )are but a few. There is however growing evidence that job satisfaction is related to intention to stay in the profession (Wang, Tao et al. 2012 , Sabanciogullari and Dogan 2015 , Lo, Chien et al. 2018 .

Burnout is a complex multidimensional construct, defined as a psychological response to chronic emotional and interpersonal work-related stressors with a core element being exhaustion whether physical, emotional and/or cognitive (Maslach 2001 , Squiers, Lobdell et al. 2017 , Rodriguez, Luck et al. 2018 ). Stress and burnout have been linked previously with compassion fatigue and/or secondary traumatic stress disorder (Beck 2011 , Li, Early et al. 2014 . The impact of burnout is known to have detrimental effects on employees' health such as a higher risk of cardiovascular disease, type 2 diabetes , hypertension and musculoskeletal disease (Richardson and Rothstein 2008) as well as resulting in higher turnover rates within organisations (Rodriguez, Luck et al. 2018 ). Some studies have identified a positive relationship between stress and intention to leave (Parasuraman 1989 , Zeytinoglu, Denton et al. 2006 , Chan, Tam et al. 2013 , burnout and intention to leave (Flinkman, Laine et al. 2008 , McGilton, Tourangeau et al. 2013 ) and a negative relationship between burnout and intention to stay (Jiang, Ma et al. 2017) .

Organisational commitment is defined as the individual's identification with, and involvement in, his or her particular work organisation and includes an individual's acceptance of the organisation's goals and values, an eagerness to work hard for the organisation along with a distinct ambition to remain working for that organisation (Porter, Steers et al. 1974 , Saridakis, Lai et al. 2020 . While predictive of turnover and positively related to intention to stay (Simon, Muller et al. 2010 , De Gieter, Hofmans et al. 2011 ,evidence also identifies that if employees believe that their work groups are supportive and cohesive, they are less critical of the organisation as a whole and are more likely to stay in that organisation (Ingersoll, Olsan et al. 2002 , Brunetto, Xerri et al. 2013 , Li, Early et al. 2014 . A recent finding indicted that commitment to the work organisation is connected to the nurse's commitments outside the organisation, implying the significance of maintaining a work/life balance (Aluwihare-Samaranayake, Gellatly et al. 2018). However, there remains a lack of consensus regarding the causality of job satisfaction and organisational commitment (Saridakis, Lai et al. 2020 ) and how they relate to intention to stay or leave.

A conceptual framework informed by the literature reviewed was developed and was adopted to drive this study. Figure 1 below provides a visual representation of the principle factors included in the framework of ITSN throughout a career lifespan. The factors that are considered the most influential to ITSN are the level 1 factors followed by level 2, 3 and 4. This paper reports on the influence of level 3 (job satisfaction, organisational commitment and stress/burnout)and 4 (demographics) factors on ITSN which have been identified previously but in a variety of combinations.

throughout the working life cycle of the nurse, there are significant life span or life experience factors which will dominate and take precedence at times including, health, environmental and social influences. The upper half of the circle represents the personal/internal dimension throughout the working lifespan while the lower half of the circle represents the professional/external dimensions which may influence ITSN.

The aim of this component of the study was to empirically assess the influence of Level 3 factors (job satisfaction, organisational commitment and stress/burnout) and Level 4 factors (demographics) on intention to stay in nursing of nurses currently working in the health service in ROI (public and private hospitals, nursing homes, community, public health, GP practices etc) throughout their career life span.

A cross-sectional survey design was used to explore the intention of nurses to stay in nursing (ITSN).

Participants were registered general nurses ( Consideration was given to the sample size needed and to the number of respondents who would receive questionnaires. Table 1 illustrates the sampling approach adopted. weariness and using a 7-point Likert scale (1=never to 7 = always) was used to measure how often Questionnaire designed to be respondent friendly by focussing on the design of the questions and layout Pre-notice letter sent 5 days before questionnaire

Questionnaire posted with detailed cover letter and return stamped addressed envelopes Replacement questionnaire plus letter sent to non respondents 6 weeks after first mailing and return stamped addressed envelopes during the previous 30 days respondents experienced particular feelings. The Organisational Commitment Questionnaire (OCQ) )(Cronbach's Alpha of .88), a 14 item scale, measured the strength of a nurse's identification with and involvement in their current work organisation (Porter, Steers et al. 1974 ). The three factors considered to characterise organisational commitment and measured using a 7 -point Likert scale (1 = strongly disagree to 7 = strongly agree) were a strong acceptance of the organisation's goals and values, enthusiasm to work hard for the organisation and a definite aspiration to remain with that organization.

