Perspectives on registered nurse retention in nursing homes in Korea: A qualitative study

Article information

J Korean Gerontol Nurs. 2024;26(4):443-451
Publication date (electronic) : 2024 November 30
doi : https://doi.org/10.17079/jkgn.2024.00528
Assistant professor, College of Nursing, Catholic University of Pusan, Busan, Korea
Corresponding author: Jiyeon Lee College of Nursing, Catholic University of Pusan, 57 Oryundae-ro, Geumjeong-gu, Busan 46252, Korea TEL: +82-51-510-0782 E-mail: jylee@cup.ac.kr
Received 2024 July 19; Revised 2024 September 6; Accepted 2024 November 23.

Abstract

Purpose

This study aimed to understand the factors influencing registered nurses’ (RNs) intentions to remain employed in their current nursing homes (NHs).

Methods

Data were collected through individual in-depth interviews with 10 RNs in five Korean NHs from May 1 to May 31, 2024, and analyzed using thematic analysis.

Results

RNs in NHs reported that their intention to stay was influenced by “positive interactions with residents,” “cooperative relationships among staff,” and “stability from long-term employment.” Conversely, their intention to leave was influenced by “work burden from insufficient RNs,” “role conflict,” and “low salaries.”

Conclusion

This study indicates that significant reforms in staffing regulations and compensation systems are required to retain RNs. Improving working conditions is crucial for healthcare systems to provide effective long-term care to older adults. These changes are essential to maintain the quality of long-term care services.

INTRODUCTION

1. Background

South Korea has one of the fastest aging populations in the world. By 2050, it is projected that 43.9% of the population will be aged 65 years or older and 16% will be aged 80 years or older [1]. With an increase in the older population, the demand for nursing homes (NHs) and registered nurses (RNs) in NHs has increased significantly. However, as the number of NHs increases, the number of RNs does not rise correspondingly. Consequently, the number of RNs employed in NHs in Korea per 100 individuals aged 65 years and over is merely 0.04, which constitutes only 2.5% of the average rate of 1.6, as observed in member countries of the Organisation for Economic Co-operation and Development (OECD) [2].

This issue is pertinent to standards for the placement of NH nursing staff in Korea. Korean NHs are required to have one RN or certified nursing assistant (CNA) per 25 residents and one care worker (CW) per 2.3 residents [3]. To minimize labor costs, most NHs opt to employ CNAs over RNs. This practice contributes to significant work stress for RNs due to role conflicts with CNAs and increased workloads. Furthermore, Korean regulations do not mandate the presence of RNs in NHs at night, resulting in most NHs lacking an on-site RN at night and relying on on-call RNs for emergencies [4]. The interplay of these factors contributes significantly to the low retention rate of RNs in Korean NHs, making it a critical issue; a survey conducted in 2020 found the RNs’ employment rate in NHs to be as low as 31.15% [5].

NH administrators face significant challenges in attracting and retaining RNs. High turnover rates among RNs in NHs are a common issue that adversely affects the quality of care provided to residents [6]. High RN turnover rates are reported to be associated with decreased activities of daily living, increased readmission rates, reduced quality of care, and higher infection rates [7]. RNs play a critical role in NHs by improving the quality of care through clinical services, care management, and evidence-based practice planning based on timely health assessments of residents [8]. Due to the lack of physicians in NHs in Korea and the constraints associated with using contracted medical institutions, RNs employ their professional judgment to deliver first-aid and skilled nursing services [9].

Research reports a range of factors that affect RN retention in NHs, encompassing both personal (years of work in current NH, salary, reason for choosing current NH, etc.) and organizational (relationship with residents and peers, professional development opportunities, peer collaboration, etc.) characteristics [5,10]. However, many studies on Korean NHs lack comprehensive descriptions of the factors that influence RN retention and turnover. Additionally, because of the increasing complexity of residents being institutionalized without corresponding adjustments to staffing levels or skill mix [10], it remains unclear whether unexplored factors affect the retention and turnover of RNs in NHs. Therefore, a more comprehensive description of these factors is required before interventions are considered.

2. Aim of the Study

The primary objective of this study was to identify the factors influencing RNs’ intention to stay in NHs.

