title: Nurses' practice environment and satisfaction with schedule flexibility is related to intention to leave due to dissatisfaction: A multi-country, multilevel study.
abstract: BACKGROUND
  Nursing turnover is a major issue for health care managers, notably during the global nursing workforce shortage. Despite the often hierarchical structure of the data used in nursing studies, few studies have investigated the impact of the work environment on intention to leave using multilevel techniques. Also, differences between intentions to leave the current workplace or to leave the profession entirely have rarely been studied.
  
  
  OBJECTIVE
  The aim of the current study was to investigate how aspects of the nurse practice environment and satisfaction with work schedule flexibility measured at different organisational levels influenced the intention to leave the profession or the workplace due to dissatisfaction.
  
  
  METHODS
  Multilevel models were fitted using survey data from the RN4CAST project, which has a multi-country, multilevel, cross-sectional design. The data analysed here are based on a sample of 23,076 registered nurses from 2020 units in 384 hospitals in 10 European countries (overall response rate: 59.4%). Four levels were available for analyses: country, hospital, unit, and individual registered nurse. Practice environment and satisfaction with schedule flexibility were aggregated and studied at the unit level. Gender, experience as registered nurse, full vs. part-time work, as well as individual deviance from unit mean in practice environment and satisfaction with work schedule flexibility, were included at the individual level. Both intention to leave the profession and the hospital due to dissatisfaction were studied.
  
  
  RESULTS
  Regarding intention to leave current workplace, there is variability at both country (6.9%) and unit (6.9%) level. However, for intention to leave the profession we found less variability at the country (4.6%) and unit level (3.9%). Intention to leave the workplace was strongly related to unit level variables. Additionally, individual characteristics and deviance from unit mean regarding practice environment and satisfaction with schedule flexibility were related to both outcomes. Major limitations of the study are its cross-sectional design and the fact that only turnover intention due to dissatisfaction was studied.
  
  
  CONCLUSIONS
  We conclude that measures aiming to improve the practice environment and schedule flexibility would be a promising approach towards increased retention of registered nurses in both their current workplaces and the nursing profession as a whole and thus a way to counteract the nursing shortage across European countries.
authors.affiliation: Stress Research Institute, Stockholm University, Stockholm, Sweden; Karolinska Institutet, Department of Learning, Informatics, Management and Ethics, Medical Management Center, Stockholm, Sweden. Electronic address: constanze.leineweber@su.se.
authors.forename: Constanze
authors.initials: C
authors.lastname: Leineweber
authors.affiliation: Stress Research Institute, Stockholm University, Stockholm, Sweden; Indian Statistical Institute, North-East Centre, Tezpur, India.
authors.forename: Holendro Singh
authors.initials: HS
authors.lastname: Chungkham
authors.affiliation: Karolinska Institutet, Department of Learning, Informatics, Management and Ethics, Medical Management Center, Stockholm, Sweden.
authors.forename: Rikard
authors.initials: R
authors.lastname: Lindqvist
authors.affiliation: Stress Research Institute, Stockholm University, Stockholm, Sweden.
authors.forename: Hugo
authors.initials: H
authors.lastname: Westerlund
authors.affiliation: Karolinska Institutet, Department of Learning, Informatics, Management and Ethics, Medical Management Center, Stockholm, Sweden.
authors.forename: Sara
authors.initials: S
authors.lastname: Runesdotter
authors.affiliation: Karolinska Institutet, Department of Learning, Informatics, Management and Ethics, Medical Management Center, Stockholm, Sweden.
authors.forename: Lisa
authors.initials: L
authors.lastname: Smeds Alenius
authors.affiliation: Karolinska Institutet, Department of Learning, Informatics, Management and Ethics, Medical Management Center, Stockholm, Sweden.
authors.forename: Carol
authors.initials: C
authors.lastname: Tishelman
mesh_terms: D005060:Europe; D006801:Humans; D007588:Job Satisfaction; D009740:Nursing Staff / Q000523:psychology*; D010558:Personnel Loyalty; D010561:Personnel Staffing and Scheduling
keywords: Job satisfaction; Multilevel analysis; Registered nurses; Workload