This study explored reasons for nurse turnover at BPKIHS hospital in Nepal. The researchers surveyed 150 current and resigned nurses about job satisfaction factors. They found that the major reasons nurses left BPKIHS were career opportunities elsewhere, opportunities for further education, negative attitudes of nursing leaders, inadequate salary, and poor promotion opportunities. The study concluded that increasing salary, job security, starting a bachelor's nursing program, a fair evaluation system, and clear promotion policies could help retain nurses and reduce turnover at the hospital.

1. REASONS FOR TURNOVER AMONG THE NURSES WORKING AT BPKIHS
Mehta*1 RS, Karki*2 P, Paudel *3 BH, Chaudhary*4 R
B.P. Koirala Institute of Health Sciences
Dharan, Sunsari, Nepal
Abstract:
Introduction: Conflict is a natural phenomenon and is inevitable in any organization.
Conflict in nursing organizations leads to turnover of nurses. Conflict, however, can also
be valuable to an organization since it promotes innovative and creative problem solving,
clarifies issues, and allows underlying problems to rise to the surface. The Objectives of
this study were to explore the factors influencing Job satisfaction among the nurses
working at BPKIHS, to investigate the reasons which have influences nurses in their
decision to leave BPKIHS and to suggest recommendations for a more satisfying working
environment by aiding staff retention.
Methodology: It was hospital based cross sectional Analytical study, conducted among
the nurses working at BPKIHS for more than six months at the time of study and those
who have resigned from BPKIHS. Stratified simple random sampling method was used
to select the nurses working in BPKIHS and purposive for the resigned nurses. Total 150
nurses were included in the study. Using pre-tested questionnaire the data was collected,
fulfilling all the ethical considerations. The collected data was analyzed using SPSS-4
package.
Results: It was found that majority of nurses (68.7%) were less the 25 years, Unmarried
(49.3%), have job experiences less than 5 years (54.7%), from sunsari (48%), and living
in quarter of BPKIHS (86%). Career opportunity elsewhere, Chance for further
education, Negative attitude of nursing leaders, In-adequate salary and poor promotion
opportunity are the Major reasons of nurses to leave or resign from BPKIHS.
Conclusion: To retain the nurses or decrease turnover there is need of increasing salary,
Job security provisions, Immediate starting of BN programme, fair evaluation system and
clear promotion policy. This study is useful for nursing leaders as well as BPKIHS
authority to take corrective action in time to improve the situation and prevent the future
consequences.
*1 Mr. Ram Sharan Mehta,( Corresponding Author) Assistant professor, Medical-
surgical nursing dept. College of Nursing, Email: ramsharanmehta@yahoo.com, *2 Prof.
Dr. Prahlad Karki, HoD, Dept. of Medicine and Hospital Director, *3 Dr. Bishnu Hari
Paudel, Asso. Professor, Dept. of Physiology, *4 Mr. Ramanand Chaudhary, Master in
Nursing, Paediatric Nursing dept. B.P. Koirala Institute of health sciences, Dharan,
Sunsari, Nepal.

2. Introduction: Health care delivery system, both curative & preventive, heavily depends
on nursing profession. The nurses are to pass on to a strong, socially relevant,
vocationally satisfied profession for future generation of nurses and citizens 1.
Twentieth century saw nursing as a profession, and a distinct discipline. Many nursing
theories were propounded, research work was undertaken, standards were set by different
nursing associations, and educational levels of nursing were streamlined, current issue
and trends found their place in nursing and expanded roles of nursing practice paved the
way towards new directions for nursing with increased autonomy 2.
Job satisfaction is a critical issue for nurses and hospital administrators. However, nurses
job satisfaction has not been measured adequately in most hospitals of Nepal. Since the
onset of restructuring measures, despite numerous and conflicting comments from nurses
and nursing managers about satisfaction and dissatisfaction with these measures. A
shortage of nurses negatively affects the safety and effectiveness of services provided.
Job–satisfaction varies intensively with staff turnover.
The desire to care for people, a family history of professional health care work, and
security in career choice are documented reasons for entering nursing. Reasons for
leaving include: workload, unsafe work environment, and harassment 3.
As per the annual report of BPKIHS, the number of nursing staff working in BPKIHS in
1993/1994 to 2003/2004 was 67, 94, 105, 116, 151, 224, 282, 257, 244, 327 and 415. The
accurate record of resignation of nurse’s year wise from 1993 was not available but as per
the mentioned record number of nurses (staff nurses and nursing officers) resigned for
BPKIHS were: in BS 2056–1, 2057–17, 2058–52, 2059–68, 2060–35 and in 2061 BS 7.
This evidence shows high turn over of nurses working at BPKIHS.
Objectives: The Objectives of this study were to explore the factors influencing Job
satisfaction among the nurses working at BPKIHS, to investigate the reasons which have
influences nurses in their decision to leave BPKIHS and to suggest recommendations for
a more satisfying working environment by aiding staff retention.
Methodology: It was Hospital based cross sectional Analytical study design, conducted
among the nurses working at BPKIHS and the nurses who resigned from BPKIHS. All
the nurses working in BPKIHS for more than 6 months, at the time of study and who
have resigned during the study period constitute the target population of the study. Total
population of the study was 256. Sample was comprise of all the nurses working in
BPKIHS who fulfill the set criteria and all the nurses who resigned during the study
period and willing to participate in the study were included and 150 Nurses were included
in the study. Nursing faculties and ANMs were not be included in the study. Nurses who
give consent to participate were only included in the study.
Stratified simple random sampling method was adopted to select the sample from the
working nurses and purposive sampling technique were used for resigned nurses. Semi-
structured Questionnaire (Job satisfaction and communication survey Questionnaire)

