Ranking retention factors and exploring preferred actions for retention across nursing subgroups: a cross-sectional study in two university hospitals

Abstract

Background

To enhance nurse retention amidst rising patient care demands and the current nursing shortage, it is essential to understand nurses’ views and preferred actions. There are various relevant retention factors at the individual, team, and organizational levels. However, it is not known what priority nurses give to the factors. Understanding this is crucial, as unmet needs, along with rising demand for care and a tight labour market, increase the likelihood that nurses will seek better working conditions elsewhere. This study aims to explore how nurses working in university hospitals across different age and educational categories rank factors that are important for their retention, and to identify their preferred action for retention.

Methods

We performed a cross-sectional study among nurses from two university hospitals, using an online survey. The survey included the ranking of retention factors from most to least important, along with an open-ended question about nurses’ preferred action for retention. Data analysis involved descriptive statistics, Kruskal-Wallis tests to examine differences in rankings across age and education groups, and a Direct Content Analysis of open-ended responses.

Results

In total 483 nurses (12.6%) responded. Nurses identified competitive salaries, career advancement, and a positive team environment as the most important factors for their retention, with significant differences between age and educational groups. Younger and higher-educated nurses prioritized career advancement, while older nurses ranked work-life balance, supportive supervision, and professional autonomy higher. Nurses’ responses to the open-ended question about preferred actions spanned all retention factors.

Conclusions

Hospital nurses’ retention priorities differ by age and education. This emphasizes the need for targeted strategies that address the specific priorities of nurses, in alignment with organizational goals and changes. Balancing nurses’ priorities, such as competitive salaries and career development, with organizational constraints is a challenge. By integrating nurses’ voices and preferences into retention strategies and understanding the underlying dynamics, healthcare leaders can develop flexible strategies that foster sustainable employability, creating a resilient and motivated nursing workforce that enhances patient care outcomes and drives organizational success.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12912-026-04602-2.

Background

Numerous countries face a nursing shortage, which has been exacerbated by the COVID-19 pandemic [1, 2]. There are an estimated 29 million nurses worldwide, with a projected shortage of 4.5 million nurses by the year 2030 [3]. This shortage results from the ageing workforce [4], along with rising patient care demands as individuals increasingly experience multiple or chronic conditions, possibly at the same time [5]. The shortage of nurses may lead to negative patient outcomes, such as reduced healthcare accessibility and quality [6] and potentially increased inpatient hospital mortality [7]. The demand for nursing care continues to outpace the growth of the nursing workforce [8].

The nursing shortage not only impacts patient care, but also results in challenges for the nursing workforce such as increased workload, stress, diminished productivity, increased absenteeism, erosion of intellectual capital, and financial costs [9–12]. Moreover, the shortage negatively impacts staff morale and nursing-team resilience [13, 14]. It is therefore crucial to recognize the multifaceted challenges posed in many countries by the shortage and devise effective retention strategies for the nursing workforce in hospitals and other healthcare settings [15]. Considering the above, investigating the factors influencing nurse retention in hospital settings is imperative.

In our previous study involving hospital nurses from various subgroups, including students, and newly graduated, experienced, specialized, and master-educated nurses, we found that that retention factors are diverse and operate at the individual, team, and organizational levels [16]. Various studies confirm this and indicate that key factors are the individual fit, motivation, autonomy, teamwork, leadership, professional development, organizational support, safety, and remuneration [6, 17, 18].

As the demand for nurses rises, unmet needs may drive them to seek better terms and conditions elsewhere, benefiting the individual but challenging the original employer and the healthcare system [19, 20]. Nurses are more likely to stay when workplace culture and conditions align with their personal and professional needs [21].

Despite this breadth of research, a significant knowledge gap persists. In particular, there is a lack of in-depth analysis of the priorities hospital nurses attach to different retention factors and their preferred action for retention. Retention factors are defined here as the individual, team, and organizational-level aspects of the work environment and job conditions that affect a nurse’s decision to remain in their nursing position. Addressing this gap would provide a more detailed understanding of which retention factors should receive the highest priority from the perspective of nurses themselves; in addition, it would provide essential information for developing targeted retention strategies that align with the needs and priorities of the nursing workforce. Our study addresses this by exploring variations in the ranking of retention factors among nurses depending on their age (categorized using ten-year intervals) and educational background (vocational, in-service, bachelor’s, or master’s). Age and educational background were chosen as they represent key sources of heterogeneity; they are non-modifiable yet influential characteristics that vary within every team or hospital. These characteristics influence retention preferences [22, 23], suggesting that different nurse groups may have distinct needs. Understanding these variations is essential for designing targeted retention strategies at all levels, ensuring alignment with the specific needs of different nurse groups. In our study, nurses were also asked to identify the most important action for ensuring they stayed at the hospital. By integrating nurses’ voices and preferences into retention strategies, hospital managers and advisors can enhance the strategies’ effectiveness and create a supportive environment aligned with the needs and priorities of the nursing workforce.