The dependent variable, intention to stay in nursing, was operationalised by the Nurse Retention Index (NRI) )(Cronbach's Alpha of .90) (Cowin 2002) . While designed to measure nurses' intention of staying in their nursing job or leaving to find non-nursing work, in this study it was used to measure intention to stay in the profession of nursing. A total of six items, four positively worded and two negatively worded are clearly related to intentions to remain in the profession of nursing. (Table 2 ). These declarative items were measured using an 8-point Likert scale ranging from 1 (definitely false) to 8 (definitely true). I would like to stay in nursing as long as possible 3

As soon as it is convenient for me, I plan to leave the nursing profession 4 I expect to keep working as a nurse 5

My plan is to remain with my nursing career as long as I am able 6

I would like to find other employment by leaving nursing.

Respondents' personal (age, gender, nationality, marital status, dependent children, other kinship responsibilities, health status), professional (level of education, professional qualifications) and employment information (years since registration, years working in current position, current type of health setting, current area of work, grade at which working, any temporary interruption in employment and reasons for that interruption) were also obtained.

Cronbach's alpha values of the four scales ranged from .88 to .94 indicating a high level of internal consistency (Hair et al.,2010) . With the exception of the SMBM, all the scales had been tested on nurses previously. The face, content and construct validity of these instruments used were established prior to data collection through the process of cognitive interviews and a pilot study (Willis and Artino 2013, de

Vaus 2014, Egger-Rainer 2019). All study instruments had their construct validity established by previous researchers using confirmatory factor analysis and or exploratory factor analysis.

Ethical approval was granted by The Human Research Ethics Committee at University College Dublin. No direct access to the contact details of registered general nurses was available and all sampling procedures were undertaken by NMBI with distribution of letter and questionnaires via a commercial mail and postal company. Approval to use the instruments outlined below was obtained from each of the license holders.

Data was analysed using SPSS (IBM version 24.0). Of the 882 questionnaires returned, 14.5% (128) were returned blank or partially completed and therefore excluded from analysis. A total of 754 completed questionnaires were returned giving a response rate of 50.26%.

Descriptive statistics were used to describe respondents' demographics and the prevalence of stress, job satisfaction, organisational commitment and intention to stay in nursing. The Pearson correlation coefficient was used to measure the strength of the relationships between job satisfaction, organisational commitment, burnout and ITSN. Scatterplots to identify any outliers which could have biased the correlation coefficient results were plotted. One-way analysis of variance was used to compare mean SMBM, MMSS, OCQ and NRI scores by marital status ,nationality, health setting and age groups with a Tukey post hoc test used for pairwise comparisons. Independent sample t-tests were used to compare mean OCQ,SMBM, MMSS and NRI scores between those who had dependent children and those who did not and for those who worked fulltime and those who did not. Multiple linear regression was used to analyse the linear combination of predictors that best explained why nurses stay in nursing while steps were taken to ensure no violations of the assumptions of normality, linearity, multicollinearity and homoscedasticity. Of note, the global measure of job satisfaction was reduced to six of the MMSS subscales for the regression analysis because the two excluded subscales (balance of family and work and professional opportunities) had a high frequency of non-responses. A previous paper also reported this finding (Tourangeau, McGillis Hall et al. 2006 ). All the tests conducted for the correlational and regression analysis were two-tailed.

The majority of the sample were female (96%), between 22 and 50 years (86%) with a mean age of 39.1, Irish (72%), married or cohabiting (74%) with three or less children (56%) and with a bachelor or higher education degree (60%). Unpaid regular help was provided to a relative, friend or neighbour by a fifth of the sample (21%, n=144). The respondents' employment profile showed that they were mostly working in fulltime employment (75%), at staff nurse grade (75%) in a public hospital (56%), had never interrupted their employment (63%) and were on average 15 years (SD=8.9) since first registration. The standard error of the sample was calculated as .35 indicating that this sample was likely to be an accurate reflection of the population of RGNs on the active Register of Nurses at the time of data collection. However, the most recent reported NMBI population in 2016 presents an altered picture with particular reference to nationality and age (Table 3) .

A strong intention to stay in nursing with an overall mean score of 39.2 for the NRI was reported by a significant majority of respondents in this study. 

Job satisfaction, burnout and organisational commitment had weak to moderate correlations with intention to stay. However, while organisational commitment had a moderate positive correlation with ITSN (r=0.46, p<0.01, n=704) , it had a stronger correlation with job satisfaction (r=0.59, p<0.01, n=704) ( 

Attitudinal characteristics within the sample were compared across different groups in order to gather a deeper understanding. While the majority of the significant results from this analysis yielded small effect sizes, a number were remarkable (Table 5) . Respondents who were married and those who had dependent children had the strongest organisational commitment, job satisfaction and ITSN and had the weakest burnout levels. The differences within nationalities revealed that non-EU respondents were the most satisfied, had the lowest burnout levels and had the strongest organisational commitment and ITSN in comparison to other EU and Irish respondents. Furthermore, Irish respondents had the weakest scores for ITSN. The 36-50 year age group had the strongest intention to stay and organisational commitment compared to the 22-35 and the 51-65 year age groups. Those working part-time had a stronger intention to stay and organisational commitment than those working fulltime while respondents working in nursing homes or hospices had the strongest intention to stay, organisational commitment, job satisfaction and lowest stress/burnout levels in comparison to those respondents working in tertiary hospitals or in the community. Significance at the level of p<.05