3. developed, tested and used by Bonnie W4, Kunaviktikul5 (Turn over of Professional
Nurses tool), and Brannon D6 (Job satisfaction and Turn over tools) were used after
modification to collect the data
The tool was given to nursing service administrators, hospital administrators,
psychologist and nurse-researchers for content validity. Necessary modification was
made after the feedback from the concerned experts. Pre-testing was done among 20
subjects and found practicable. Some modifications were also made after pre-test.
Written permission was obtained from the concerned higher authority. Lists of nurses
working in all the units/wards were prepared separately. By using stratified simple
random sampling technique the specified numbers of Nurses were selected from each
ward. Using purposive sampling technique all the nurses resigned during the study period
was also included in the study. After taking verbal consent from them individually a
questionnaire and blank self addressed envelope was given. They were requested to fill
up the Questionnaire and put in envelope and seal it; and return to the Investigator.
Individual responses were scored. A total score was then obtained for each factor on the
questionnaire by adding the numerical responses on the Likert scale.
Once all the data were collected then, focus group discussion was arranged. Focus groups
i.e. one group for nursing officers, one group for senior staff nurse and four groups for
staff nurses were arranged. In-depth discussion was made on focus group on various
components of Job satisfaction and turnover. Feedback and suggestions were collected
and analyzed.
Verbal informed consent was obtained from each subject before giving her
Questionnaire. The information given by subjects was kept confidential and used only for
this study. Anonymity in the Questionnaire was maintained. Self-addressed envelope also
facilitates confidentiality.
The data collected was based on the opinion of the working nurses, hence it might not
reflect true picture, but there is not feasibility of contacting each nurses, who left. Hence,
we have to rely on data/opinions given by currently working nurses.
Results:
Socio-demographic profile of the subjects: The majority of the nurses i.e. 68.7% were
of less than 25 yrs of age; only 14% were of more than age 35 yrs. About half of the
subjects were unmarried. Among the married only 52% was living with their husband.
About half of the nurses had experiences of nursing for less than 5 yrs. and only 9.3%
had experiences of more than 20 yrs. Majority of the nurses i.e. 86% were staying in the
residence / Quarter provided by BPKIHS as this institute is residential institute having
very good facility of quarter for employees. About half of the subjects were from sunsari
district, as there is three municipalities i.e. Dharan, Ithari and Inruwa lie in this district.
Motivating factors to work in BPKIHS: The main motivating factors to work in
BPKIHS are Big institution or university (51.3%), Quarter facilities (48%), safe place
(48%), chance of further education (32%), educational benefits (25.3%), Non-

