Factors associated with registered nurse retention in Korean nursing homes: A cross-sectional study

Article information

J Korean Gerontol Nurs. 2025;27(4):375-382

Publication date (electronic) : 2025 November 28

doi : https://doi.org/10.17079/jkgn.2025.00066

Jiyeon Lee

Assistant Professor, College of Nursing, Catholic University of Pusan, Busan, Korea

Corresponding author: Jiyeon Lee College of Nursing, Catholic University of Pusan, 57 Oryundae-ro, Geumjeong-gu, Busan 46252, Korea TEL: +82-51-510-0782 E-mail: jylee@cup.ac.kr

Received 2025 February 26; Revised 2025 September 2; Accepted 2025 November 10.

Abstract

INTRODUCTION

Registered nurses (RNs) are foundational to the formal long-term care system, particularly in nursing homes (NHs), where they play an indispensable role in improving care quality [1]. They deliver essential clinical services, manage care, and develop evidence-based practice plans based on timely health assessments of residents [2]. The professional expertise of an RN is critical for providing first-aid and skilled nursing services [3]. Consequently, RN retention is closely related to the stability of healthcare service delivery and is a critical determinant of care quality [1]. Moreover, the significance of RN retention goes beyond individual and organizational benefits to support the broader objectives of the quadruple aim in healthcare, which encompasses improved patient experience, improved population health, cost efficiency, and the well-being of the healthcare provider [4].

The nursing workforce faces a global shortage, with projections indicating over one million retirements by 2030 [5]. In Korea, this challenge is particularly acute in NHs, where the recruitment and retention of RNs is extremely difficult. Recent data show that RN retention rates in Korean NHs are as low as 68.9% [6]. Moreover, because Korean staffing standards allow NHs to hire certified nursing assistants (CNAs) instead of RNs, only 21.3% of NHs hire RNs, further aggravating this issue [7].

This issue is especially critical in NHs, where residents typically present with complex chronic conditions, cognitive impairments, and functional limitations, requiring continuous and skilled nursing care [1,5]. Unlike in acute care settings, RNs in NHs often work with less immediate access to physicians and diagnostic resources, making their clinical judgment and continuity of care essential to resident outcomes [3]. Furthermore, in the Korean context, the social perception of NHs and the low reimbursement levels in long-term care insurance have contributed to a challenging work environment for RNs, further discouraging retention [3,6].

Low retention imposes significant financial and operational burdens on the NHs. Recruitment and onboarding processes, as well as the subsequent disruption in the continuity of care, strain the resources and reduce overall efficiency [1]. Moreover, low RN retention adversely affects resident care by hindering the ability of the nurses to accurately assess and address individual residents’ requirements and preferences [8]. In addition, it exacerbates workplace stress, decreases job satisfaction, and hinders the employment continuity of the nurses, ultimately risking the quality of resident care [9]. A prior study has identified that personal factors, such as RN age, professional identity, and resilience, as well as organizational dynamics, leadership practices, supportive work environments, and other variables, are important determinants of RN retention [8].

Despite extensive research on RN retention in various settings, a notable gap exists in our understanding of the specific requirements and dynamics of Korean NHs. This study aims to bridge this gap by examining both individual-level characteristics—aggregated at the NH level—and organizational factors as predictors of RN retention in NHs. Such insights are important for developing evidence-based strategies to improve RN retention and sustain the workforce.

As Korea’s aging population continues to grow, the demand for skilled nursing professionals is also expected to increase. Addressing RN retention is not only a response to an ongoing workforce challenge but also a proactive strategy for ensuring high-quality care for vulnerable older adults. By identifying effective organizational practices, this study aims to provide actionable insights for healthcare leaders to foster supportive work environments and, ultimately, improve RN retention rates in Korean NHs.

METHODS

3. Variables and Measurements

Data were collected from the following sources: (1) NH administrators for the dependent variable (RN retention rate); (2) the National Health Insurance Service website, which provided information on NH staffing and organizational characteristics; and (3) participating RNs for individual characteristics. The general and individual characteristics of participants are summarized in Table 1, and the descriptive statistics of the dependent and independent variables used in the analyses are presented in Table 2.

Table 1.

General and Individual Characteristics of Participants

Table 2.

Descriptive Statistics of Dependent and Independent Variables

1) Dependent Variable

(1) Nursing home retention rate

The dependent variable was RN retention rate, defined as the percentage of RNs who remained employed at the same NH for 1 year or longer out of those initially employed [11]. Descriptive statistics for this outcome variable are provided in Table 2.

2) Independent Variable (Organizational Characteristics)

(1) Staffing characteristics

Staffing characteristics included the resident-to-RN ratio, calculated as the number of residents per RN in the NH, and the RN-to-total nursing staff ratio, representing the proportion of RNs to the total nursing staff, including both RNs and CNAs.

