Design

This study is a cross-sectional descriptive design and adheres to the STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) checklist for cross-sectional studies.

Sample and setting

The study was conducted across Türkiye, with the target population consisting of nurses working in hospitals who were directly responsible for patient care. The minimum sample size was calculated using a sampling method based on a known population. The formula \(n =  \frac{Nt^2pq}{d^2(N-1) +  t^2pq} \) was applied, with a 95% confidence interval, a 5% margin of error, and a 50% incidence (p) rate, which represents the maximum value for sample size calculations. The sample size calculation was based on the total number of nurses actively working in Türkiye (243,565), as reported in the 2022 statistical yearbook of the Ministry of Health. This calculation determined that a minimum sample size of 384 nurses was required to achieve a 95% confidence level and a 5% margin of error. A “required to answer” sign was added to all questions in the questionnaire. Nurses participating in the study could not proceed to the next question or submit the form without responding the previous one. A total of 464 nurses who completed the questionnaire constituted the sample of the study. The participants were selected using convenience sampling. The inclusion criteria were: (1) working directly in patient care in a hospital in Türkiye, (2) having been employed at the same institution for at least one year, and (3) voluntarily agreeing to participate in the research. The first page of the questionnaire included three questions to verify whether nurses met these criteria: working directly in patient care at a hospital, had been employed at the same institution for at least one year, and voluntarily agreed to participate in the study. Participants were not allowed to proceed without responding these questions. A random sampling method was used to select the nurses included in the final sample.

Measurement

Data collection

Data were collected between March 4th and May 14th, 2024. The questionnaire was created using Google Forms, and the link was shared through social media platforms such as Instagram, Facebook, and WhatsApp. Nurses who responded to the questionnaire were included in the sample.

Ethical considerations

This study was conducted in accordance with the Declaration of Helsinki, and all procedures involving human participants were approved by the Istanbul University Social Sciences and Humanities Research Ethics Committee (Approval Date: February 12, 2024, Approval Number: 2415631). Permission to use the Turkish version of the adapted scales was obtained via email from the original authors. A consent form was provided on the first page of the questionnaire, where participants were asked to choose between “I agree to participate in the study” or “I do not agree to participate in the study.” Only participants who chose “I agree to participate in the study” were allowed to proceed with the questionnaire.

Statistical analysis

In this study, the normality of continuous variables was assessed using the Kolmogorov-Smirnov test. Categorical variables were presented as frequency (n, %) and continuous variables as mean and standard deviation. Cronbach’s alpha coefficients were calculated to assess the reliability of the scales. Comparisons between two groups for continuous variables were performed using an independent samples t-test, while one-way analysis of variance (ANOVA) was used for comparisons involving more than two groups. Pearson’s correlation test was used to examine the correlation between two continuous variables. Multivariate linear regression analysis was conducted to assess the effect of independent variables on the dependent variable (turnover intention). The results were evaluated with 95% confidence intervals, and statistical significance was set at p < 0.05. No data were missing for the statistical analyses. The sample size was determined using the known population sampling formula. All statistical analyses were performed using SPSS software, version 26 (IBM Corp., Armonk, NY, USA).

Characteristics of the participants

A total of 464 nurses participated in the study, with an average age of 34.74 ± 8.31 years, 82.5% of whom were female. Regarding demographic characteristics, 71.3% of the nurses were married, and 60.6% held an undergraduate degree. In terms of occupational characteristics, 37.1% worked in a ward, 32.5% in the operating room, 17.7% in the intensive care unit, and 57.5% in private or foundation hospitals. Additionally, 79.3% of participants were working as nurses, with 40.1% on constant day shifts, 31.9% on constant night shifts, and 28% working rotating shifts. The mean total professional experience, years of experience in their current unit, and years of experience in their current position were 12.93 ± 8.03, 10.36 ± 5.95, and 11.89 ± 7.59 years, respectively (Table 1).

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Table 1. Profile of the respondents.

https://doi.org/10.1371/journal.pone.0316895.t001

Descriptive information of hierarchical career plateau and turnover intention

The mean level of hierarchical career plateau among nurses was 23.03 ± 7.29 (range: 8–35), while the mean turnover intention level was 34.61 ± 9.37 (range: 13–47). A statistically significant positive correlation was found between nurses’ hierarchical career plateau level and their turnover intention, with turnover intention increasing as the level of hierarchical career plateau increased (r =  0.821; p <  0.001) (Table 2).

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Table 2. Hierarchical career plateau and turnover intention scale scores and the level of correlation between scales.

https://doi.org/10.1371/journal.pone.0316895.t002

Univariate analysis results

No correlation was found between nurses’ age, length of experience in the position, length of experience in the unit, and length of professional experience and turnover intentions. Nurses who worked in private/foundation health institutions (t = 5.013; p < 0.001) and enjoyed their profession (t = 10.824; p < 0.001) were found to have statistically significantly lower turnover intention. No statistically significant difference was found in turnover intention according to sex, marital status, educational level, unit, work schedule and position of nurses (p > 0.05) (Table 3).