The aim of this study is:

1. to explore how nurses working in university hospitals across different age and educational categories rank factors that they consider important for their retention, and.

2. to identify their preferred action for nurse retention in the hospital.

Methods

We conducted a quantitative study with a cross-sectional design among hospital nurses, using an online survey.

Sampling and recruitment

In September 2021, the study was conducted at two university hospitals undergoing an administrative merger. Both hospitals provide high-complexity clinical care, conduct scientific research, and offer professional education, employing more than 15,000 healthcare professionals across patient care, research, and teaching activities. All registered nurses (n = 3,836) with a formal nursing position in the personnel system of two university hospitals in the Netherlands were invited by their hospital to take part in the survey via the online survey platform Survio (software). Inclusion criteria included having an employment contract (temporary or permanent) at one of the two university hospitals and having a formal nursing position. The hospital secretary sent an email to all nurses containing information regarding the objectives and content of the study, along with comprehensive details about the study’s context and privacy. For this survey, no formal ethical approval was required, since the participants were not subjected to procedures or required to follow rules of behaviour (according to the Dutch Act - Medical Research Involving Human Subjects [24]). Participation in the survey was voluntary and participants were informed that their responses would be coded and analyzed in aggregate, ensuring that individual responses could not be traced back to any participant. In accordance with the Dutch General Data Protection Regulation [25], the study was exempt from Medical Ethical Review and informed consent was deemed unnecessary. The results of the survey were stored and analysed anonymously. This study adhered to the Declaration of Helsinki [26]. Within an hour of the initial communication, nurses received an email through the survey tool, containing a personal link to the survey. The link remained active between 1 and 26 September 2021. Reminders to complete the questionnaire were included in the hospital’s newsletters and mentioned by nurse managers during team meetings. Nurses also received up to three reminders via Survio.

Data collection

The questionnaire used to collect the data built on findings from our previous qualitative study [16], which identified thirteen factors essential for the retention of hospital nurses (Table 1). The questionnaire was developed for this study to address the research objectives and gather relevant data from participants. Nurses were asked to rank these thirteen factors in order of importance, from most [1] to least [13] important. Next, an open-ended question was presented to identify the preferred action for change within the hospital: ‘If you could change one thing within the hospital, what would this be?’ The survey concluded with questions regarding age and the highest educational qualification (vocational, in-service, bachelor, or master).

Table 1.

Factors important for the retention of nurses in hospitals [16]

Retention factors
• Active participation in structures of control, at all levels in the organization • Autonomy and control over professional practice • Competitive salary, room for (extra) rewards and fringe benefits • Constructive collaboration with physicians • Facilitating supervisor • Nursing professionalization facilitated by the organization • Personal motives to keep working in the nursing profession	• Pleasant team • Professional nursing career opportunities in daily practice • Safe working and learning environment • Stimulating culture • The ability to find and follow personal development directions • Work that fits individual challenges during the life course

The questionnaire was piloted first by three nurses from the two hospitals using the think-aloud method, in which nurses were instructed to read the questions aloud and articulate their thoughts in response. No adjustments were deemed necessary. Beside this face validation, the questionnaire did not undergo further formal psychometric validation. The complete questionnaire is included in the supplement.

Data analysis

Descriptive analyses were performed to outline the background characteristics of nurses, including their age (in categories in ten-year intervals) and highest level of education. We used a contingency table to examine the interrelationship between age and education among nurses.

The ranks of the retention factors were described using measures of central tendency (median and mode) and dispersion (interquartile range, IQR). We applied a 2-step approach to gain insight into differences between subgroups (age, education). As we were mainly interested in differences between the most important factors (ranks 1,2, and 3), as a first step we compared the top 3 factors between the different age and educational groups respectively. Next, Kruskal-Wallis tests were conducted to test for statistically significant differences between subgroups (age, education) in the ranking of retention factors, followed by Dunn’s pairwise post hoc tests using the Bonferroni correction to locate specific group differences. All analyses were performed using an adjusted significance level of p < 0.05. Data analysis was conducted using the Statistical Package for the Social Sciences (SPSS), version 28, and Excel 2016.

