Original Article

Intention to Leave the Profession in Nursing: A Hybrid Concept Analysis

Introduction

Leaving the profession is a major global challenge in all organizations, irrespective of their types or geographical locations.¹ By definition, leaving the profession is the withdrawal of workforce from an organization in a given period of time.² Two review studies estimated that the rate of leaving the profession was 4%–68%.^3,4 A cross-sectional study in European countries showed that 33% of nurses intended to leave their profession and 9% of them eventually left their profession.⁵ A study in Taiwan also showed that 56.1% of nurses intended to leave nursing and 2.5% of them left their profession in one year.⁶ Other studies reported that the rate of intention to leave the profession (ILP) in nursing was 32.7% in Iran,⁷ 35.5% in Italy,⁸ and 67.8% in Ethiopia.⁹

Employees play significant role in organizational success and survival¹⁰and hence, organizations spend heavy costs on empowering their employees and improving their knowledge, skills, and performance.¹¹ Therefore, leaving the profession among nurses imposes heavy costs on governments and healthcare organizations.¹² Studies showed that the financial cost of leaving the profession per nurse was 48 790 dollars in Australia, 20 561 dollars in the United States, 65 226 dollars in Canada, and 71 123 dollars in New Zealand.¹³ Leaving the profession is also a major cause of staff shortage which is an international challenge in nursing.¹⁴ Moreover, leaving the profession among nurses negatively affects care quality and nurses’ well-being, imposes financial strains on hospitals,¹⁵ and requires healthcare organizations to recruit novice nurses. Limited skills and efficiency among novice nurses are in turn associated with reduced competition, innovation, and care quality.¹⁶

ILP is a multifactorial phenomenon determined by many different factors such as occupational, personal, and organizational factors. Occupational factors include limited job satisfaction, limited workplace safety, work style, organizational and managerial factors, workplace tensions, mandatory overtime work, low salaries, long work shifts, high expectations, staff shortage, and workplace characteristics. Personal factors include age, work experience, educational level, and self-confidence, personal errors due to heavy workload, and limited competence and self-efficacy to manage new clinical conditions.^17-19

ILP is a good predictor of the rate of actual leaving of the profession.^20,21 ILP is the cognitive step before actual leaving of the profession and refers to a mental decision whether to stay in the profession or not.²² Evidence shows that ILP is based on a former awareness and readiness for leaving an organization. In other words, employees do not suddenly leave an organization; rather, they think about it over time, develop their ILP, consider the opportunity of employment in other organizations, and finally decide on staying in or leaving their organization.²³

Despite the importance of ILP to the prediction of actual leaving of the profession, there are limited data about its attributes, antecedents, and consequences. A concept analysis into ILP revealed that ILP is a multiphasic process with negative psychological reactions to internal and external occupational contexts which may lead to turnover-related cognitions and behaviors and eventually make employees actually leave their organization.²⁴ An integrative review also highlighted that demographic, work-related, and personal factors can affect ILP.³

Besides the paucity of data about ILP, the concept of ILP is context-based and hence, the available data in this area may not easily be generalizable to other contexts. Accordingly, further studies are needed to provide more in-depth data about ILP. Also, this analysis of the associations for nurses could help us improve our understanding of why members of the target group may wish to leave the profession. Implementing appropriate reforms to improve specific work conditions could lead to timely and specific prevention of departure from the profession. This would help retain the necessary staff in hospitals and ensure that Iranian hospitals continue to function efficiently. The present study was conducted to narrow this gap. The aim of this study was to analyze the concept of ILP, determine its attributes, antecedents, and consequences, and provide a clear definition for it.