METHODS

Ethic statements:The study was conducted with the approval of the Institutional Review Board of Catholic University of Pusan (CUPIRB_2024-022 “IRB”). The content and methods of the study and the non-use of the data for purposes other than the study were explained to the study participants, who understood and consented to the study’s purpose. In addition, all participants provided written informed consent, and understood that they could withdraw from the study at any time they wanted to.

1. Study Design

This was a qualitative descriptive study. The entire study process was documented in alignment with the Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines [11].

2. Sample and Setting

The study selected RNs with over 1 year of experience as RNs, excluding those holding the position of administrator. Interviews were conducted until the participant repeatedly discussed the same content and situations, with no new information emerging in the conversation, and the same concepts repeatedly appeared in the analysis, leading the researcher to determine that theoretical saturation had been reached. Ten RNs from five NHs across three cities and provinces participated in this study. RNs were: all female (100%), with an average age of 51 years (range, 28~73 years), were employed full-time (80.0%), and had worked for an average of 8 years in the current NH (range of 1~18 years) (Table 1).

General Characteristics of Participants

3. Researcher Preparation

The researcher has extensive experience in conducting qualitative research on RNs in NHs and has participated in various projects related to NHs. This involvement provided the researcher with a comprehensive understanding of the working environment and the challenges faced by RNs in these settings.

4. Data Collection

A list of NHs (including employed RNs and contact information) was obtained from the website (www.longtermcare.or.kr). Given that employing RNs is not mandatory in Korean NHs, the number of NHs with RN is limited. After identifying the NHs that employed RNs, the researcher contacted their administrators to explain the purpose and methodology of the study. NHs were requested to post a notice inviting participation, and interested RNs could contact the researcher via phone or email. Interviews were conducted at a location chosen by the RN (nursing room in the NH, seminar room, or home) and lasted an average of 45 minutes to 1 hour. During the interview, the researcher meticulously observed and documented the participant’s non-verbal cues, such as behavior, facial expressions, and tone of voice, in field notes. The field notes amounted to a total of 23 pages on A4-sized paper. These notes served as a valuable reference for subsequent analysis. Interviews were recorded using a smartphone by the research assistant. After the interview, a thorough data analysis was conducted. The analysis revealed recurring themes as well as new content. Data collection was concluded based on the determination that theoretical saturation had been achieved. The participants received a $50 e-gift card as compensation for their time and participation. Interviews were conducted from May 1 to May 31, 2024. The RNs were asked the following main questions:

“What personal and organizational factors contribute to continued employment in NHs?”

“What personal and organizational factors contribute to leaving an NHs?”

5. Data Analysis

The transcription of the collected data resulted in a total of 232 pages on A4-sized paper. Data analysis was conducted using six steps of thematic analysis [12]. First, the interview recordings were transcribed verbatim and read thoroughly by the two researchers to facilitate deep engagement with the data. Initial codes were manually generated across the dataset to identify the significant features relevant to the research questions. These codes were then organized into potential themes, which were refined and reviewed to ensure that they accurately represented the data. Each theme was defined and named to capture its essence and to provide clear boundaries. Finally, the themes were integrated into a coherent narrative that addressed the research questions, supported by illustrative data extracts.

6. Ensuring the Quality of Research Results

This study ensured rigor by adhering to four qualitative research criteria: reliability, appropriateness, auditability, and confirmability [13]. To ensure reliability, the participants reviewed the transcribed interview data for accuracy and consistency with their intended meanings. Investigator triangulation was employed to enhance the reliability of the analysis and interpretation through discussions among the researchers. Appropriateness was established by presenting the general characteristics of participants and providing detailed, rich descriptions of the findings. For auditability, a thorough account of the research context, participant access, and data collection process was provided, including verbatim quotes, to allow readers to verify the interpretations. Confirmability was achieved by documenting the researcher’s prior understanding and biases in a personal journal that was used for reflection throughout the research process.

7. Ethical Considerations

Ethical approval (CUPIRB-2024-022) was obtained from the Catholic University of Pusan Institutional Review Board. Participants were informed about the study’s purpose and methodology, and interviews were conducted with those who voluntarily consented to participate. Participants were notified about the recording and transcription, with assurances of confidentiality and anonymity. They were also informed of their right to withdraw from the study at any time.