Direct Content Analysis was employed to explore responses to the open-ended question about the preferred action for retention at the hospital [27]. In conducting this analysis, the three phases outlined by Elo & Kyngas were followed [28]. During the preparatory phase, responses to the open-ended question were reviewed by two of the researchers, AS (MSc, background in nursing and socio-cultural sciences), and BdK (MSc, background in health sciences). Initially, responses from the open-ended survey were transferred from Survio to Excel, where the information was consolidated into a table. Two researchers (AS and BdK) read and re-read the answers to familiarize themselves with the data.

In the organizational phase, a categorization matrix was developed based on the thirteen factors identified as essential for nurse retention [16]. An additional open category was included to capture responses that did not fit the predefined factors. Subsequently, transcripts were deductively coded using this matrix. The coding was conducted independently by two researchers (AS and BdK), and their results were then compared to ensure consistency. During this comparison, selected text segments and summaries of their meanings were thoroughly examined. Disagreement emerged in seven out of 483 responses; this was resolved through discussion with a third researcher (NR). In the reporting phase, the answers to the open-ended question were discussed in meetings with the entire research team, which possesses extensive expertise in qualitative research.

Results

Participants

In total 1,879 nurses opened the questionnaire, and 483 nurses successfully completed the questionnaire (response rate 12.6%). The largest group of respondents when grouped by age category was aged between 26 and 35 (31.9%). The majority of respondents held a bachelor’s degree (53.4%), as shown in Table 2. The contingency table revealed that nurses with in-service training were over 45 years old. Younger nurses, particularly those aged under 46, predominantly held vocational or bachelor’s qualifications.

Table 2.

Demographic characteristics of survey respondents (n = 483)

	n (%)
Age (ten-year interval) ≤ 25 years 26–35 years 36–45 years 46–55 years ≥ 56 years	48 (9.9%) 154 (31.9%) 81 (16.8%) 96 (19.9%) 104 (21.5%)
Highest level of education Vocational training In-service A-nurse Bachelor degree Master degree Missing	55 (11.4%) 114 (23.6%) 258 (53.4%) 31 (6.4%) 25 (5.2%)

Ranking of retention factors

Overall, nurses ranked competitive salary, room for (extra) reward and fringe benefits as the most important factor for retention (Table 3). The two other factors making up the top three were nursing professionalization facilitated by the organization and pleasant team. In contrast, active participation in structures of control at all levels in the organization was rated least important, i.e. ranked thirteenth.

Table 3.

Ranking of the most important retention factors (1 = most important, 13 = least important) according to nurses in two university hospitals, broken down by age (ten-year categories) and level of education

