This review of the literature uses Whittemore and Knafl’s (2005) guidelines for integrative review methods. An integrative review method is an approach that summarizes past literature to provide a comprehensive understanding of a problem or phenomenon, in order to build nursing science and inform nursing research, practice, and policy (Whittemore & Knafl, 2005). The stages of an integrative review are as follows: (1) problem identification; (2) systematic literature search; (3) data evaluation; (4) data analysis; and (5) presentation (Whittemore & Knafl, 2005).

Comprehensive, systematic literature searches were conducted in PubMed, CINAHL, and Web of Science databases, with the assistance of a health services research librarian in July 2024. Search strategies were adjusted for each database using MeSH terms, subject headings, and text-word searches to maximize search results. Search terms for identifying articles examining intent to leave included “Job Change”, “Personnel turnover”, “Career mobility”, “Intent”, and “Leave” as well as terms to specify a nursing population. Details on our search strategies by database are presented in Table 1. Additionally, references lists were searched for additional data sources per Whittemore and Knafl’s (2005) guidelines. Searches were limited to studies published since 2009, as the most recent review on intention to leave the nursing profession reviewed literature published 1985-July 2009 (Flinkman et al., 2010).

Inclusion criteria were: (1) studies of RNs employed in nursing roles in the U.S.; (2) studies that examined factors associated with intention to leave the profession of nursing, and (3) studies that were published in English. Studies were excluded if: (1) they were not peer reviewed research studies; (2) they were editorials, opinions, or discussions; (3) they included nurses working outside of the U.S.; (4) they exclusively addressed job turnover intention, (5) they addressed only intent to stay in the nursing workforce, (6) they surveyed nurses who had already left the workforce; and (7) if the study sample included only nurse practitioners, nurse administrators, or nurses working in academic positions.

Combined, the database searches located 20,601 studies. After excluding duplicates and screening titles and abstracts, 532 articles remained for full-text screening. Application of full inclusion and exclusion criteria eliminated an additional 497 articles, leaving 36 studies for analysis. Three additional studies were located in reference lists, resulting in a total of 39 studies in the final analysis. Figure 1 illustrates the screening process, including reasons for exclusion of those studies that were reviewed in full.

Per Whittemore and Knafl’s (2005) methodology for integrative reviews, data were extracted from each study and displayed in tables to facilitate comparison across studies. The data analysis process was iterative, with qualitative and quantitative data findings examined separately and then integrated. Qualitative data were analyzed for recurring themes in participants’ perceptions and experiences, while quantitative data were examined for statistical trends. These findings were integrated by mapping overlapping themes and examining how quantitative results supported or contradicted qualitative insights. Discrepancies were explored to provide a comprehensive interpretation of the evidence. The findings were then categorized into broad themes, which were refined through a process of constant comparison. The analysis process was carried out collaboratively by KLL and AWS, allowing for a balanced interpretation of the evidence. Data integration and synthesis were achieved through consensus discussions and iterative refining of the themes identified. The quality of included studies was appraised using tools appropriate for the study design. Study strengths and weaknesses were evaluated using the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklists (von Elm et al., 2014), the Critical Appraisal Skills Programme (CASP) Qualitative Checklist (CASP, 2022), and the Joanna Briggs Institute Critical Appraisal checklist for Quasi-Experimental studies (Joanna Briggs Institute, 2017). Studies were not excluded from analysis due to quality.

The majority (28) of the articles used quantitative research designs, with the remaining articles using qualitative designs (n=8) (Hover & Williams, 2022; L. W. Moore et al., 2013; Pellico et al., 2009; Rozo et al., 2017; Simons & Mawn, 2010; Slusser et al., 2022; Wolf et al., 2017; Woodward et al., 2024), mixed-method (n=2) (Christianson et al., 2023; Maiden et al., 2011), and quality improvement (n=1) (Arbios et al., 2022). Most of the reviewed studies included RNs only, with a few including licensed practical nurses too. Several studies sampled nurses in a particular specialty, including critical care (n=3) and emergency (n=3). Several studies also specifically sampled newly licensed RNs in their samples (n=7) (Hover & Williams, 2022; Pellico et al., 2009; Simons & Mawn, 2010; Unruh et al., 2016; Unruh & Fottler, 2016; Unruh & Zhang, 2013; Vogelpohl et al., 2013). One study sampled only nurses aged 55 and older (Slusser et al., 2022), while another only sampled RNs that were Black, indigenous, or people of color (BIPOC) (Woodward et al., 2024).