Multiple regression analysis was used to identify the best predictor of RGNs' ITSN. Initially guided by the conceptual framework of ITSN, variables that displayed a significant relationship with ITSN in bivariate analysis were entered into the regression models and the results are presented in Table 6 . Initially, eight predictor variables including four demographic predictor variables (marital status, nationality, worked fulltime, had dependent children) were entered simultaneously into the linear regression model. The final model indicated that four of the 8 predictor variables explained 27% of the variance in ITSN.

Specifically, organisational commitment was the strongest predictor of ITSN (β=.32,p=.000) followed by stress/burnout (β=-.26,p=.000), job satisfaction (β=.030,p=.618) and working partime(β=.056,p=.227).

These results indicate that ITSN is complex and there are further predictors that might explain ITSN. In addition, it is evident that organisational commitment is a stronger factor than job satisfaction in staying in nursing throughout a career lifespan. 

This paper reports on a component of a larger study that explored nurses' intention to stay in nursing throughout their career lifespan. Informed by a conceptual framework of intention to stay in nursing (ITSN), level 3 factors including job satisfaction, stress/burnout and organisational commitment were investigated on general nurses working throughout the health services in the Republic of Ireland (ROI).

This study sought to determine how these factors work together to influence nurses' ITSN and to gather an insight at one point in time of nurses working in many different areas throughout the country. The analyses reported is supportive overall of the framework of ITSN. In the analyses, the majority of respondents (70%,n=515) had a strong intention to stay in nursing throughout their career lifespan while the strongest predictor of ITSN was organisational commitment. These results indicate that regardless of where they were working, there is an imperative to stay in the profession that overrides the particular nursing job despite many obstacles. The results also indicate that commitment to the organisation is more important than specific feelings or satisfaction about the job in order for respondents to stay in nursing throughout a career lifespan. The implication of these results is that respondents have a belief in the organisation's goals and values and want to work for the organisation as well as being ambitious to remain working for that organisation. It is evident therefore that the organisations in which the respondents work meet whatever expectations respondents have.

Additional results from this study provide an explanation as to why respondents have such a degree of commitment to their organisations and concur with the level 3 factors in the Framework of ITSN. Given that respondents were most satisfied with their nursing peers, had low burnout levels while the most satisfying practice environment were those with supportive co-workers, facilitative scheduling and good effective social interaction supports the premise that their work organisations were meeting their expectations. There is considerable previous literature that concurs with these results. For example satisfaction with social interaction with colleagues (Brunetto, Xerri et al. 2013 can increase the successful retention of nurses (Flynn and McCarthy 2008, Ahlstedt, Eriksson Lindvall et al. 2019) while if employees perceive that their work colleagues to be supportive and cohesive, there is less criticism of the organisation as a whole (Ingersoll, Olsan et al. 2002 , Garavan and McCarthy 2008 , Cowden, Cummings et al. 2011 ) and can buffer the development of burnout in the practice environment (Shirom 2009 , Chan, Tam et al. 2013 , Chen, Li et al. 2020 , Li, Zhang et al. 2020 ) .

The level of satisfaction with scheduling reported here is consistent with a European study which included nurses working in Irish hospitals (Leineweber, Chungkham et al. 2016) . There is also evidence that work settings which provide predictable yet flexible work scheduling for nurses can reduce sick leave, increase job satisfaction, be a good place to work as well as attract and retain nurses (McClure, Poulin et al. 1983 , Tourangeau, Cummings et al. 2010 , Garde, Albertsen et al. 2012 . Inflexible work schedules, by contrast, have been found to affect nurses' decisions to leave (Huntington, Gilmour et al. 2011) to adversely affect decisions to stay or to return to nursing (Sjogren, Fochsen et al. 2005) or to increase intention to leave in young nurses (Flinkman, Laine et al. 2008 ) providing additional evidence to support this study's results.

The results of how the level 3 and 4 factors relate to each other are indicative of the role that family responsibilities play in explaining how 70% of respondents had a strong level of ITSN. Comparison of differences of ITSN between some of the demographic groups in this study also strongly indicate that it is where respondents are at in their lifespan that dictates where and how they work yet stay in nursing working within the health services. Those who were married or co-habiting with dependent children, working part-time within the 36-50 year old age group, working in nursing homes/hospices and are non-EU had the strongest ITSN. Previous studies reported lower or equivalent levels of intention to stay using samples of nurses working in acute hospitals only (Flinkman, Laine et al. 2008 , Sabanciogullari and Dogan 2015 , Van Bogaert, Peremans et al. 2017 , Lo, Chien et al. 2018 ) while demographics such as marital status (Toren, Zelker et al. 2012 , Satoh, Watanabe et al. 2018 ) and having dependent children Table 3 . Disrespect for nurses, staff shortages and lack of patient safety were cited as the primary reasons to leave nursing in Ireland and to emigrate (Humphries, Mc Aleese et al. 2015) .