RESULTS

1. Reasons to Stay

RNs working in NHs reported that their intention to remain with their organization was influenced by personal factors such as “positive interactions between RNs and residents,” and “cooperative relationships among staff members,” and an organizational factor such as “stability offered by long-term professional employment” (Table 2).

Theme and Condensed Meaning Units

1) Positive Interactions Between RNs and Residents

RNs gave substantial importance to their relationships with residents, often experiencing strong bonds rooted in mutual respect and interest. Unlike in acute care hospitals, RNs expressed satisfaction with the work environment in these NHs, where communication with residents is prioritized, and they felt supported by the residents. Moreover, as residents aged and spent more time with the RNs, familial intimacy developed. The RNs found it particularly rewarding to see the residents’ happiness when even minor requests were fulfilled. This sense of fulfillment was attributed to the unique environment of the NHs, where, unlike in acute care settings, there is sufficient time to foster communication with residents. These positive interactions are described as “breathing holes” in a challenging work environment and served as a robust motivation for RNs to continue their employment in NHs.

In the intensive care unit, there is no bond with patients. I felt depressed when going to work. Since coming here, I’ve been able to talk to the elderly, regardless of whether they have dementia, and I really enjoy the physical contact.” (Participant 7)

I’ve been working here for 8 years, and now I’m 71. When I see long-term residents, it feels like we’re aging together, and perhaps that’s why they feel more like family to me. We’ve been together for so long that we communicate well.” (Participant 1)

2) Cooperative Relationships Among Staff Members

Supportive and meaningful cooperative relationships within an organization were significant factors influencing retention intentions. While there were initial difficulties in the relationships among RNs, CNAs, and CWs, job satisfaction increased as cooperative and respectful relationships were gradually established. Unlike long-term care hospitals, NHs primarily employ Korean CWs to facilitate clear communication and cooperative relationships. Additionally, the director’s active support and encouragement positively affected retention intentions. The director established a rapid communication system through a 24-hour chat room to reduce the burden on members who often had to make independent decisions in the absence of a doctor. This significantly improved retention intentions by allowing members to feel part of a supportive community rather than isolated.

Although my relationship with CNAs and CWs was a bit difficult in the beginning, I felt rewarded at seeing how CNAs and CWs followed and respected my nursing instructions.” (Participant 2)

Because the administrator is supportive and encouraging, the organizational atmosphere has become more cooperative, which I really appreciate.” (Participant 2)

If an emergency arises when I am the only RN on duty, I can post the situation in the chat room where the administrator is available 24 hours a day. This makes me feel less alone and reduces my burden.” (Participant 4)

Unlike the previous long-term care hospital, all the CWs here are Korean, so handovers go smoothly, and communication is clear, making me feel like we are all working together.” (Participant 7)

3) Stability Offered by Long-Term Professional Employment

The ability to continue working as a professional RN into an older age significantly influenced the retention intention. Given the physical and mental challenges of reaching retirement age as a hospital RN, many choose to work in NHs to maintain their careers and demonstrate expertise in stable environments.

I am grateful to be able to work at the age of 70. I will continue to work as long as I can until they tell me to leave.” (Participant 1)

I worked at a university hospital for 10 years but quit to take care of my children and stayed at home. By chance, I came here, and I believe I can work here even as I get older. The person I work with is 68 years old... It’s not common to be able to work after retirement age, which is why I keep coming here.” (Participant 9)

I think the appeal of being a facility nurse is that, rather than simple labor, I can perform a professional job that allows me to make decisions and continue working well into my old age.” (Participant 5)

2. Reasons to Leave

Unfortunately, RNs indicated that their intention to leave their current positions was influenced by a personal factor such as “role conflict as a professional,” and organizational factors such as “work burden due to an insufficient number of RNs,” and “low salaries” (Table 2).

1) Role Conflict as a Professional

RNs indicated that the failure of CNAs and CWs to adhere to their instructions and advice, coupled with unclear roles and occupational boundaries, increased their turnover intentions. The allowance for NHs to hire CNAs rather than RNs exacerbated this issue and diminished RNs’ professional identities.