Table 2 summarizes the studies’ methods and design while Table 3 describes which study elements are present and absent from each article. Supplemental Content A describes the strengths and weaknesses of each study design using an appropriate critique tool for the study’s methodology.

Numerous studies included in this review were conducted during the COVID-19 pandemic. Many of them utilized similar variables to the research conducted pre-pandemic, and the findings were fairly consistent. The main difference was in the number of studies conducted on this topic, with 16 studies published just since the start of the pandemic in March 2020. Only a few studies examined COVID-19 specific factors (n=3). One study found that those who cared for COVID-19 patients were actually less likely to report intent to leave nursing compared with those who did not (Christianson et al., 2023). Another study of older nurses found that pandemic concerns did not contribute to any intentions to leave nursing (Slusser et al., 2022). Similarly, another study found that the impact of COVID-19 on nurses’ personal and home lives was not associated with intent to leave the profession (Yu et al., 2023).

Across the literature, numerous individual and work-level factors were found to be unrelated to intent to leave the nursing profession. Examination of several demographic factors revealed no relationship with intention to leave, including age (DiMattio et al., 2010; O’Hara & Reid, 2024; Stovall & Hansen, 2021; Unruh & Zhang, 2013), gender (Fitzpatrick et al., 2014; Unruh & Zhang, 2013), and nursing tenure (Cortelyou-Ward et al., 2010; DiMattio et al., 2010; Stovall & Hansen, 2021; Unruh & Zhang, 2013). Another individual factor that was unrelated to intent to leave the profession was nursing specialty certification (Fitzpatrick et al., 2010, 2011, 2014). Work-level factors that were found to be unrelated to intent to leave included wages (Christianson et al., 2024; Unruh & Zhang, 2013) and hospital or unit-level programs intended to help retain or benefit nurses, including hospital Magnet status (Unruh & Zhang, 2013), use of meaningful recognition programs (Kelly & Lefton, 2017), and use of a nurse mentorship program (Wallen et al., 2010). See Supplemental Content B for a summary of these non-significant factors.

Study strengths and weaknesses were identified using critical appraisal tools appropriate for the study methodology. Supplemental Content A summarizes the strengths and weaknesses of each study and which tool was used for quality appraisal, while Table 3 summarizes which study elements were present or absent from each study. Methodological weaknesses were prevalent in quantitative studies, including inadequate control for confounders, poor handling of missing data, unclear participant eligibility, low survey response rates, and insufficient analysis of demographic factors. Discussions rarely addressed generalizability or non-significant results. Lastly, numerous quantitative studies did not explicitly describe using a theoretical framework to drive study aims and design or used frameworks intended to examine job turnover.

Across the included qualitative literature, common methodological weaknesses included lack of a guiding theory or philosophical underpinning to guide study aims and methods, limited discussion of participant recruitment and selection processes, failure to address data saturation, and limited reflection on researcher positionality. Additionally, several of the included qualitative studies were limited in their methodological rigor due to their data sources, which were open-ended questions in surveys or comment sections at the end of surveys.

Despite these methodological weaknesses and limitations, the included articles also had numerous methodological strengths. Nearly all articles provided detailed background information and rationale for the study investigation. Most articles also utilized well-validated measures and reported relevant reliability statistics. All quantitative studies reported participant demographic data. All articles also discussed the research and practice implications of study findings, as well as potential study limitations.

