Nurses are the largest healthcare workforce in the world and play a critical role in the delivery of healthcare services. The socioeconomic development and population aging have been accompanied by a growing demand for nursing staff (1). However, the shortage of nursing workforce is a global issue (2), and a high rate of turnover of nurses has exacerbated the shortage of nursing workforce, causing serious concerns about patient safety and quality of care. A meta-analysis showed that more than 27% of the intensive care nurses had the intention to leave worldwide covering 23 countries (3).

Extensive studies have been conducted regarding turnover intention of nurses, the strongest predictor of nurses leaving the healthcare industry (3). Work-related factors including high job demand (4–6), job stress (7–9), job dissatisfaction (10–12), and low organizational commitment (13–15) have been blamed for triggering turnover intention of nurses apart from family commitment.

The shortage of nurses in China has attracted serious concerns. Over the past few decades, the Chinese government has made great efforts to boost the supply of nursing workforce. By 2018, the number of registered nurses eventually overtook the number of medical doctors, reaching a doctor-nurse ratio of 1:1.14 (1:1.17 in 2021) (16, 17), but the ratio is still lower than that of many other countries and yet to achieve its goal of 1: 2 (18). China had 2.94 nurses per 1,000 population in 2018, compared with an average of 7.5 in the OECD (Organization for Economic Cooperation and Development) countries (19).

There is paucity in the literature documenting losses of clinical nurses in China, although the work environment of nurses in China is evidently suboptimal. Most nurses in China are employed by hospitals (over 75% in public hospitals) (16), which provide both unreferred primary care and specialist care. Patients in China enjoy the freedom to bypass primary care facilities in seeking medical attention from hospitals, putting enormous pressure on hospitals (20). Hospital nurses have to work long hours, including more frequent night shifts, in response to the high demands of patient care (21, 22). In recent years, workplace violence incidents in hospitals have been frequently reported, and they are most likely directed towards nurses as nurses have close contacts with patients and they are most approachable (23).

This study aimed to address the gap in the literature by investigating the association between quality of working life (QWL) and turnover intention in hospital nurses in China. QWL assesses the influence of both job and organizational factors on individual employees, such as work-related stress, fatigue, and burnout (24–26). QWL is directly linked to the health and wellbeing of the nurses, which is presumably associated with their turnover intention. Meanwhile, low QWL of nurses is also associated with poor safety and quality of nursing care (27). Despite the critical role of QWL, our understanding about the link between QWL and turnover intention, in particular in the context of the Chinese hospital system is limited. This current study contributes to the literature by answering the research question: “To what extent, QWL is associated with turnover intention in hospital nurses in China after adjustment for variations in other determinants.”

High levels of turnover intention in clinical nurses are evident in mainland China. Almost 43% of our study participants expressed turnover intention, which is much higher than those revealed in other studies of nurses. A recent meta-analysis reported a pooled global prevalence of turnover intention 27.7% in intensive care nurses from 23 countries (n = 23,140) (3).

QWL is a significant predictor of turnover intention in nurses, according to the findings of our study. We found that higher levels of job and career satisfaction, professional pride, and a balance between work and family are associated with lower turnover intention. These results are consistent with the findings of previous studies. Job satisfaction in nurses and its effects on turnover intention have been well documented (10, 12, 36). A meta-analysis of 191 studies concluded that family–work conflict is a significant predictor of turnover intention in nurses (37). One study of 1,187 registered nurses in 27 healthcare facilities in the Netherlands showed that burnout is a critical factor triggering turnover intention, and work–family conflict can aggravate the degree of burnout (5). The medical dominance and hierarchical culture in healthcare services have long been a concern for ensuring safety and quality of patient care (38), which also jeopardizes professional pride of the nurses (39, 40).

The association between QWL and turnover intention is echoed by the sociodemographic and work-related predictors of turnover intention revealed in our study, such as workplace violence, sleep deprivation, and lower levels of professional title. Overload has been found to be associated with accumulative fatigue (41), increased occupational injuries (42), and higher turnover intention (43) in nurses in previous studies. Night shifts are common in nursing jobs, which can result in night sleep deprivation and shift work disorder (SWD), leading to ill health, reduced working capacity, and turnover intention (44, 45). The negative effect of workplace violence on turnover intention has also been reported in previous studies in various settings (46, 47).

Unfortunately, the current system environment has imposed significant challenges for addressing the above-mentioned concerns. There has been a serious shortage of nursing workforce in China. The doctor-nurse ratio reached 1:1.14 in 2018 (1:1.17 in 2021), but is still lower than that of many other countries and China’s national goal of 1:2. Over the past decade, there have been increasing concerns about workplace violence against health workers in China. Indeed, 70.8% of our study participants reported encounter of workplace violence (15.2% frequently). Workplace violence is a dangerous behavior that negatively affects nurses’ physical and mental health (48), and also affects the professional pride of nurses. Tackling workplace violence requires a systems approach involving governmental agencies, funding bodies, healthcare providers, and the public (49, 50).

It is important to note that high levels of turnover intention in nurses are likely to be a widespread problem across China. Our multivariate regression modelling showed no gender, regional, and workload differences in turnover intention in nurses. However, higher turnover intention was identified in the nurses aged between 30 and 40 years. Nurses in such an age range have accumulated extensive clinical experiences. Many have taken a leadership role. They account for a large, if not the largest, proportion in nursing workforce and are the backbone of nursing services. Losing them may present a profound risk to quality delivery of patient care services.

There is not a silver bullet to address all of the challenges of nursing work environment. The findings of our study imply that targeted interventions are needed to address the concerns of nurses in job and career satisfaction, professional pride, and a balance between work and family. Some researchers recommend the use of robots to help reduce the workload of nurses and to achieve work-life balance (51), while others argue that human contacts and empathy are an essential element of nursing services, which is not replaceable (52). It is important for healthcare managers to demonstrate increased recognition and appreciation of the professional contributions of nurses. The findings of our study indicate that a proper career pathway and professional promotion may help reduce turnover intention in nurses. However, these need a change in the culture of the healthcare industry. Currently, there exists great inequality between nurses and medical doctors in the professional promotion systems largely because of the varied educational qualification requirements. Arguably, the professional promotion systems should be more closely aligned with job performance rather than prerequisite qualifications. It cannot be overstated how crucial team efforts are in ensuring the high quality of patient care; both medical and nursing services are indispensable for optimal care outcomes (38).

High levels of turnover intention are evident among nurses employed by public hospitals in China, especially those aged between 30 and 40 years. Low quality of work life (QWL) and poor work environments emerge as significant predictors of turnover intention. Targeted interventions are necessary to address nurses’ concerns related to job and career satisfaction, professional pride, and achieving a balance between work and family. These interventions should adopt a systems approach and aim for a cultural shift in the healthcare industry, fostering greater appreciation for the professional contributions of nursing services.

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

The studies involving humans were approved by Ethics Committee of Tongji Medical College, Huazhong University of Science and Technology (No: IORG0003571). The studies were conducted in accordance with the local legislation and institutional requirements. Written informed consent for participation in this study was provided by the participants’ legal guardians/next of kin.

CT: Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Writing – original draft, Writing – review & editing. SZ: Data curation, Formal Analysis, Investigation, Methodology, Writing – original draft. CL: Conceptualization, Methodology, Project administration, Supervision, Writing – review & editing. RM: Data curation, Formal analysis, Investigation, Methodology, Writing – review & editing. RC: Data curation, Formal analysis, Methodology, Project administration, Supervision, Writing – review & editing. TL: Data curation, Formal analysis, Methodology, Supervision, Writing – review & editing.