It’s difficult because it feels like the boundary between RNs and CNAs has been broken.” (Participant 6)

In hospitals, the roles of RNs and CNAs are different, establishing a clear hierarchy. Here, the work is similar, and when they can’t hire an RN, they hire a CNA. This leads them to ignore my instructions, questioning the difference between an RN and a CNA.” (Participant 3)

I’m an RN, but I wonder why I’m working as a CNA. I feel that I need to return to the hospital to regain my expertise.” (Participant 3)

CWs are older, but when I point out something is wrong, they seem to dismiss it as if it’s just coming from a young kid, regardless of my professional experience.” (Participant 2)

2) Work Burden due to Insufficient Number of RNs

Current NH staffing regulations require an RN (or CNA) to resident ratio of 1:25. However, considering the three shifts and days off work, this results in one RN caring for approximately 100 residents at a time. Additionally, these regulations allow for CNAs to be hired instead of RNs, leading to a lack of continuity in nursing care and limited opportunities for RNs to work with their peers. RNs often had to make decisions alone, especially in emergency situations, which significantly increased their work burden and turnover intention.

There are over 100 residents in this NH, but I am the only RN on one shift. There are many tasks I need to do, including bedsore care, but I don’t have enough time to do so. The severity of cases has increased, and I feel so exhausted that I wonder if I should go back to the hospital.” (Participant 5)

It’s fortunate if there is at least one RN in the NH. Our NH has two RNs, but we can’t work together. I am alone on my shift, and it’s a huge burden, especially in emergency situations.” (Participant 3)

When I was at the hospital, there was always a doctor on duty and senior RNs to consult. Here, I work alone, with no other RNs to assist me, which makes me seriously consider changing jobs.” (Participant 6)

I think there should be one RN per duty. Only then can we ensure continuity of care... It’s very challenging.” (Participant 10)

3) Low Salary

Low salaries were a significant factor in leading nurses to consider changing jobs. The requirement to make independent decisions as a professional RN was not adequately reflected in their compensation. Additionally, the small salary difference between RNs, CNAs, and CWs, coupled with the large salary gap compared with hospital RNs, made continuing at the NH a concern. This issue persisted despite the other satisfactory aspects of the NH.

Even though I have been working for 10 years, my salary has barely increased. There is not much difference in the salary of a CNA. As a professional RN, I often question whether it is right for me to continue working for a similar salary.” (Participant 6)

Because of the salary, it is sometimes difficult to tell friends who are working at university hospitals to come here. I am single now, but I worry about whether I will continue earning this salary if I get married.” (Participant 2)

DISCUSSION

This study provides an understanding of the critical factors that influence NH RNs’ decisions to remain in or leave their positions. Our findings indicate that for most nurses, no single factor emerged as the primary determinant of their retention or turnover intentions. Instead, the reasons were complex and included a combination of previous experiences, personal considerations, and external influences. As factors contributing to nurses’ retention, personal factors such as positive interactions between nurses and residents, as well as cooperative relationships among staff, and organizational factors such as job stability were identified. Factors leading to nurses’ turnover included a personal factor such as professional role conflict, and organizational factors such as workload due to insufficient nursing staff, professional role conflict, and low salaries.

As a personal factor contributing to nurses’ retention, positive relationships with residents play a crucial role in RNs’ decisions to remain in NHs. Previous research has demonstrated that a genuine passion for work and enjoyment of working with older adults are significant factors contributing to job satisfaction among RNs in NHs [10]. Consistent with the findings of a previous study [14], this study revealed that participants frequently perceived their relationships with certain residents as familial, evoking memories of their family members. This relates to the unique characteristics of NHs, where interaction is especially important because of the longer duration of residents’ stays compared with other settings [6]. These positive interactions provide the strength to endure poor working conditions, such as nursing shortages. However, if these conditions persist, they can lead to frustration and career changes [14]. This underscores the importance of addressing institutional and organizational barriers to support the development of RN-resident relationships, thereby improving job satisfaction and retention.