Retention factor	Median (IQR)	Mode	Age categories	Median	Mode	p-value	Education	Median	Mode	p-value
1. Competitive salary, room for (extra) reward and fringe benefits	1 (1–3)	1	≤ 25 years 26–35 years 36–45 years 46–55 years ≥ 56 years	2 2 1 1 1	1 1 1 1 1	0.31	Vocational In service Bachelor Master	1 1 2 2	1 1 1 1	0.003
2. Nursing professionalization facilitated by the organization	4 (2–7)	2	≤ 25 years 26–35 years 36–45 years 46–55 years ≥ 56 years	7 4 5 4 4	10 2 2 2 2	0.008	Vocational In-service Bachelor Master	4 4 4 4	2 2 2 3	0.36
3. Pleasant team	5 (2–10)	2	≤ 25 years 26–35 years 36–45 years 46–55 years ≥ 56 years	3 4 5 5 6	3 1 2 2 12	0.006	Vocational In-service Bachelor Master	4 6 4 8	2 and 3 12 2 13	≤ 0.001
4. The ability to find and follow personal development directions	5 (4–8)	4	≤ 25 years 26–35 years 36–45 years 46–55 years ≥ 56 years	5 6 5 5 6	5 4 and 6 4 4 5	0.59	Vocational In-service educated Bachelor Master	5 6 5 5	4 4 4 5 and 6	0.31
5. Safe working and learning environment	6 (3–10)	2	≤ 25 years 26–35 years 36–45 years 46–55 years ≥ 56 years	5 6 6 7 7	2 2 6 9 9	0.20	Vocational In-service Bachelor Master	7 6 5 10	10 2 2 12	≤ 0.001
6. Personal motives to keep working in the nursing profession	6 (4–9)	5	≤ 25 years 26–35 years 36–45 years 46–55 years ≥ 56 years	7 6 7 5 5	6 5 3 3 3	0.08	Vocational In-service Bachelor Master	5 5 7 8	3 3 5 and 6 5 and 11	≤ 0.001
7. Work that fits individual challenges during the life course	7 (5–9)	5	≤ 25 years 26–35 years 36–45 years 46–55 years ≥ 56 years	8 8 6 6 6	9 7 5 6 5	≤ 0.001	Vocational In-service Bachelor Master	7 6 7 7	5, 7 and 8 5 and 6 5 and 9 10	0.03
8. Professional nursing career opportunities in daily practice	7 (4–12)	13	≤ 25 years 26–35 years 36–45 years 46–55 years ≥ 56 years	6 5 7 10 10	13 3 12 13 13	≤ 0.001	Vocational In-service Bachelor Master	8 11 6 4	13 13 3 2	≤ 0.001
9. Facilitating supervisor	8 (6–10)	6 and 10	≤ 25 years 26–35 years 36–45 years 46–55 years ≥ 56 years	9 8 8 8 7	10 10 9 6 6	0.013	Vocational In-service Bachelor Master	8 8 8 8	10 and 11 6 9 6	0.60
10. Stimulating culture	8 (7–10)	7	≤ 25 years 26–35 years 36–45 years 46–55 years ≥ 56 years	8 9 9 8 8	11 11 8 and 10 8 7	0.17	Vocational In-service Bachelor Master	9 8 8 7	11 7 7 7 and 9	0.28
11. Constructive collaboration with physicians	9 (6–11)	11	≤ 25 years 26–35 years 36–45 years 46–55 years ≥ 56 years	8 9 9 9 9	8 11 and 12 11 11 11	0.16	Vocational In-service Bachelor Master	9 10 9 9	11 11 11 11	0.71
12. Autonomy and control over professional practice	9 (7–11)	12	≤ 25 years 26–35 years 36–45 years 46–55 years ≥ 56 years	11 10 9 9 8	12 12 12 8 and 9 8	≤ 0.001	Vocational In-service Bachelor Master	10 9 10 8	12 9 and 10 12 8	≤ 0.001
13. Active participation in structures of control, at all levels in the organization	13 (11–13)	13	≤ 25 years 26–35 years 36–45 years 46–55 years ≥ 56 years	13 13 13 12 12	13 13 13 13 13	0.002	Vocational In-service Bachelor Master	13 12 13 12	13 13 13 13	≤ 0.001

Ranking differences by age

The top three most important retention factors were largely consistent across the different age categories (Table 3). However, nurses aged under 26 ranked a safe working and learning environment in their top three instead of nursing professionalization facilitated by the organization. Additionally, nurses aged over 55 ranked personal motives to keep working in the nursing profession instead of a pleasant team among their top three factors (Fig. 1).

Fig. 1.

Ranking of retention factors among nurses across different age categories. Importance as indicated by the median, from most important (median 1) to least important (median 13). *** Significant at the ≤ 0.001 level; ** Significant at the 0.01 level; * Significant at the 0.05 level

Nurses in different age categories differed significantly in their ranking of seven retention factors. Nurses aged 26–35 ranked professional nursing career opportunities in daily practice significantly higher than nurses aged 46 and older (p < 0.001). Nurses aged under 25 (p = 0.007) and those aged 36–45 (p = 0.032) also ranked this factor higher than nurses aged 56 and older. A higher rank indicates greater importance, with rank 1 representing the most important factor.

Nurses aged 36 and older ranked work that fits individual challenges during the life course significantly higher than younger peers aged 26–35 (36–45 years, p = 0.026; 46–55 years, p = 0.041; ≥56 years, p = 0.002). Similarly, nurses 56 and older ranked autonomy and control over professional practice significantly higher than nurses under 35 (≤ 25 years, p = 0.004; 26–35 years, p = 0.006). Nurses aged 56 years and older ranked a facilitating supervisor significantly higher than nurses aged under 25 (p = 0.014). Nurses over 46 ranked nursing professionalization facilitated by the organization higher than nurses aged under 25 (46–55 years, p = 0.004; ≥55 years, p = 0.015). Conversely, nurses aged under 35 ranked a pleasant team significantly higher than nurses aged 56 years and older (≤ 25 years, p = 0.020; 26–35 years, p = 0.027).

Nurses aged over 55 ranked active participation in structures of control differed significantly higher than nurses aged 26–35 (p = 0.007) and 36–45 years old (p = 0.025).

Ranking differences by educational level

The top three most important retention factors varied across the different educational groups (Table 3). While competitive salary was consistently ranked first across all educational levels, nursing professionalization facilitated by the organization and a pleasant team were not uniformly prioritized. Nurses with vocational training or a bachelor’s degree attached a higher priority to having a pleasant team, ranking it within their top three. In contrast, nurses who were trained in-service prioritized personal motives for continuing to work in the nursing profession over a pleasant team, placing it in their top three. Master’s degree nurses, on the other hand, ranked professional nursing career opportunities in daily practice above a pleasant team (Fig. 2).