Materials and Methods

This concept analysis was done using the hybrid model. The hybrid model is a method for conceptualization, concept development, and theorization which integrates both deductive and inductive methods to refine widely used concepts.²⁵ The hybrid model is based on the existing literature and the experiences of involved individuals, provides a clear understanding about the concept of interest, and hence, is preferred over other methods for concept analysis.²⁶ This model has three main phases, namely theoretical phase, fieldwork phase, and final analysis phase.²⁷ The theoretical phase includes reviewing the relevant literature in order to discover the essence of the concept and the available definitions. In the fieldwork phase, the concept of interest is further explored and refined through a qualitative study. In the final analysis phase, the findings of the first and the second phases are compared and integrated and a clear and comprehensive definition is provided for the concept.²⁶ The concept of ILP is significant in nursing science and practice. The lack of awareness around ILP can have huge implications for the healthcare system. Due to the ambiguities in the literature surrounding the concept of ILP, this concept was selected for analysis.

Theoretical Phase

In this phase, ILP-related literature was reviewed. Accordingly, an online literature search was performed in national and international databases, namely Magiran, Iran Medex, SID, Science Direct, Web of Science, PubMed, ProQuest, Scopus, and CINAHL. Search keywords were “intention to leave”, “turnover intention”, “intention to change job”, and “nurse” and search date was limited to 2000–2023. Eligibility criteria were inclusion of keywords in the title, relevance to the concept of ILP in nursing, publication in English or Persian, and accessible full-text. Letters to the editor, abstracts with no full-text, and commentaries were not included. A data sheet was used for data extraction. The items of the sheet were on study aims, methods, participants, ILP definitions, ILP attributes, ILP antecedents, and ILP consequences. Two authors independently evaluated the study quality based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2009.

Fieldwork Phase

Design and Participants

A descriptive qualitative study was conducted in this phase to explore nurses’ experiences of ILP. Participants were twenty employed nurses, nurses with the history of leaving their service, and nursing managers. They were purposively selected with maximum variation respecting their age, work experience, work shift, and affiliated ward. Study setting was several hospitals in Tehran, Isfahan, and Kashan, Iran.

Data Collection

Data were collected through face-to-face semi-structured interviews. The main interview questions were, “Have you ever experienced ILP as a nurse?” “In which situations and conditions were you more intended to leave the profession?” “Why do employees stay in their organizations?” “How does ILP physically and emotionally affect you?” and “What strategies do you recommend to prevent ILP?” Probing questions such as “May you provide an example?”, “May you provide more explanations?”, and “What do you mean by this?” were also used to further explore participants’ experiences. Interviews were conducted in nurses’ lounge in the study setting by appointment. The length of interviews was fifty minutes on average. All interviews were digitally recorded. Data collection was continued to reach data saturation which was achieved after interviewing twenty participants. Saturation is achieved when data collection and analysis produce no more new data and all findings are fully developed.²⁸

Data Analysis

Collected data were analyzed concurrently with data collection through the content analysis method proposed by Graneheim and Lundman.²⁹ Each interview was transcribed word by word and the transcript was read for several times in order to immerse in the data. Then, meaning units were identified and coded and the codes were grouped into subcategories and categories according to their similarities.²⁹ All authors of the study participated in data analysis.

Trustworthiness

Guba and Lincoln’s criteria were used to ensure trustworthiness. These criteria are credibility, dependability, transferability, and confirmability.³⁰ Credibility was maintained through constant comparison, prolonged engagement with the data, and member checking by several participants. Dependability was ensured through external peer debriefing by two external qualitative researchers who assessed and confirmed the accuracy of data analysis. Moreover, detailed descriptions about the study context and the characteristics and experiences of participants were provided to ensure transferability. To ensure confirm ability, all steps of the study were documented so that other researchers can track the steps of the study.

Final Analysis Phase

In this phase, the findings of the first two phases were compared and combined, final subcategories and categories were developed, and a final definition for ILP in nursing was provided. Table 1 shows examples of data analysis in the three phases of the study.

Results

Theoretical Phase

A total of 230 articles were found and 57 eligible articles were included in the study (Figure 1).

Close

Figure 1.

PRISMA diagram for the selection of studies

Figure 1.