The most methodologically rigorous of the included quantitative studies pointed to several factors that are especially impactful for intent to leave the nursing profession. High workload and job demands were consistently associated with greater intent to leave nursing (Friese et al., 2024; Martin et al., 2023; Unruh et al., 2016; Unruh & Zhang, 2013). Conversely, access to resources, including sufficient staffing, was associated with lesser intent to leave (DiMattio et al., 2010; DiMattio & Spegman, 2019; Fitzpatrick et al., 2010; Zurmehly et al., 2009). Poor work environments were associated with greater intent to leave (Cortelyou-Ward et al., 2010; Friese et al., 2024; Mays et al., 2011; Zurmehly et al., 2009). The social aspects of the working environment were of particular importance, with factors such as RN-physician relationships, relationships with management/leadership, and experience with bullying or incivility associated with intent to leave the nursing profession (Friese et al., 2024; Vogelpohl et al., 2013; Yu et al., 2023). Of note, while the relationship between age and intent to leave was largely not consistent across studies, some of the most recent studies have found that younger age is associated with greater intent to leave the profession, particularly when nurses of retirement age are excluded from analysis (Friese et al., 2024; Martin et al., 2023; O’Hara & Reid, 2024)

Many of the factors associated with intent to leave nursing identified in the most rigorous qualitative literature mirrored the quantitative results. Workload and work demands were associated with greater intent to leave (Slusser et al., 2022; Wolf et al., 2017; Woodward et al., 2024), and a lack of support and resources to cope with these demands resulted in burnout (Wolf et al., 2017; Woodward et al., 2024) and moral distress (Hover & Williams, 2022; Rozo et al., 2017; Wolf et al., 2017).

This integrative review identifies individual and work-level factors associated with intention to leave the nursing profession in the United States. Individual factors associated with intent to leave nursing included individual beliefs, nurse health and wellbeing, and individual nurse experiences. Nurses who had suffered more physically or mentally were also more likely to report intent to leave nursing. Similarly, those who reported negative or traumatic work experiences were more likely to report intent to leave. Conversely, those nurses who reported high levels of job satisfaction were less likely to report intent to leave.

Work-level factors associated with intent to leave nursing included job demands, resources and support, and work environment. Nurses who reported experiencing higher job demands reported greater intent to leave the profession. Additionally, experiences stemming from inability to cope with job demands were also associated with intent to leave. Included literature consistently showed that nurses who reported greater access to resources and support in the workplace reported less intention to leave nursing. Lastly, nurses who experienced healthier or more positive work environments were less likely to report intent to leave.

While some findings from this review overlap with those in Flinkman’s 2010 review, many factors were identified by this review as related to intent to leave the nursing profession that were absent from the previous review. Of particular note is the increase in the number of work-related factors related to professional turnover intent, including workload, job resources, and work environment. This likely signals an increased focus from researchers on working conditions as the factors that can be modified to prevent nurses from leaving the profession prematurely.

This integrated review identified few studies with nationally representative samples. Additionally, few studies examined the role of physical health on career intentions, with only two qualitative studies noting that participants reported the physical toll of nursing as a reason for considering leaving the profession (Pellico et al., 2009; Slusser et al., 2022), and only one quantitative study addressing physical health and wellness at all (Sinclair et al., 2015). Given the physical demands of direct-care nursing practice, it seems likely that physical wellbeing would have an impact on intent to leave the profession.

While several studies examined factors associated with intention to leave the profession in newly licensed RNs, there is a paucity of longitudinal studies to show how the factors impacting nurses’ career intentions might change over time and over the course of a nurse’s working life. While there were studies examining the very beginning of a nurse’s career and the very end (pre-retirement), there were no studies looking at early to mid-career nurses and which factors might be specific to their career intentions.

Also, while there are several qualitative studies in this review, most were not conducted with the aim of understanding intent to leave the nursing profession. Instead, these studies were focused on other experiences (such as moral distress or bullying) and incidentally discovered a relationship with intention to leave the profession. Qualitative or mixed-methods studies examining intent to leave the profession would provide a richer and more complete picture of nurse career intentions and factors that impact occupational turnover intention.

The findings from this integrated review, as well as the identified gaps in the literature, have implications for future research. Research should investigate the relationship of nurse physical and mental health on intent to leave, using validated measures, due to a lack of recent U.S. studies. Research on this topic could be valuable in helping to understand how health impacts nurses’ career decision-making, as well as helping to understand how to better protect nurses from occupational injury and illness and retain them in the workforce.