Fig. 2.

Ranking of retention factors among nurses across different educational groups. Importance expressed as the median rank, from most important (median 1) to least important (median 13). *** Significant at the ≤ 0.001 level; ** Significant at the 0.01 level; * Significant at the 0.05 level

Nurses in different educational groups differed significantly in their ranking of eight retention factors. Nurses with a bachelor’s degree (p < 0.001) and nurses with a master’s degree (p = 0.004) ranked professional nursing career opportunities in daily practice significantly higher than nurses with in-service training.

Nurses with vocational training (p = 0.019), nurses with in-service training (p = 0.006) and bachelor’s degree nurses (p < 0.001) ranked a safe working and learning environment higher than nurses with a master’s degree. Personal motives to continue working in the profession were ranked higher by nurses with in-service training and nurses with vocational training than nurses with a bachelor’s degree (p = 0.013; p = 0.021) and nurses with a master’s degree nurses (p = 0.034; p = 0.023). Nurses with in-service training (p < 0.001) and nurses with a master’s degree (p = 0.025) ranked autonomy and control over professional practice significantly higher than nurses with a bachelor’s degree. Nurses with in-service training ranked active participation in structures of control significantly higher than nurses with a bachelor’s degree (p < 0.001). In-service trained nurses ranked work that fits individual challenges during the life course significantly higher than nurses with a bachelor’s degree (p = 0.043). Finally, nurses with a bachelor’s degree ranked a pleasant team significantly higher than in-service (p = 0.019) and master’s degree nurses (p = 0.037).

Preferred actions for retention

Analysis of answers to the open-ended question (Table 4) revealed that nurses’ preferred actions for change covered all thirteen retention factors. The most frequently mentioned factors were competitive salary, work that fits individual challenges during the life course and nursing professionalization facilitated by the organization. In addition, three new factors were identified, namely increased nursing capacity, enhanced facility support, and sustainable care delivery. The quotes in the table give specific examples of preferred actionable changes.

Table 4.