PRISMA diagram for the selection of studies

Definition of the ILP Concept

Webster’s dictionary defines intention as “what one intends to do or bring about”. Some scholars defined ILP as a conscious and thoughtful desire to leave the organization.³¹ILP reflects employees’ interest to seek alternative jobs and leave the organization and is an indicator of actual leaving of the profession.³²ILP is broadly defined as an attitudinal, decisional, and behavioral process for leaving the profession.³³ Moreover, it is defined as the amount of movement an employee has towards cancelling membership in a social system and is started by the worker himself/herself.³⁴ In other words, ILP is the conscious desire for resigning from an organization and leaving it and may not necessarily lead to actual leaving of the organization but denotes its possibility in a near future.³⁵ Contrary to actual leaving of the profession, ILP is not manifest; rather it refers to thinking about leaving the profession in a given period of time and is an essential prerequisite for actual leaving of the profession.³⁶

ILP Models

Based on ILP antecedents, there are two main types of ILP model, namely models based on organizational factors and models based on personal factors. Examples of the first type of models are the Deconinck and Stilwell’s model and the Gaertner’s model and examples of the second type of models are the Lee and Michel’s model and the Maertz and Griffith’s model.

Deconinck and Stilwell’s model: This model addresses the relationship of leaving the profession with organizational justice (consisted of distributive and procedural justice), role states, payment satisfaction, and supervisor satisfaction. It states that payment satisfaction is explicitly affected by distributive justice and implicitly affected by role states, while supervisor satisfaction is explicitly affected by procedural justice and role states. Moreover, payment satisfaction and supervisor satisfaction affect organizational commitment and thereby, determine ILP.³⁷

Gaertner’s model: This model holds that payment, role ambiguity, role conflict, peer support, role expectations, autonomy, routinization, promotional chances, distributive justice, and supervisory support affect ILP through affecting job satisfaction and organizational commitment.³⁸

Lee and Mitchell’s model: The major assumption of this model is a mental shock and analysis which happens before action. The shock forms the thought of leaving the profession and subsequently, the employee decides to either leave or stay in the organization.³⁹

Maertz and Griffith’s model: This model states that eight main categories of motivational forces affect ILP. These categories are as follows:

Affective forces: Positive or negative forces which affect workers’ decision to stay in or leave the organization;

Calculative forces: Staying in or leaving the profession depends on the possibility to attain important values or goals in the organization;

Contractual forces: Refers to the perceptions of the level of reciprocal dependence of the organization and employees;

Behavioral forces: Entails the costs of leaving the organization;

Alternative forces: Refers to self-efficacy beliefs about obtaining alternative jobs or values in the organization or other organizations;

Normative forces: Refers to perceived expectations of family members or friends with respect to staying in or leaving the organization;

Moral forces: Refers to values and beliefs about leaving the organization;

Constituent forces: Refers to forces related to coworkers or groups in the organization.⁴⁰

Antecedents of ILP

Antecedents of ILP in the theoretical phase came into four main categories, namely demographic factors, psychological factors, interpersonal factors, and occupational factors.

Demographic factors: Demographic factors such as gender, age, educational level, work experience, and marital status can affect ILP. Some studies reported higher ILP among men,^41,42 while a study reported higher ILP among married women.⁴³ Moreover, some studies reported that ILP had significant positive relationship with age and work experience,^41,43 while some studies reported the significant negative relationship of ILP with age and work experience.^44,45 Studies into the relationship of ILP and educational level reported contradictory findings.^42,46

Psychological factors: Psychological factors such as stress, job burnout, organizational commitment, and job satisfaction can affect ILP. Occupational stress has significant positive relationship with ILP.¹⁸ The main sources of occupational stress are inadequate payment, work inequity, heavy workload, staff shortage, limited promotional chances, limited job security, and limited managerial support.¹⁷ Staff shortage and heavy workload are associated with job dissatisfaction and job burnout.⁴⁷ Job burnout in turn has significant positive relationship with ILP.^45,48 Organizational commitment and job satisfaction also have significant negative relationship with ILP.^44,45,48