4. transferable job (23.3), whereas only 9.4% only mentioned that pay scale is motivating
factor. Only 48% subjects reported that they would stick to nursing profession in future.
These findings clearly illustrate the reasons for turnover of nurses. Majority of the
subjects (66%) mentioned that they joined nursing profession, as they are intrested to be
nurse; where as 55.3% mentioned the reasons for joining nursing is easy access to job and
35% mentioned the parental force to join nursing. In contradictory to this only 48%
reported that they want to stick to this profession.
Job satisfaction among the nurses: Twenty-six items of job satisfactions were analyzed
using four point likert scale. Very few percentages of subjects were fully satisfied with
the components of job-satisfaction. Majority of the subjects were moderately satisfied or
just satisfied with the available facilities. The percentage of not satisfied at all with
various comments of job-satisfaction is also high.
With pay scale none of the subjects were fully satisfied, 24.7% were moderately satisfied,
40% just satisfied and 35.3 were not satisfied at all. Which clearly shows the need of
incensement of salary. The positive motivating factors to work in BPKIHS are, prestige
of organization, work it self, responsibility, quarter facilities and achievements. The
satisfaction with pay scale/salary, monetary benefits, recognition of good work done,
promotion opportunity, general administration, nursing administration, job description
and evaluation system is not good.
More than half of the subjects (56.7%) mentioned that they want to serve in BPKIHS
Less than 5 yrs only. About 15% reported that they want to serve more than 15 years; this
picture clearly illustrates the higher incidences of nurses to leave BPKIHS. About 77%
nurses were intrested to go abroad to serve, which clearly illustrate the scope of nursing
in world and may create manpower crisis in future. Majority of the nurses (80%) were
only just satisfied with nursing profession as carrier and 48% wants to stick to this
profession in future, where as 66% nurses became nurse with their own intrest. This
picture clearly illustrates the poor motivating job factors, which needs detailed
exploration.
Reasons influence nurses to leave BPKIHS: The Turnover of nurses at BPKIHS is
very high. The major reasons influencing nurses to leave BPKIHS are: Career
opportunity else where, further education opportunity, Attitude of nursing leaders,
frequent night duty, attitude of medical team., stress at work place, pay scale / salary,
poor promotion opportunity, and administrative problems.
Suggestions to improve nurses’ retention at BPKIHS: At present the high turnover of
nurses is a burning issues for nursing administration. It is crucial time to initiate the
appropriate nursing action to take corrective action, to retain the nursing manpower at
BPKIHS. The main action needed for initiations are: Increase the pay scale / salary,
immediate starting the BN course at BPKIHS, investigate and eradicate partiality and
favorism, fair evaluation system, starting continuous in-service education program in
each specialty areas, routine clinical supervision system, strengthen inter and intra
department communication, and increase the moral of the nurses.

5. Improved communication, feedback both positive and negative, increasing socializing
amongst the unit members and the creation of a more relaxed working environment were
suggestions proposed to overcome the turnover found by mathew8 in her study. Similar
suggestions were reported by the nurses in this study to increase Job satisfaction and
decrease turnover.
The details of the results are mentioned in table-I to IV.
Discussion:
Nurses’ turnover is expensive. It affects the safety and effectiveness of service in
hospital. Recruitment and retention of sufficient number of nurses to work is a major
challenge for nursing administrators 8. A recent survey of nearly 1,000 nursing homes
estimated the annual turnover among nurses is almost 1 in 5, or 20% according to
American nurse’s association9.
A study conducted by Irvine 16, reported that, a strong positive relationship was indicated
between behavioral intentions and turnover; a strong negative relationship between job
satisfaction and behavioral intentions, and a small negative relationship between job-
satisfaction and turnover. Variables related to nursing job satisfaction, work content and
work environment has a stronger relationship with job satisfaction than economic or
individual difference variables.
A study conducted by Davidson 18 among 736 hospital nurses reported that, important
determinants of low satisfaction were poor instrumental communication within the
organization and too great a workload. Intent to leave was predicted by the perception of
little promotional opportunity, high routinization, low decision latitude and poor
communication. Predictors of turnover were fewer years on the job expressed intend to
leave, and not enough time to do the job well.
A study conducted by Symes 19 among 183 new graduates reported that, 47% new
graduates had unspecified personal stressors related to lack of confidence and discomfort,
35% with dying patients, 46.5% with personal finances, and 43% reported traumatic life
events before the age of 16 and 50% after the age of 16.
Mathews 8 found in her study that frequent night duty considered the highest scoring
factors, influencing nurse’s decisions to leave hospital. Which is similar to this study.
Psychological effects are immense, lack of participation in social activates leads to a
feeling of Isolation, for some nurses a good self image is hard to maintain due to chronic
fatigue, anxiety results from going to work in shift busy duty and feeling of neglect arise
from inadequate time spent with family and friends mentioned by Mathews8 in her study,
which are similar to this study. Similar findings were reported by Irvine16 and
Davidson18 .