In various healthcare settings, relationships with staff significantly shape perceptions of the work environment [15]. Studies on RN retention in different healthcare contexts have highlighted the importance of peer and administrator support [15,16]. As a personal factor, this study confirmed that cooperative relationships among employees enhance RNs’ retention intentions. In NHs, cooperation among various staff members is particularly important in situations where these different roles must collectively provide care to a single resident. In Korea, care is provided by RNs, CNAs, and CWs in NHs [9]. CNAs assist with bathing and feeding under RNs’ supervision, and receive certification after high school. CWs support older individuals with daily activities such as grooming, dressing, and eating [17]. Conflict situations are likely due to differences in educational background, duration of education, and licensure status, all of which necessitate mutual understanding and respect. Considering that RNs often make decisions without a doctor, administrator of NH support is crucial. The American Nurses Credentialing Center developed an educational program for administrators on decision-making, team recognition, and support during hazardous events [18]. A similar program tailored to the needs of Korean NHs should be developed and implemented.

As an organizational factor, this study confirmed that job security has a positive impact on the intention to stay. Numerous studies have indicated that job security significantly enhances RNs’ intentions to remain employed by increasing their job satisfaction and organizational commitment [19,20]. Job security alleviates RNs’ anxiety and allows them to plan for a long-term career in the workplace, thereby strengthening their intention to stay. In Korea, the average age of hospital RNs is reported to be 36.2 years, whereas that of RNs in NHs ranges from 45.6 to 52.4 years [4,5,21]. This data correlate with the findings of this study, which indicate that RNs in NHs experience higher job satisfaction and are able to continue working as professional RNs, regardless of their age. In light of these findings, it is imperative that NHs use job security as an incentive to retain RNs. Ensuring continuous employment of RNs will not only attract and retain skilled RNs but also contribute to the stability of the organization, which is based on an experienced and competent workforce. While the influence of job stability on retention intentions has been previously reported, a new finding of this study is that NHs are highlighted as good places to demonstrate professional expertise based on job stability. This has become a driving force for their retention. In light of this, it is necessary to provide continuous job training for NH nurses and to introduce a career development system similar to that implemented for hospital nurses, allowing NH nurses to further develop their expertise and contribute to improving residents’ health outcomes.

When queried about motivations for departing from NHs, RNs expressed concerns about workplace and organizational dynamics. The shortage of RNs is consistent with the results of previous studies [22]. According to Korean NH regulations, one RN or CNA is assigned to every 25 residents [3]. As institutions prefer hiring CNAs to RNs, RNs face overwhelming workloads and lack professional peers [5]. Additionally, the handover process is problematic due to shifts not being covered by RNs. These regulations create ambiguities between the roles of RNs and CNAs, leading to conflicting roles. Role conflict is a personal factor that causes nurses to leave their jobs. CNAs often do not follow RNs’ instructions, which increases tension and hinders effective care. Clear regulations for nursing staff placement and cooperative programs are required. Internationally, programs based on appreciation and respect have been developed to enhance cooperation among different professions in NHs [23]. Given that RNs in Korea report increased job turnover intention due to these issues, the development and implementation of similar programs are essential. The need for more RNs in NHs to improve residents’ health-related quality of life is well-documented [9]. However, there is a lack of such legislation in Korea. Countries including the United States, Canada, Germany, the United Kingdom, Norway, and Sweden have already instituted policies requiring the assignment of RNs to NHs [24]. Since 2001, the United States has enacted institutional frameworks like the Nurse Practice Act, requiring adequate nursing staff in NHs to ensure RNs provide at least 0.75 hours per resident day [24]. In accordance with this global trend, since 2019, a pilot project mandates one RN or CNA per six residents, with 60% of the RNs working 24/7 in Korea [21]. Evaluating the effectiveness of this initiative is crucial for advocating the related legislation.