Interpersonal factors: ILP is also affected by interpersonal factors such as managerial style, managers’ characteristics, and leadership style, participation in decision making, social support, teamwork, and interpersonal relationships. Studies reported that perceived organizational justice,⁷ ethical leadership,⁴⁹leadership style, positive perception of participation in organizational affairs,⁵⁰ transformational leadership, managerial support,⁵¹ managers’ organizational power, and teamwork⁵² can reduce ILP. Moreover, interpersonal relationships, including nurse-nurse, nurse-manager, and nurse-physician relationships, can affect nurses’ mental health, professional performance, and productivity.⁵³ Inappropriate workplace relationships may also make nurses leave their profession or organization.¹⁷

Occupational factors: Occupational factors such as quality of working life, workplace environment, and organizational culture may act as the antecedents of ILP. Employees with high quality of working life have stronger organizational identity, higher job satisfaction, and better occupational performance and are less likely to leave their job or organization.¹⁸ Professional respect and autonomy, two key components of the quality of working life, have significant relationship with ILP.⁶ Moreover, occupational control is associated with better quality of working life, lowers organizational indifference, and thereby, reduces ILP.⁵⁴ Autonomy in decision making is a component of occupational control and has significant relationship with ILP.⁵⁵ A significant factor in ILP is inappropriate work conditions consisted of heavy physical and mental workload, time pressure, shortage of equipment and staff, role ambiguity, and job instability.^7,48 A study in ten European countries reported that ILP among nurses with positive workplace-related perceptions was 30% lower.⁵ Some studies showed that ILP had significant positive relationship with workplace violence,⁴⁵ inappropriate workplace relationships,⁴⁸ and occupational hazards,⁵⁶ and had significant negative relationship with organizational culture.^57,58 Organizational culture refers to a set of values, beliefs, and behavioral patterns which form the identity of an organization and the behaviors of its workers.⁵⁷ A study reported that individuals in different countries have different values. For instance, collectivistic cultures are more common in Asian countries, while individualistic cultures are more common in western countries. Individuals in collectivistic cultures depend on each other and prefer groups over self, while individuals in individualistic cultures are independent and value their personal goals more than group goals. Accordingly, workers with collectivistic morale in Asian countries may be more satisfied with their workplace, show greater organizational commitment, and have lower ILP.⁵⁸

Consequences of ILP

The consequences of ILP are patient-related, nurse-related, and organizational consequences.

Patient-related consequences: ILP can lead to staff shortage which is a leading cause of clinical errors. Errors in turn prolong hospital stay and increase healthcare costs, infection rate, and mortality rate.^59,60 Moreover, leaving the profession requires organizations to recruit novice nurses to reduce staff shortage. Limited experience of novice nurses reduces competition, innovation, and care quality,¹⁶ negatively affects the provision of safe, fair, and effective patient-centered care, and reduces patient satisfaction with care.⁶¹

Organizational consequences: Leaving the profession is associated with reduced professional performance, reduced organizational productivity, increased workload, lower ability to adhere to ethical principles, and increased turnover of other employees. Moreover, it increases employment-related financial costs, alters organizational functions, and reduces organizational effectiveness^16,62

Nurse-related consequences: The nurse-related consequences of ILP include undermined morale of workers, damage to peer relationships, reduced interactions, reduced sense of responsibility, change in roles, and senses of instability, detachment, and isolation.^63,64

Fieldwork Phase

Participants in this phase were eight employed nurses, six nurses with the history of leaving their service, and six nursing managers (Table 1). A total of 650 codes were generated during data analysis which were grouped into three main categories, namely antecedents of ILP, strategies to reduce ILP, and consequences of ILP (Table 2).

Antecedents of ILP

The six main antecedents of ILP were social acceptance of the profession, limited professional interest, limited professional development, unsafe work environment, inappropriate work conditions, and managerial insufficiency.