However, in response to a national call during the 2020 COVID 19 pandemic, 1,169 nurses returned to

Ireland or returned to nursing (Nursing Midwifery Board of Ireland 2020) demonstrating a willingness to do the right thing by rising to that challenge and wanting to make a difference.

The continued relevancy of the results of this study is evident even during the 2020 pandemic. The COVID-19 pandemic has exposed the challenges that have been continually faced by nurses trying to stay in nursing regarding scheduling and the adequate provision of childcare. In Ireland the closure of creches, child care facilities and schools along with the directive not to require grandparents, particularly those aged 65 years or older to care for children is posing major challenges for the Irish government to address (Wall 2020) . In the UK, the government have tried to facilitate essential workers, including nurses during this COVID-19 crisis by attempting to provide childcare and retain school openings for those workers (Langfitt 2020) . Other challenges include the physical and psychological impact of working throughout the pandemic, the risk to their lives and to their families of getting the virus as well as whether there is adequate PPE to protect them (Fernandez, Lord et al. 2020 ). However, while such a crisis can be seen as fostering professional collegiality and group cohesion, organisations need to be mindful and seen to be supporting their nurses during and after the impact of this pandemic in order to prevent burnout and nurses leaving the profession.

This study had many strengths; however, a number of limitations were identified regarding design, sampling, and instrumentation. The non-experimental correlational design used in this study cannot prove causation therefore the possibility of an alternative explanation for registered general nurses' ITSN cannot be excluded. However, this study built on findings from previous research by identifying independent variables which were related to and were predictive of intention to stay and that were representative of the study population. Despite a useable response rate of 50% cent, 40% did not respond. The possibility of sampling bias and sampling error is acknowledged. However, sampling problems were reduced due to the sampling strategy adopted and the limited eligibility criteria for inclusion which was decided following pilot testing. In addition, the sample was representative of the population of nurses in Ireland. Four internationally validated and reliable instruments were used together for the first time and extensive pre-testing was conducted to improve the validity on an Irish nurse population. It is acknowledged that similar results may not be obtained from a sample of nurses working in countries other than Ireland.

It is clear from this study that organisational commitment and low burnout were the key concepts that enable nurses to stay in nursing. There is general consensus that retaining nurses wherever they work be it in primary, secondary or tertiary healthcare organisations is essential for the continued delivery of seamless healthcare. Organisations need to be cognisant of these results and strive to facilitate staff to maintain a reasonable work/life balance by being open and flexible.

While the results from this study provide a comprehensive picture of nurses' intention to stay, it is also evident that further research is required. Longitudinal designs that will follow the career path of nurses over 15 years would address a gap in the understanding of intention to stay. In particular, investigating nurses' career decision making processes from completing their undergraduate degree to the career choices they make and why they choose to move from one position to another is necessary.

The results from this study confirm that the factors that contribute to ITSN are not linear. The majority of respondents had a strong intention to stay in nursing throughout their career lifespan indicative of a group of people who really want to stay in the profession. In addition, organisational commitment was the strongest predictor of ITSN highlighting that this concept may be mitigating against weathering the storm of job dissatisfaction. While the vast majority work throughout the public sector, less than half the respondents in this study were working in areas other than acute hospitals indicating that nurses must make career decisions to work in different areas to stay in nursing. It is acknowledged that a lot is known about ITSN, particularly in recent years with the predominant research focus being quite rightly on the number of nurses and the ratios of nurses to patients, yet there is limited in-depth evidence about how and why nurses move jobs/roles throughout their careers in order to stay in nursing. In particular, longitudinal research is needed to track how and why nurses move between the multitude of healthcare settings throughout their career be it from public to private, from hospital to community, from hospital to nursing home, from hospice to community, from ward to unit, from ward to specialist role. Given the global nursing response to the 2020 pandemic, now more than ever in the year of the nurse and midwife, there is an opportunity to enable more nurses to stay in nursing through noticeable strategic policy, investment and research.

No conflict of interest has been declared by the authors AUTHOR CONTRIBUTIONS

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All authors have agreed on the final version and meet at least one of the following criteria [recommended by the ICMJE (http://www.icmje.org/recommendations/)]: substantial contributions to conception and design, acquisition of data, or analysis and interpretation of data;  drafting the article or revising it critically for important intellectual content