As an organizational factor, salary is a fundamental component of job satisfaction that directly affects employees’ decision to remain in their current position. A low salary has been identified as a factor influencing NH RNs’ turnover intention [25]. In addition to low absolute salaries, RNs face a small salary gap compared to other occupations within the same organization, such as CNAs and CWs, unlike their counterparts in acute care settings. This small salary differential can lead to a feeling of relative deprivation among RNs. As of 2020, the average salary for RNs in NHs is about 25,300 USD, which is only 70.2% of the average salary for RNs in acute care settings (about 36,000 USD) [26]. Addressing salary disparities is essential to reduce RN turnover in NHs. It has been reported that low wages increase the turnover intention of NH nurses. However, beyond the simple fact that low wages lead to higher turnover intention, this study newly found that feelings of disillusionment arise from the fact that the pay structure is not significantly different from that of other staff members. Furthermore, the negative emotions caused by the substantial salary gap between nurses working in acute care hospitals and those in long-term care facilities, despite holding the same license, also contribute to increased turnover intention. Policymakers and healthcare administrators should consider implementing competitive salary structures that reflect the critical role of RNs in these settings. By increasing salaries, NHs can not only reduce turnover rates but also enhance job satisfaction and morale among RN. Competitive salaries can attract more qualified and experienced RNs, thereby improving the overall quality of care provided to residents.

Despite its strengths, this study has several limitations. First, the interviewed nurses do not represent all nurses in elderly care facilities in Korea; therefore, the findings should be interpreted with caution. Finally, there is a potential bias in analyzing and interpreting data collected within one’s profession or clinical practice [27]. To minimize this, all team members reviewed the results.

CONCLUSION

There is an urgent need to prioritize retaining RNs in NHs to address their shortage. This study examined the factors influencing retention and turnover intentions among RNs NHs in Korea and suggested that significant reforms are necessary if retaining RNs is a priority for staffing regulations and compensation systems. NH work environments face increased pressure because of an aging and shrinking workforce, a perceived lack of professional status, the demanding nature of the job, and the need to care for increasingly complex older residents. Improving the working conditions of staff is essential for the healthcare system to continue providing effective long-term care to the older population.

Notes

Authors' contribution

JL had role in the study design, data collection and analysis, and writing the manuscript.

Conflict of interest

No existing or potential conflict of interest relevant to this article was reported.

Funding

This work was supported by the National Research Foundation of Korea (NRF) grant funded by the Korean government (2022R1F1A1068575) and by the research fund of the Catholic University of Pusan. The funders had no role in the study design, data collection and analysis, decision to publish, or the preparation of the manuscript. We have no conflicts of interests to declare.

Data availability

The data are not publicly available for legal and privacy issues.

Acknowledgements

We wish to thank the participating administrators of the Nursing Homes and Registered Nurses for their support.

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Article information Continued

Table 1.

General Characteristics of Participants

Variable Value
Female sex 10 (100)
Age (year) 51.01±18.42 (28~73)
Employment status
 Full-time 8 (80.0)
 Part-time 2 (20.0)
Years working in current nursing home 8.03±4.58 (1~18)

Values are presented as number (%) or mean±standard deviation (range).

Table 2.

Theme and Condensed Meaning Units

Theme Condensed meaning units
Reasons to stay
 Personal factor Positive interactions between RNs and residents • Experiencing strong bonds rooted in mutual respect and interest
• Feeling supported by the residents
• Development of familial intimacy
• Sufficient time to foster communication with residents
Cooperative relationships among staff members • Increased job satisfaction from respectful relationships among staff members
• Clarification of communication through hiring Korean CWs
• Reduced decision-making burden from the director’s support and encouragement
 Organizational factor Stability offered by long-term professional employment • Continuation of professional RN work into older age
• Maintenance of careers and demonstration of expertise in stable environments
Reasons to leave
 Personal factor Role conflict as a professional • Increased turnover due to unclear roles and non-adherence to instructions
• Diminished professional identity from hiring CNAs instead of RNs
 Organizational factor Work burden due to insufficient number of RNs • Requirement of a 1:25 RN (or CNA) to resident ratio under NH staffing regulations
• Option to hire CNAs instead of RNs
• Increased burden and turnover intention from RNs making decisions alone in emergencies
Low salary • Low salaries as a significant factor in RNs considering job changes
• Inadequate compensation for independent decision-making responsibilities as an RN
• Concern over the small salary difference between RNs, CNAs, and CWs
• Large gap compared to hospital RNs

CNA=Certified nursing assistant; CW=Care worker; NH=Nursing home; RN=Registered nurse.