Social acceptance of the profession: Participants’ experiences showed that the social acceptance of each profession depends on its responsibilities towards the society. Participants noted that the public image of nursing and social support for nurses can affect nurses’ self-confidence, resistance to different tensions, and ILP. They introduced unacceptance of nursing by the society, family, and other healthcare providers as the most important factors in nurses’ ILP.

“The social status of nursing is very important. Inappropriate nursing-related advertisements and content in media lead to the formation of unrealistic images of nursing. Television serials depict nurses as physicians’ handmaidens who just follow physicians’ orders. This poor media image of nursing questions nurses’ autonomy” (P. 9).

Limited professional interest: According to the participants, limited professional interest, negative attitudes towards the profession, and limited job motivation are among the most important antecedents of ILP. They noted that nurses with high job motivation experience interest and pleasure at work and highlighted the importance of nurses’ awareness of their nursing- and care-related attitudes, values, and expectations and their effects on nursing care.

“The very basic necessity is interest, meaning that you have to like nursing and patient care. Disinterest is associated with limited motivation for knowledge and skill development as well as discouragement. I worked in nursing without any motivation and finally decided to leave it” (P. 6).

Limited professional development: Limited changes in work characteristics over time, prolonged care provision in certain wards, and frequent performance of repetitive daily tasks can be associated with reutilization, senses of boredom and stasis, job burnout, and low job motivation and eventually move nurses towards leaving the profession.

“I started my mandatory post-graduation service in this ward and now it is for several years that I’m doing repetitive daily tasks in this ward. There is neither attraction nor creativity; rather, I repeat the same procedures every day in the same ward and the same rooms with the same colleagues. I’m really tired. Sometimes, I think about leaving the profession” (P. 7).

Unsafe work environment: Participants noted that inappropriate physical workplace environment, critical conditions in hospital wards, risk of affliction by infectious diseases, exposure to different dangerous chemicals and diagnostic and therapeutic radiations, and shortage of standard equipment and medications make nurses’ work environment unsafe and move nurses towards leaving the profession.

“I worked in infectious diseases ward, where there was neither adherence to clinical guidelines, nor appropriate personal protective equipment. I was always worried about affliction by infectious diseases or transmission of infectious diseases to my family members. I always liked a pleasant and safe work environment” (P. 11).

Inappropriate work conditions: Participants also reported heavy workload, rotational work shifts, long work hours, rest and sleep disorders, long waking hours, unfair payments, shortage of welfare facilities, and inappropriate employment opportunities as main occupational factors contributing to job dissatisfaction and ILP.

“The number of nurses’ work shifts is very high and their workload is heavy. Their documentation-related tasks are also heavy and tire them. On the other hand, their salaries are not proportionate to their services” (P. 18).

Managerial insufficiency: Participants highlighted that managers’ and authorities’ incompetence, unclear job specifications, inappropriate feedback and performance evaluation, injustice in rules and regulations, limited attention to care quality, and great emphasis on non-professional affairs significantly affect nurses’ ILP.

“I saw some colleagues did not adhere to the regulations but were not punished for their non-adherence because head nurse liked them. For example, they were not punished for late attendance at work and absence from work, while I was punished for such things” (P. 1).

Strategies to Reduce ILP

The two main strategies for reducing ILP were developing an appropriate organizational structure and improving the quality of working life.

Developing an appropriate organizational structure: Organizational structure refers to the roles of different employees and the pattern of relationships among the roles in the organization. In other words, organizational structure is role expectations and relationships. Organizational roles are usually determined through job descriptions and written documents. Our participants highlighted the necessity of meritocracy, clear job descriptions, effective workforce management, ethical practice, organizational justice, job security, and participatory decision making to develop an appropriate organizational structure.

“In each system, organizational structure should be so appropriate that all employees like to stay and work in the organization. In other words, each employee should be at his/her appropriate place based on his/her competence” (P. 13).