Nurses’ preferred action for retention in two university hospitals

Retention factor	Preferred action for retention	# factor was men-tioned	Example
1. Competitive salary, room for (extra) reward and fringe benefits	Competitive salary	36	‘Higher salary so that colleagues don’t move to municipal institutions or companies, where the wages are a lot higher and there are fewer disadvantages (such as night shift/weekend shift/holidays).’
	Room for (extra) reward	31	‘Reward for work, so that greater effort is actually rewarded, people who work extra also get the credit for that.’
	Fringe benefits	9	‘That I could travel by car, with a good kilometre allowance and parking facilities.’
2. Nursing professionalization facilitated by the organization	Time, space and/or resources for competence training and professional development	29	‘Revitalize the working groups within our department.’
	Time, space and/or resources for improving quality of care	14	‘Stop the overkill of unnecessary diagnostics.’
3. Pleasant team	Equality within the team: respect and acceptance	3	‘Discussing problems with each other.’
	Engaged colleagues, personal attention	19	‘Hold an occasional team day so that the team has space and time to work on topics with each other (without being disturbed by the […] direct care for patients). Make sure everyone gets to know one another better during these team days.’
	Tailor-made induction programme	4	‘Perhaps organize more possibilities for induction. One colleague said she would like to have an extra day, without patient care, for the induction programme, to go through all the information again with new colleagues in the department, which sounds like a good plan to me.’
4. The ability to find and follow personal development directions	Availability of and insight into education and development opportunities	8	‘More courses facilitated by the department.’
	Insight into personal development needs	7	‘Have some sort of career plan for each employee.’
	Support and encouragement of development by the hospital	9	‘More attention paid to personal talent and more encouragement from the supervisor to work on those personal talents. For me personally, it is now an issue that makes me doubt my future at the hospital, and that after 20 years…’
5. Safe working and learning environment	Safe working environment	1	‘Nice working environment.’
	Safe learning environment	2	‘Much safer learning environment for students.’
6. Personal motives to keep working in the nursing profession	Contributing to quality of life of the patient (and family)	9	‘Taking everyone’s well-being and what is good for the patient far more as the starting point, rather than what is most convenient for the organization.’
	Structure of professional practice: patient population, roles, and tasks	7	‘That we can treat and care for all the specialties in the ICU. The patient population is too one-sided at the moment and far too demanding. The more minor surgery patients (cardio, general surgery and trauma surgery) are no longer handled here and won’t be coming back. People are really unhappy about that. I am expecting a lot of colleagues to leave.’
	Development and quality of nursing care	9	‘Administration way too much at the expense of the patient with no added value. Even bad for the patient because you are busy with something else.’
7. Work that fits individual challenges during the life course	Acceptable physical and emotional workload	46	‘Burnout prevention.’
	Schedule that fits work/life balance and is life-stage dependent	25	‘Make sure you have contracts that still work well when you become a mum or dad.’
8. Professional nursing career opportunities in daily practice	Investigate development wishes and possibilities in the department	13	‘More challenges for nurses who are up to it, opportunities for progression and a paid school day. After all, the department also benefits from me becoming a HBO-educated nurse.’
	Improve facilitation of professional nursing career opportunities through support from supervisors, cooperation with physicians and by creating the preconditions	4	‘Working with nursing specialists.’
	Up-to-date and clear job descriptions for all nursing functions	5	‘Opportunities to combine the day-to-day patient care — at the bedside — with your ambitions (in other areas).’
9. Facilitating supervisor	Improve team cooperation: make team approachable	3	‘Improve team cooperation.’
	Personal appreciation: positive feedback or good relationship	9	‘More appreciation for your hard work from the managers, and not by just giving you some trinket or other.’
	Vision to improve quality and efficiency of nursing care	3	‘Looking less at the number of beds and more at the number of patients with their individual care needs and allocate your staff accordingly.’
	Personal attention and support: show interest in work and development	3	‘Be a person and not a number.’
	Visibility of supervisor for individual and team support	11	‘Look at what can be done instead of what cannot be done. And then the managers should also ensure that there are more opportunities (in the broad sense so budget, time, support etc.) for nurses.’
	Structure of task specification and its rewards	1	‘More appreciation of nurse specialists by listening more to their wishes and requirements.’
	Stimulation and support for proposing and developing improvement ideas	1	‘A more encouraging and transparent manager.’
	Clear and honest communication	5	‘Honest information provision for staff.’
10. Stimulating culture	Collaboration within the team and care disciplines	13	‘Get your heads together and evaluate and improve the current processes, create order out of chaos, offer structure instead of separate projects.’
	Equality within the treatment team	4	‘Everyone getting the same appreciation regardless of education, experience, age, and background.’
	Everyone’s input is valued and weaknesses are compensated for	4	‘Respect for nurses.’
11. Constructive collaboration with physicians	Recognize and support each other’s functions and tasks on the basis of equality	5	‘Be seen by physicians as full partners in discussions, not just implementers of their wishes.’
	Good cooperation to make better patient care possible	2	‘Better cooperation with doctors; they are now too busy to have enough time for extensive questions and contact with the patient.’
	Easy contact	1	‘Lack of 24/7 on-site physician presence.’
12. Autonomy and control over professional practice	Responsible for the quality and structure of nursing work	6	‘Dividing all the children’s wards by age (rather than by specialism).’
	Making independent choices about the content of the tasks	8	‘I don’t want to work on a ward where only 50% of the patient population is my own specialization and 50% is a completely different specialization.’
	Time, space and/or resources for participation in own professional practice and development	5	‘Material always in order and rooms neatly tidied instead of wasting time in putting things in order.’
13. Active participation in structures of control, at all levels in the organization	Nursing presence in the leadership structure or board is mandatory	8	‘The huge hierarchy; there should be fewer management layers.’
	Input from nurses is taken seriously	16	‘Listening more to the colleagues doing the day-to-day work, to address all their problems. Because all the problems that the work floor predicted have come true. That wouldn’t have happened if something had been done about it.’
	Position nurses as valuable partners, participating in policy development and decision making at the organizational level	10	‘Serious participation by nurses. So not merely being allowed to read a draft afterwards and give input for form’s sake. This when it has all already been fixed.’
	Nurses receive relevant information from the organization	1	‘Transparency and integrity from senior management.’
Other	More nursing capacity	27	‘Better staffing/more nurses in a team, so you don’t end up with a couple of colleagues having to handle everything if people drop out.’
	Better (facility-based) support and facilities	37	‘More workstations with better computers, newer and more advanced ultrasound equipment.’
	Strategic perspective: multi-year plan	1	‘Multiyear plan.’
	Sustainability in care delivery (better for the environment)	3	‘Don’t waste so much medication. Disgusting how much is thrown away; I am ashamed.’

Discussion

Main findings

Our study investigated how hospital nurses rank factors that have previously been shown to be important for their retention and explored their preferred action for retention, differentiating between age and educational groups. Our findings revealed that hospital nurses rank competitive salary, organizational support for professionalization and a pleasant team as the most important factors for their retention.