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Table 3. The level of nurses’ turnover intention according to the introductory. Characteristics.

https://doi.org/10.1371/journal.pone.0316895.t003

Multivariate analysis results

Multivariate linear regression analysis was conducted to identify the independent variables associated with nurses’ turnover intention (Table 4). The model explained approximately 70.5% of the variance in the total turnover intention score. An increased hierarchical career plateau (β =  0.738; p <  0.001) and working in a public institution (β =  0.189; p <  0.001) were found to have a positive effect on turnover intention, while willingly choosing the nursing profession (β =  -0.349; p <  0.001) had a preventive effect on turnover intention (Table 4).

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Table 4. Factors influencing nurses’ turnover intention.

https://doi.org/10.1371/journal.pone.0316895.t004

Discussion of hierarchical plateau and turnover intention averages

The average hierarchical career plateau level of nurses in this study was found to be high, consistent with findings from the literature [15,18,20]. However, there are also a limited number of studies that report contrary results [15]. This difference can be explained by the fact that career plateau is both an objective and subjective phenomenon, influenced by personal characteristics, organizational factors, and the opportunities and privileges available to individuals, as well as their perceptions of these opportunities [17]. In a study by Zhu and Li [20] on career plateau among 2,680 senior nurses, it is reported that the highest incidence rate is associated with hierarchical plateau, which one of the dimensions of the career plateau. As reported in the literature, this finding may be attributed to the hierarchical structure of organizations, which often resemble a pyramid. Consequently, the number of promoting nurses is limited, reflecting the reduced likelihood of vertical progression within the organization. Therefore, optimizing job positions and offering more promotion opportunities and career development paths may help alleviate the hierarchical career plateau experienced by nurses.

In this study, nurses’ turnover intention was found to be above average. Similar studies conducted in Türkiye have also reported moderate to high levels of turnover intention among nurses [34,35]. Some studies in the literature have shown that nurse turnover rates vary across continents and that this is related to differences in health systems, working conditions, and health policies between developed and developing countries [10,21,36].

Discussion of the impact of willingly choice of careers on turnover intentions

It was found that nurses who willingly chose the nursing profession had lower turnover intention. Nurses may choose the nursing profession for various reasons, including personal interest, perception of the professional image, a desire to help others, job security, favorable living conditions, recommendations from family, friends, and teachers, opportunities for migration abroad, family pressure, parental authority, social influences, or even chance (such as placement based on university exam scores) [37–42]. A study conducted in China found that nurses who were assigned to their job roles or chose their careers based on the wishes of their parents did not demonstrate expertise in their current profession and were less interested in their work. Additionally, this study reported that 72.5% of retired nurses who left the profession had not chosen nursing willingly [43]. Similarly, a study by Yeşilyurt et al. [44] conducted across Türkiye found that nurses who did not willingly choose the profession had higher turnover intentions [44]. Another study conducted with nurses in a public hospital in Türkiye also reported that those who did not willingly choose the nursing profession had higher turnover intentions compared to those who chose willingly [34]. A study conducted among nursing students in Türkiye found that two-thirds of the students chose nursing primarily due to job security [42]. Nurses who willingly enter the profession and have a passion for their work tend to focus on the positive aspects of their role, rather than the negative factors such as challenging working conditions. This mindset helps them to remain resilient against the prevailing organizational challenges, fostering a long-term commitment to their profession [45]. Adib-Hajbaghery et al. [45] emphasize that a lack of passion for the nursing profession can increase the likelihood of nurses distancing themselves from their professional roles, experiencing burnout, and ultimately leaving the profession [45]. Nurse managers should develop strategies to enhance nurses’ interest in the profession and offer career counseling. Additionally, before entering nursing education, prospective nursing students should receive proper information about the profession, and support should be provided to help them explore their areas of interest within nursing.

Discussion of the relationship between working in a private or public hospital and turnover intentions

According to the results of the study, it was found that working in public institutions increased nurses’ turnover intention. While similar findings have been reported in studies conducted in Türkiye [46], other studies have indicated that nurses working in private hospitals have higher turnover intentions compared to those in public hospitals [2,44,46,47].

The literature indicates that the type of employment (public or private) plays a significant role in determining job security, with nurses in government positions reporting significantly higher job security [48]. Studies showing lower turnover intentions among nurses in public hospitals attribute this finding to the greater job security offered by public organizations [2,48]. Huaman Ramirez and Lahlouh [23] also suggest that employees who choose to work in public organizations may be less concerned with advancing in hierarchical positions and may prioritize other factors, such as job security, more highly [23]. In the present study, it was observed that nurses in public hospitals tend to work longer due to job security, which may contribute to the lower frequency of managerial turnover. This stability in management could, in turn, influence the higher turnover intention among nurses. Future studies may explore variables such as job security through incorporating into the model for further research.