Improving the quality of working life: Quality of working life refers to employees’ satisfaction with occupational need fulfillment, resources, and activities. Participants highlighted that effective professional communication, fair and timely payment, benefits and rewards, and adequate health, welfare, and safety facilities for nurses can improve their quality of working life, quality of life, job motivation, and job satisfaction.

“Stronger support and better salaries should be provided to nurses. Nurses with lower financial problems can spend more energy at work. Organizational support is also needed to improve our motivation. By support, I don’t necessarily mean financial support; rather, I mean verbal encouragement about our activities” (P. 7).

Consequences of ILP

The three main consequences of ILP were impaired care quality, diminished organizational productivity, and mental health issues.

Impaired care quality: Participants noted that while nursing means effective care provision to clients, ILP can reduce nursing care quality through reducing nurses’ ability and motivation to pay close attention to their clients’ needs and values, use the nursing process, establish effective communication with clients, provide quality education to clients, develop their own professional knowledge and skills, provide care based on ethical principles, and use scientific evidence in practice.

“Care quality is not important for me; rather, I just want to finish work and go home. I have no mood for talking with patients, assess their needs, and provide them with education” (P. 12).

Diminished organizational productivity: Participants reported that ILP can be associated with different problems such as frequent absence from work, late attendance at work shifts, disharmony at work, non-adherence to organizational regulations, inattention to organizational goals, non-participation in continuing education and accreditation programs, and reduced satisfaction of patients, colleagues, and managers.

“Frequent absence of some nurses increases their colleagues’ workload, reduces their colleagues’ ability to provide professional care, and makes patients complain of not receiving the necessary services” (P. 17).

Mental health issues for nurses: Participants reported reduced self-confidence, fatigue, despair, disability, disinterest, low motivation, isolation, sense of humiliation and worthlessness, depression, low mood, cigarette smoking, drug abuse, psychological strains, and low job motivation as the mental consequences of ILP for nurses.

“I have a sense of humiliation. I work in a low-level and worthless profession and hence, I always feel despair. Sometimes, I feel remorse at selecting this profession” (P. 13).

Final Analysis Phase

Comparison of the findings of the first and the second phases in the final analysis phase revealed great similarities between findings (Table 3). The results of the theoretical phase revealed ILP as a conscious desire to leave the organization which is in agreement with the findings of the fieldwork phase. The only difference between the findings of these two phases was that participants in the fieldwork phase introduced some ILP antecedents which were not reported in the reviewed literature. Examples of these antecedents were reutilization, senses of boredom and stasis, and subsequent limited professional development. Moreover, participants in the fieldwork phase highlighted that ILP is a process which occurs due to stress caused by unmanaged personal and organizational challenges and reported that limited professional interest, negative attitude toward nursing, and organizational factors can affect ILP. Based on the results of the theoretical and the fieldwork phases, ILP can be defined as “a voluntary and gradual process occurred due to professional disinterest, negative professional attitude, and unmanaged organizational stresses and is associated with reduced job motivation, fatigue, and thoughts about leaving the organization which eventually leads to decision about staying in or leaving the organization”.

Discussion

This study aimed at analyzing the concept of ILP, determining its attributes, antecedents, and consequences, and providing a clear definition for it. Findings revealed ILP as a process occurred under the effects of contextual factors, such as personal and organizational challenges, which requires nurses to think about possible solutions to their problems, and may eventually lead to leaving the profession if they cannot successfully manage their problems. There are many different theories and models to explain leaving of the profession behavior of employees. Intention is the best predictor of behavior.⁶⁵ Therefore, organizational authorities should develop effective strategies to identify and manage ILP antecedents in their organizations, prevent their employees from leaving their organizations, identify and fulfill employees’ needs, and thereby motivate them to stay in the organization. A study in Italy reported that the three main causes of nurses’ ILP were seeking for a better job (31%), seeking for better living conditions (28%), and seeking for better career advancement opportunities (11%).⁶⁶