Our analysis identified differences among nurses depending on their age and educational background in ten out of the thirteen retention factors. The nurses’ responses to the open-ended question about their preferred action for change were largely in line with previously identified retention factors [16]. Three new factors were also mentioned: increased nursing capacity, enhanced facility support, and sustainability in care delivery.

Our findings revealed that salary and professional development are ranked as most important for nurse retention. This aligns with findings from numerous other studies, which have highlighted competitive salary and professional development as critical factors for nurse retention [6, 18, 29–32].

Younger nurses prioritized a pleasant team and career opportunities, which aligns with findings from studies conducted in Turkey, Malaysia, and Australia [33–35], showing that early-career nurses often focus on team dynamics and career progression. In contrast, older nurses prioritize work-life balance, supportive supervision and professional autonomy, and organizational participation. This is consistent with research highlighting the importance of work-life balance for older nurses and its connection to the intention to continue nursing [36].

Experienced nurses value leaders who positively impact their work environment and respect their experience [37]. Older nurses similarly seek greater autonomy and control over their work environment [32]. At the same time, other research challenges the view that generational cohorts have distinct values, suggesting that differences in work preferences are more likely driven by factors such as career stage or life phase [22].

Together, these findings underscore the evolving nature of retention priorities across different life stages, with younger nurses valuing immediate team dynamics and career progression opportunities, while older nurses prioritize work-life balance and autonomy due to their higher intrinsic or learned ability to navigate work conditions [38].

Regarding education, nurses with a bachelor’s and master’s degree ranked professional career opportunities higher. These findings align with research which support the notion that educational degrees shape nurses’ priorities, with advanced degrees correlating with a focus on career advancement [39, 40] .

At the same time, other evidence underscored that the influence of education level on nurses’ priorities varies depending on individual career goals and organizational contexts [41].

Moreover, certain factors appear to be critical across all educational levels, which challenges the notion of a straightforward link between educational level and priority focus [42]. This is also apparent in our results, as factors such as nursing professionalization facilitated by the organization, a pleasant team environment, and the ability to find and follow personal development directions were deemed important across all educational groups.

When asked to pinpoint one key factor for their retention, the factors highlighted by the responding nurses covered the full spectrum of retention factors. This finding is consistent with previous literature, which suggests that multiple, interrelated factors are critical for nurse retention [6, 18]. Furthermore, other research shows that no single factor alone can ensure retention; instead, a combination of these factors is crucial [32]. This suggests that hospitals should develop retention policies that integrate various factors, tailored to the specific needs of nurses, to ensure long-term retention.

While nurses in our study prioritize competitive salaries and career development, these needs may not always align with organizational goals such as cost management. This misalignment complicates the creation of effective retention strategies. To bridge this gap, leadership that aligns individual and organizational priorities is essential. In particular, transformational leadership can foster alignment.

by creating a supportive environment where individual needs and organizational goals are interconnected [43].

Transformational leaders promote employee engagement, provide nurses with a voice in decision-making, and support personal development. They also foster trust and collaboration within teams, helping to create the conditions necessary for sustainable retention strategies while maintaining focus on the differing retention priorities across nurse subgroups [44, 45].

Implications

Our findings have several implications for practice and future research. The nursing workforce is heterogeneous, with varying needs. Hospital nurses prioritize competitive salaries and career development for their growth; therefore awareness of these factors is crucial for effective retention. With increasing care complexity and a growing demand for specialized nurses, a nurse who leaves is both difficult and costly to replace. Nurse turnover has significant economic and non-economic impacts [46]. Therefore, retaining nurses is vital for maintaining the quality of care and workforce stability. Our results also suggest that retention strategies should be tailored to address the specific needs of nurses based on their age and educational level. Given that career advancement is most important for younger and higher-educated nurses, retention strategies for these groups should focus on career development opportunities in daily practice. Retention strategies aimed at older nurses should focus on work-life balance, supportive supervision, and professional autonomy. Furthermore, retention strategies aimed at vocationally trained and in-service trained nurses should focus on a positive team environment, while strategies for nurses with a master’s degree should focus on professional autonomy. Beyond age and education, characteristics like life phase and career stage may also shape nurses’ needs, emphasizing the need to explore other distinguishing characteristics. Thus, retention strategies should incorporate these aspects to effectively address diverse needs. While nurses’ priorities do not always align with organizational goals of cost management and resource allocation, understanding what matters most to nurses at different career stages is vital. Additionally, hospitals must acknowledge that all the identified retention factors are highly significant to nurses. To ensure effective retention, it is crucial to involve nurses in the decision-making process regarding retention policies, giving them a voice in shaping their work environment. Transformational leadership can play a key role in this by empowering nurses, fostering a sense of trust, and aligning individual and organizational priorities in the creation of retention strategies.