It has been reported in the literature that a more positive perception of the work environment reduces turnover intentions [49]. Studies that report high turnover intentions in the public sector often attribute these intentions to negative working conditions, such as ineffective communication, inadequate compensation, poor management, availability of resources, participation in decision-making, transformational leadership, low organizational support, collegial and superior support, procedural justice, lack of career advancement opportunities, and inadequate staffing [50–52]. In private hospitals, it has been reported that turnover intention decreases in institutions that have more positive work environment factors such as perceived managerial support, and less negative factors such as occupational stress and work-family conflict [50]. In this context, there has been a growing demand for better working conditions, particularly in the public sector, accompanied by a rising turnover intention [2]. Additionally, the mandatory nurse-to-patient ratio standards in private hospitals, particularly for inpatient services, contrasts with the lack of enforceable standards for nurse-patient ratios in public hospitals, except in specialized units such as intensive care. This discrepancy may have led to increased workload in public hospitals, contributing to higher turnover intention. Furthermore, while the recruitment of new nurses in public hospitals may require several procedures and government approval to open new positions, the faster hiring process in private hospitals may have resulted in a heavier workload for nurses in private institutions, which increased turnover intention in these settings.

One study highlights that additional support systems, such as transportation, childcare, housing, and private health insurance, offered in private hospitals, are considered critical for employee retention. In contrast, the absence of such supports in public hospitals is identified as a significant reason for nurses’ turnover behavior [47]. In the present study, the lack of additional support services, such as childcare, housing, and transportation services for each shift, which are commonly offered in private hospitals, may have contributed to higher turnover intention in public hospitals.

In a study comparing management practices in public and private hospitals, it is reported that public hospitals appear to be less efficient in promoting and rewarding highly motivated employees or providing incentive plans to remove low performers [53]. In a meta-analysis by Hur and Abner [51] of studies conducted on the reasons for turnover in public organizations, promotion, diversity management, performance appraisal/feedback, satisfaction with practices such as training/development and salary and rewards have a negative association with turnover intention [51] A qualitative study investigating the reasons for turnover and retention of nurses in private and public hospitals in Türkiye emphasizes that the lack of objective criteria for promotion and inequalities in promotion in public hospitals are associated with turnover, while faster hierarchical advancement and merit-based advancement are important for retention in private hospitals compared to public hospitals [47]. Freire and Azevedo [2] have found that normative commitment has a direct and negative significant effect on turnover intention of nurses in public hospitals, while affective commitment has a direct and negative significant effect on turnover intention of nurses in private hospitals [2]. In public hospitals, nurses’ turnover intention may be high due to several factors, including normative commitment, long-term employment of nurse managers driven by job security, and slow hierarchical progression. Other contributing factors include the perceived lack of fairness in promotion decisions, unclear promotion criteria, and the prioritization of seniority over merit when making promotion decisions. These elements may lead to frustration and decreased job satisfaction, ultimately increasing turnover intention among nurses in public hospitals.

The findings of this study suggest that the quality of the private hospitals where the nurses in the sample work may also play a role in influencing their turnover intentions. Some private hospitals in Türkiye are accredited and offer favorable working conditions, good physical infrastructure, and additional benefits, which can contribute to higher job satisfaction and lower turnover intentions. These results highlight the significant impact that the type of hospital—whether public or private—has on the facilities and benefits provided to employees, ultimately influencing their turnover intention. For healthcare organizations and managers, it is necessary to diagnose the situation and define the most appropriate policies for each sector as a strategy to retain healthcare workers.

Discussion of the relationship between career plateau and turnover intention

In the present study, it was found that as the level of hierarchical career plateau of nurses increased, their level of turnover intention also increased. This finding is consistent with previous research in various sectors [27,54] as well as in nursing [14,29], which has shown a positive correlation between hierarchical plateau and turnover intention. In other words, a higher perceived hierarchical plateau tends to lead to an increased turnover intention. A study by Ng et al. (2024) has found that employees with high career plateaus had a weaker negative correlation in career planning and turnover intention, while those with high level of career plateau have higher turnover intentions [55]. A systematic review and meta-analysis has also reported that turnover intention among nurses is significantly associated with promotion and career development opportunities [56]. Turnover intention often results from the negative experiences encountered by employees. In a qualitative study by Zhu et al. [14], which examined the career plateau experiences of nurses who resigned due to limited career advancement opportunities, all participants stated that they did not make a direct decision to resign due to their perception of being stuck. However, they had previously faced restricted opportunities to advance their careers, leading to negative emotions such as uncertainty, unhappiness, disappointment, and job dissatisfaction. As a result, these negative feelings caused nurses to lose confidence in their current organization and seek employment elsewhere, with better prospects for career growth and promotion [14]. Similarly, Yeşilyurt et al. [44] found that nurses dissatisfied with the career opportunities provided by their hospital exhibited a higher level of turnover intention [44]. De Clercq et al. [57] also noted that when employees perceive their employers as providing insufficient career support, they may feel that their employers are not meeting their obligations, leading to feelings of frustration and dissatisfaction.

According to the meta-analytical review by Lu et al. [58], the deterioration of the psychological contract between nurses and their employers negatively impacts turnover intention. The Social Exchange Theory suggests that when employees perceive their employer as failing to fulfill their obligations, they may feel justified in not fulfilling their own, which can lead to job dissatisfaction and ultimately, turnover. Based on the findings of the present study, nurses may intend to leave their positions to seek better promotion opportunities and other resources that they feel are unavailable in their current workplace.