6. Implications: Nursing practice is based on mixture of research, anecdote, tradition,
theory, and hunch. Job satisfaction is a key indicator of good working environment,
employee retention and management of the institute. This study help to implement
policies and practices to optimize staff satisfaction, staff retention, quality care provision
and co-ordination. The study also gives the insight and feedback to nursing administrator
and authority of BPKIHS to think the problem seriously and take corrective action. The
study also helps supervisors to change their attitude so that quality patient care can be
provided. This study emphasis the need of continuous in-service education in their
respective specialty. The study explores the immediate need to start BN Nursing
programme at the institute. Regular interactions between the supervisors and their
subordinates are essential in fostering employee relationship that increases the likely
hood of productivity of organizations. The effective communication is essential in any
institute to eradicate the misconceptions and raise satisfaction. Finally, the result can be
used for planning and implementing the remedial measures to improve nursing service at
BPKIHS, and decrease the turnover rate of nurses.
Recommendations:
1. This study can be conducted in similar setting hospitals like: TUTH, BPKMCH,
Bir-hospital, Patan hospital, Manipal and others to compare the results.
2. This study can also be conducted at similar government hospitals to find the
differences in results.
3. Periodically, conducting this type of study gives insight to take corrective action
in time. Hence, this type of study must be repeated every 3-4 years.
4. This study can be conducted among nursing faculties and ANMs working at
BPKIHS as well as other institutions.
5. Similar study can be conducted among doctors and other technicians and
paramedics to compare the differences.
Problem Faced During The Study:
Following problems were encountered during the study:
1. Few respondents were hesitated to give the answers of the questions.
2. It was found difficult to grade the satisfaction level and perception level because
different individual perceives it differently.
3. Measurement of individual differences found difficult to grade.
4. It was found difficult to grade the facilities available with the subjects and to
recall the past events. It is also difficult to measure quantitative form exactly.
5. Some problems were encountered for arranging the focus group discussion,
because of busy schedule of nurses and shift duty.
Limitations of the study:
The limitations of the study are as follows:
Subjects: the staff nurses, senior staff nurses and nursing officer / sisters were only
included in the study. The nursing faculties, senior nursing officers and ANMs were not
included in the study.
Period: The data collection period was from 1 August 2005 to 30 August 2005.
Sample size: Only 150 nurses were involved in the study.

7. References:
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Health Sciences; Dharan, Nepal; 2000: 30-31.
2. Mehta RS. VISION: SOUVENIR, B.P. Koirala Institute of Health Science,
Dharan, Nepal; 1999: 1-3.
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conflict, conflict management, Job satisfaction, intent to stay, and turnover of
professional nurses in Thailand. Nursing and Health Science. 2003; (2): 9-16.
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Environmental Factors Associated with high and low Nursing Assistant
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7. Diane MI, Martin GE. Model of nurse Turnover behaviors. Nursing research.
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10. Sherman DW. Nurses’ stress and Burnout. AJN. 2004; 104(5): 48-55.
11. Pataliah BA. Aptitude about nursing among nursing profession. NJI. 2004, XCV
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18. Yaktin, Umayma S. Personal characteristics and Job satisfaction Among Nurses
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8. Table: - I
Distribution of subjects according to the various motivations Factors to work in
BPKIHS
N=150
S. N. Item/Particular Percentage (%)
1. Motivating factors to work in BPKIHS (MR)
a. Pay scale 9.3
b. Quarter facilities 48.0
c. Safe – place 48.0
d. Non – transferable job 23.3
e. Big institution /university 51.3
f. Educational benefits 25.3
g. Chance for further education 32.0
h. Others 10.0
Table: -II
Reasons for choosing nursing profession (MR):
N=150
S. N. Item/Particular Percentage (%)
1. Reasons for choosing nursing profession (MR):
a. For easy access to Job 55.3
b. Because my parents wanted me to join nursing 36.0
c. I was very interested to become a nurse 66.0
d. There is glamour in this profession 8.0
e. Due to financial problems 4.0
f. Thinking I would join other profession later 4.7
g. Due to peer pressure 4.0
I. Others. 8.0

9. Table – III
Reasons for turnover /resignation of nurses at BPKIHS
N=150
S. N. Reasons for turnover of nurses Percentage (%)
1. No Responses (N = 35) ---------
2. Responses (N = 115) 100
a. Carrier opportunity else where 60
b. For further education 55
c. Permanent in HMG 52
d. Poor cooperation & attitude of nursing leaders 48
e. Unfair evaluation 43
f. Poor promotion opportunity 42
g. Favorism and partiality from supervisors 41
h. Rules and regulations not transparent 35
I. Salary/pay inadequate 32
Table – IV
Suggestions to improve staff retention at BPKIHS
N=150
S.N. Suggestion for staff retention Percentage (%)
1. No response (N=36) ...........
2. Responses (N=114) 100
a. Increase salary/pay scale 80
b. Job security (permanent) 75
c. Avoid partiality & favorism 62
d. Immediate starting of BN course 60
e. Fair and proper facilities for nurses 57
f. Adequate further education opportunities 57
g. Regular & impartial evaluation system 56
h. Continuous in-service education in related are as 55
I. Establish transparent rules for promotion 42