Our findings revealed that personal challenges such as limited professional interest and negative professional attitude were antecedents of thinking about leaving the profession. Similarly, a qualitative study on young nurses found limited interest in nursing and incongruence between mental and actual images of nursing as the reasons for ILP.⁶⁷Another study also reported the significant relationship of professional interest with ILP among nurses.⁶⁸ Traditional models of ILP, appeared in 1980–1990, included attitudinal models on job satisfaction, commitment, and seeking for alternative jobs.⁶⁹ Non-traditional models, appeared after 1990, omitted the constructs of attitude and seeking for alternative jobs and introduced constructs such as organizational attachment and interpersonal differences as the main ILP antecedents.⁷⁰ The limited professional interest antecedent of ILP in the present study is in agreement with the non-traditional models of ILP antecedents.

The findings of the present study revealed developing an appropriate organizational structure and improving the quality of working life as strategies to reduce ILP. In line with this finding, a previous study reported that occupational characteristics such as skill diversity, occupational identity, occupational importance, autonomy, and constructive feedback as well as organizational factors such as environmental conditions, rewards, and supervisory support can affect nurses’ organizational loyalty and ILP.⁷¹ Another study reported workload reduction as a significant factor in retaining nurses in the profession.²¹ Similarly, a study reported that hospital managers can improve nurses’ retention and reduce their ILP through improving work environment, generating positive psychological capital, and enhancing job satisfaction.⁷²

We also found that nurses’ ILP has negative consequences for patients, nurses, and healthcare organizations. Therefore, nurses’ ILP should be reduced through strategies such as recruiting committed nurses to the profession and improving nurses’ professional commitment. Strategies for professional commitment improvement include improving work conditions, increasing work importance, and improving professional interest, while factors such as injustice in organization, inattention to employees’ needs, limited participation in organizational affairs, and limited professional interest can reduce professional commitment. Participation in organizational affairs and organizational decision making and effective communication with managers create an environment in which employees feel more job satisfaction and show more organizational commitment.^73,74

It is worth mentioning that some factors, such as low wages for nurses in Iran, mandatory overtime due to the workforce shortage crisis in hospitals, and the differing acceptance and social status of the nursing profession in society, are undeniable.

Conclusion

This study concludes that ILP is affected by many different personal, interpersonal, occupational, professional, organizational, environmental, and social antecedents and is associated with many different patient-related, nurse-related, care-related, and organizational consequences. Developing ILP assessment instruments based on the findings of the present study is recommended for accurate ILP assessment and effective ILP prevention and management. Given the negative effects of ILP on care quality and organizational productivity, effective strategies are needed to improve clinical and organizational environments, nurses’ job satisfaction, and their professional development. Examples of these strategies are recruitment of competent nurses to the profession to reduce nurses’ workload and work hours, timely payments, education of communication skills, promoting autonomy in clinical decision making, clarifying job descriptions, improving self-confidence and organizational support, and using a supportive leadership style. These strategies will help nursing managers reduce and prevent ILP and thereby, reduce the heavy costs of recruiting, developing, and retaining nursing staff. Nursing education authorities can also use educational interventions to inform nursing students about the realities of nursing practice and help them make better decisions whether to stay in nursing or not.

One of the limitations of the present study was that, just English and Persian languages publications were analyzed. Therefore, some important works in other languages might have been missed.

Acknowledgements

The authors would like to acknowledge all the participants whose contribution enabled the production of this paper.

Competing Interests

The authors declare that there is no conflict of interest.

Data Availability Statement

The data that support the findings of this study are available from the corresponding author, upon reasonable request.

Ethical Approval

The Ethics Committee of Kashan University of Medical Sciences, Kashan, Iran, approved this study (code: IR.KAUMS.NUHEPM.REC.1398.074). Participants were informed about the study aim, voluntariness of participation in and withdrawal from the study, and confidentiality of their data, and their informed consent was obtained.

Research Highlights

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