The decision to change careers is a significant one, and it is likely complex and multifactorial. A qualitative or mixed-methods research approach would allow for a deeper understanding of how nurses’ career decision making processes occur and which individual- and work-level factors are involved. Additionally, longitudinal studies that assess how nurses’ career plans and goals change over time could be valuable in strengthening our understanding of how to retain nurses in the workforce. Lastly, the studies included in this review surveyed nurses who were all or mostly hospital-based nurses. There is a need for research on factors associated with intent to leave the profession for nurses working outside the hospital setting.

The findings of this review have significant implications for nursing practice and leadership. Access to resources, including personnel, equipment, information, and power was associated with the intention to leave the profession. Given the importance of work environment and experiences on intention to leave the profession, healthcare leaders need to be aware of how their nurses are perceiving their working environment and work lives. Interventions and policies geared toward improving nursing work life and job satisfaction can help reduce intention to leave the nursing workforce. Nurses themselves have particularly identified staffing as a major factor impacting their work experience and mental health. A recent study conducted by Aiken et al. (2023) found that 87% of nurses ranked “improved nurse staffing” as the most important management intervention for improving their mental health (Aiken et al., 2023). Similarly, a recent statewide survey of Michigan RNs found that the top workplace concerns, both for currently practicing nurses and nurses who had left the profession in the last two years, were adequate staffing, patient safety, and staff safety (Medvec et al., 2023). In nurses who had recently left nursing practice, the most frequently reported reasons for departure (other than retirement) were job stress and inadequate staffing. To retain nurses in the profession, healthcare organizations must strive to improve nurse staffing and provide safe working environments for nurses. Lastly, this review identified organizational and supervisor support as factors associated with intent to leave the nursing profession. Healthcare organizations and specific units need to investigate what support their nurses require and work towards better providing it.

The findings of this review can help direct federal and state policies that help retain nurses in the workforce. Many workforce researchers propose that rather than a shortage of nurses, the United States is suffering from a shortage of hospitals that nurses are willing to work in, and thus we can address ongoing nursing shortages by improving nurse work environments to prevent workforce losses (Costa & Friese, 2022; Muir et al., 2024). The findings from this review support several federal and state policy changes that could improve nurse working conditions and therefore retention in the profession.

Given that some of the most consistent predictors of intent to leave the nursing profession are job demands, workload, and adequate staffing resources, federal policies should focus on three areas. First, regulating workload through safe staffing ratios and reduced documentation burdens (Costa & Friese, 2022); second, improving work environments via funding for safety interventions and innovative care models; and third, mitigating work-family conflict with childcare incentives (e.g., onsite childcare or subsidies) and elimination of mandatory overtime.

States can also enact similar policies to ensure the retention of nurses in the profession. State policies on mandatory nurse-to-patient ratios and the prohibition of mandatory overtime could help prevent workforce losses due to high job demands and unsafe working conditions (Costa & Friese, 2022). To ensure safe working environments for nurses, states can also implement and enforce Occupational Safety and Health Administration programs and plans that go above and beyond federal requirements for worker protection, which would allow for the protection of nurses and healthcare workers beyond the minimum federal standards already in place (Enablon, 2021). Currently, 22 states have OSHA-approved state plans. Finally, states could also provide innovation grants to allow hospitals to implement new programs that promote healthier work environments (Costa & Friese, 2022).

This integrative review had several limitations. The primary author of this review completed all article screening, based upon the agreed upon inclusion and exclusion criteria. Additionally, due to the heterogeneity of terms used to refer to intention to leave the nursing profession, it is possible that relevant studies were missed in the literature search. The scope of this review was also limited by the inclusion and exclusion criteria, which specified studies that addressed intention to leave nursing, rather than reasons for leaving the nursing profession previously. Inclusion of these studies may have identified additional factors. International studies were also excluded, meaning the generalizability of findings beyond the United States is limited.

This review identified several individual and work-related factors associated with intention to leave the nursing profession. Many of these factors, including work environment and experiences, and job resources/support, are factors that can be improved by healthcare organizations to improve nurse retention in the workforce. Additionally, nurse health and wellbeing are associated with intent to leave, suggesting that healthcare organizations and nursing researchers should work towards the protection of nurses’ occupational health and wellness to facilitate improved retention of nurses in the workforce.