Future research should aim for validation of the survey instrument. Research should also continue to explore the nuanced relationships between age, educational qualification, other characteristics, and nurse retention priorities, potentially incorporating longitudinal studies to examine how these priorities may shift over time. Moreover, it is also important to explore the effects of various types of organizational and contextual changes on the ranking of retention factors across different nursing subgroups. Examples of such changes include mergers, policy shifts, organizational restructuring, and alterations in the workplace environment. Exploring how the prioritization varies across diverse contexts could provide a more comprehensive understanding and would inform the development of more effective retention strategies. Investigating other significant characteristics such as specialization and personal circumstances could further enrich the understanding of nurse retention priorities. Additionally, expanding research to include a variety of different types of healthcare institutions would enhance the generalizability of the findings. Geographical context may also play a critical role, as local economic conditions, healthcare infrastructure, and available resources could influence the prioritization of factors [48]. Dutch nurses, for instance, have lower salaries (adjusted for cost of living) than Belgian nurses [2]. In addition, global challenges like the COVID-19 pandemic amplified dissatisfaction, with frontline nurses being more likely to leave due to the intensified stress and burnout [47, 48]. By addressing these aspects, future research could offer a more holistic and actionable insight into the complex dynamics of nurse retention.

Strengths and limitations

The study included a sample of 483 nurses from two university hospitals, with variation in age and educational level. Our sample was sufficiently large to draw conclusions, yet, the response rate was 12.6%. Selection bias may have occurred, as we do not have information about reasons for non-response. However, the distribution of respondents by age and level of education approximately matched that of the two organizations’ nursing populations. Our large sample allowed for thorough exploration of the wide variety of open-ended responses and provided for heterogeneity needed for the transferability of findings within the university hospital setting. The solid theoretical foundation of our questionnaire from a previous qualitative study is a strength. It is a limitation that, beside face validity, we dit not do any additional psychometric testing. Also, diversity in age and education was accounted for, other potentially significant factors—such as specialization and personal circumstances—were not included in the analysis. This limitation might reduce the value of the conclusions and suggests that the findings may not fully capture how nurse priorities might evolve over time or in response to different organizational changes. Additionally, these findings may not be transferable to other geographical contexts or types of healthcare institutions due to the sample being limited to two university hospitals. It is possible that differences in patient population, institutional resources, geographical influences, and opportunities for research and professional development specific to the academic settings where this study was conducted may influence the factors that nurses prioritize for retention.

Conclusions

Competitive salaries, career advancement, and a positive team environment are crucial for nurse retention, with their relative importance varying by age and educational level.

Career advancement is highly valued by younger and higher-educated nurses, whereas work-life balance, supportive supervision, and professional autonomy are more important for older nurses. And a positive team environment is particularly important for retaining vocationally trained and in-service trained nurses, whereas professional autonomy is more highly valued by nurses with a master’s degree.

These findings underscore the need for targeted retention strategies that consider the specific priorities of different nurse groups. Involving nurses in decision-making and fostering supportive leadership can help align individual and organizational priorities, potentially contributing to a more motivated and sustainable nursing workforce, enhanced patient care outcomes and organizational success. Future research should formally validate the survey instrument, incorporate additional nurse characteristics, track nurse retention priorities over time within organizations, and extend the study to other healthcare settings.

Supplementary Information

Below is the link to the electronic supplementary material.

Author contributions

AS was responsible for the entire study, including the design, data collection, analysis, and writing of the manuscript. BdK contributed to the data analysis for the results section. CB provided guidance throughout the study and held overall responsibility for the research process. MvG, MvV, and IJ reviewed and supervised the study at various stages, ensuring the rigour of the analysis and the interpretation of findings. All authors reviewed and approved the final manuscript.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Data availability

The data sets that were used and analysed are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

For this survey, no formal ethical approval was required, since the participants were not subjected to procedures or required to follow rules of behaviour (according to the Dutch Act - Medical Research Involving Human Subjects [24]). Participation in the survey was voluntary and participants were informed that their responses would be coded and analyzed in aggregate, ensuring that individual responses could not be traced back to any participant. In accordance with the Dutch General Data Protection Regulation [25], the study was exempt from Medical Ethical Review and informed consent was deemed unnecessary. The results of the survey were stored and analysed anonymously. This study adhered to the Declaration of Helsinki [26].

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.