(2) Nursing home characteristics

NH characteristics included organizational size, measured by the number of beds in the facility, and ownership type, categorized as for-profit or non-profit. Descriptive statistics for these organizational-level variables are provided in Table 2.

3) Independent Variable (Individual Characteristics)

(1) Background data

General demographic and work-related data were collected from participating RNs to describe their individual characteristics, which are presented in Table 1. The variables included age, years of work experience at the current NH, number of financially dependent family members, history of night-shift work (yes/no), and monthly income in US dollars.

(2) Nursing professionalism

The level of nursing professionalism was measured using the Nursing Professionalism Scale [12]. This instrument consisted of 18 items across five domains: professional self-concept (six items), social perception (five items), professionalism in nursing (three items), the role of nursing (two items), and nursing autonomy (two items). Each item was rated on a 5-point Likert scale, with higher scores indicating a stronger professional identity. In this study, the Cronbach’s α for the total scale was .87, with subscale reliabilities ranging from .72 to .89. Descriptive statistics of overall professionalism scores are reported in Table 2.

(3) Resilience

Resilience was assessed using the Korean version of the Connor–Davidson Resilience Scale [13], which includes 25 items organized into five categories: hardiness (nine items), persistence (eight items), optimism (four items), support (two items), and spirituality (two items). Each item was rated on a 5-point Likert scale (0~4), with higher scores indicating greater resilience. In this study, the Cronbach’s α for the overall scale was .86, with domain-specific reliabilities ranging from .71 to .97. Descriptive statistics of resilience scores are shown in Table 2.

RESULTS

2. Regression Analysis

Table 3 presents the final model derived from all-subsets regression analysis, which systematically evaluated all possible combinations of predictors. The model was selected based on adjusted R-squared, AIC, and theoretical relevance to ensure optimal model fit and interpretability.

Table 3.

Results of Regression Analysis for Final Model

Three variables were identified as statistically significant predictors of RN retention. First, for-profit ownership was associated with lower retention (B=-7.41, 95% CI=-14.55 to -0.27, p<.05), indicating that RN retention rates were lower in for-profit NHs compared to non-profit NHs. Second, tenure at the current NH was positively associated with retention (B=0.38, 95% CI=0.13 to 0.63, p<.01), suggesting that longer employment at the same facility contributed to increased RN retention. Lastly, resilience was the strongest positive predictor of retention (B=0.66, 95% CI=0.39 to 0.94, p<.001), indicating that RNs with higher levels of psychological adaptability and recovery were significantly more likely to remain in their positions.

DISCUSSION

The findings of this study provide valuable insights into the factors influencing RN retention in NHs, which are crucial for ensuring both quality care and organizational stability [14]. To improve retention among NH RNs, identifying not only organizational (NH) characteristics but also individual (RN) factors that affect retention rates is essential. This study aimed to measure the retention rate of RNs in South Korean NHs and determine the organizational- and individual-level factors most significantly influencing it. The results revealed that the type of ownership was significant among the organizational characteristics examined, while years of employment and resilience emerged as key personal factors. These findings provide a multidimensional understanding of RN retention by highlighting how institutional structures and individual psychological resources interact to influence long-term employment decisions.

The average RN retention rate in Korean NHs is 77.4%. Although studies investigating NH RN retention rates are limited globally, making comparative analysis challenging, this figure is lower than the reported retention rate of hospital RNs, which ranges from 82.0% to 86.0% [8]. However, this figure exceeds the US NH nurse retention rate of 64.4% and the data surveyed in Korea in 2019, which is 68.9% [6,14]. This study observed an SD of 21.2%, indicating significant variability among NHs. This suggests that some NHs had relatively high retention rates. An in-depth analysis of the operational practices of these NHs, as well as the identification of the factors contributing to their success, could serve as the basis for an effective benchmarking strategy, allowing such practices to be disseminated to other NHs. However, further studies are required to confirm these findings. This result also implies that NH characteristics—such as leadership style, teamwork climate, or staff mix—may differ widely across NHs in Korea, warranting in-depth case studies of high-performing NHs.

The negative association between for-profit ownership and RN retention highlights the challenges faced by NHs in maintaining a stable workforce. According to previous research, for-profit NHs frequently prioritize cost efficiency, which can lead to decreased job satisfaction, increased workload, and limited opportunities for professional development, which negatively affects RN retention [14,15]. In contrast, non-profit NHs tend to prioritize non-monetary goals, such as social value, because of their structural prohibition on profit distribution [16], fostering supportive organizational cultures that emphasize employee well-being and job satisfaction [17]. Korea’s introduction of a long-term care insurance system in 2008 resulted in a sharp increase in for-profit NHs, which now account for 59.6% of all NHs, a significantly higher proportion than Canada’s 29.0% [18-20]. This study discovered that RN retention rates are lower in Korea’s for-profit NHs, underscoring the need for further research to analyze how the characteristics of for-profit and non-profit NHs differ and their influence on RN retention. Policymakers should consider how regulatory strategies, financial incentives, and workforce standards might be differentiated between for-profit and non-profit institutions to ensure equitable nurse retention outcomes.

The positive association between the tenure of an RN in their current NH and overall retention highlights the importance of a stable work environment. Longer RN tenure may indicate greater organizational commitment, familiarity with institutional protocols, and a stronger sense of belonging, all contributing to sustained employment [12,21]. Previous research suggests that emotional bonds that RNs develop with residents and their families can strengthen retention intention, particularly in NHs where long-term care enables ongoing and meaningful relationships [6]. Consistent with these findings, such bonds may serve as psychological barriers to turnover, resulting in higher retention rates. To capitalize on this, NHs can implement structured onboarding programs, mentorship initiatives, and career development paths that actively encourage RNs to remain in their positions for longer periods [22]. In addition, this study suggests that an RN’s tenure should not be treated solely as a numerical value but rather viewed as a critical indicator of workforce stability and sustainability within the institution.

Resilience, defined as the ability to cope positively with stress and adversity [23], has emerged as the strongest positive predictor of RN retention. This finding highlights the importance of individual adaptability and psychological well-being for continued employment, consistent with previous research that highlights the importance of resilience in mitigating workplace stress and preventing burnout [24,25]. RNs working in NHs who care for older adults over extended periods and perform repetitive caregiving tasks are particularly susceptible to high stress levels, making resilience a key factor in determining whether they continue to work [6,26]. Although acute-care hospital residency programs have proven effective in providing clinical and psychological support [27], various situational constraints (e.g., time and location) have prevented their widespread adoption by all RNs [28]. Alternatively, recent approaches involve brief and easily implemented activities during work hours aimed at reducing stress and increasing resilience [29], which have shown positive effects in reducing stress and improving psychological well-being [29]. Despite ongoing efforts to develop resilience programs for RNs, none of them have been tailored to the unique environment of NHs. Given that systematic interventions to strengthen resilience are expected to improve retention rates in NHs, and considering the findings of this study that RNs’ resilience positively impacts retention, developing and implementing resilience programs specifically designed for NH RNs is warranted [30]. Such programs may also have a positive spillover effect by improving team dynamics, job satisfaction, and quality of care in the NH setting.

These findings provide practical implications for gerontological nursing in three key areas. First, in education, nursing schools and continuing education programs should incorporate resilience training modules and ethical decision-making exercises tailored to the unique demands of long-term care, thereby preparing nursing students and practicing RNs to effectively address challenges specific to gerontological settings. Second, in clinical practice, NH administrators should develop and implement targeted staff support interventions, such as mentorship systems and peer-support programs, designed to help RNs manage the chronic stressors inherent in caring for older adults. Third, in research, future studies should employ longitudinal and multi-level designs to examine how individual factors—such as resilience—interact with team dynamics and facility-level policies to influence RN retention in gerontological care environments. Through these multidimensional efforts, nurses and organizations can foster long-term employment, enhance job satisfaction, and ultimately improve the quality of nursing care provided in NHs.

One potential limitation was the representativeness of the sample. Although 300 NHs were randomly selected with proportional regional allocation, only 38 participated, limiting the generalizability of the results. Inclusion was based on voluntary consent; therefore, non-participating NHs and RNs may have had different retention characteristics. Larger sample sizes and robust sampling methods may benefit the future research. Furthermore, as this study used a cross-sectional design to examine retention and related factors at a single point in time, drawing definitive causal inferences was challenging. The retention rate was calculated over a specific period, potentially overlooking seasonal or short-term fluctuations. For example, some NHs may experience a surge in turnover or, conversely, little change during specific periods, diverging from the annual trends. Additionally, although individual-level data were collected, all analyses were conducted using NH-level aggregated data. This may have limited the ability to detect within-facility variation in factors affecting RN retention. Future research should consider employing multilevel modeling to better capture the nested structure of such data and to more precisely examine both individual and organizational influences on RN retention.

CONCLUSION

This study demonstrates the multifaceted nature of RN retention in Korean NHs, identifying ownership type, years of employment, and resilience as key influencing factors. Specifically, for-profit NHs showed lower retention rates, indicating the need for targeted organizational and policy strategies. Longer tenure was linked to stronger commitment and retention, while resilience emerged as the most robust predictor, underscoring the value of psychological adaptability in long-term care environments. These results point to the importance of integrating resilience-building into staff development and nursing education, particularly in NH settings. Establishing supportive workplace environments and tailored retention initiatives may contribute to a more stable workforce and improved resident outcomes. Future studies should employ longitudinal or mixed-method designs to further explore contextual and team-level factors affecting RN retention.

Article information Continued