INTRODUCTION
1. Background
Nurses are essential healthcare professionals who provide direct patient care and play a pivotal role in ensuring patient safety and improving care quality within hospital settings [1]. Although approximately 436,000 nurses hold active licenses in South Korea as of 2021, only about half—roughly 216,000—were employed in healthcare institutions [2]. Moreover, the nurse turnover rate has risen steadily, from 15.8% in 2021 to 18.7% in 2023 [3]. In addition, the average patient-to-nurse ratio in Korean hospitals is 12.3, which is higher than that in Thailand at 10.0 and China at 6.8, as well as in the United States at 5.3, indicating a relatively high workload among nurses [4]. These indicators suggest staffing strain and workforce instability, which may contribute to unfavorable working conditions and create a cycle that further challenges workforce stability. Consequently, rather than focusing solely on factors contributing to turnover, identifying strategies that enhance nurses’ retention intention has been suggested as a more effective approach to workforce management [5].
Retention intention, defined as a nurse's willingness to remain in their current position and avoid seeking alternative employment [6], is widely recognized as a key indicator of nursing workforce stability [7]. Previous research has consistently demonstrated that a healthy work environment is a critical factor influencing nurses’ job satisfaction and retention intention [8]. The American Association of Critical-Care Nurses (AACN) [9] defines a healthy work environment as a therapeutic setting that respects the rights, values, and needs of all stakeholders, including patients, families, and healthcare professionals. In this study, the quality of the healthy work environment was employed as a key construct to examine organizational factors that support nurses’ professional sustainability.
A healthy work environment extends beyond physical and structural conditions and functions as an essential organizational resource that supports nurses’ psychological stability and fulfillment of basic needs [10]. In clinical settings, nurses often experience unmet basic needs due to shift work-related sleep deprivation, inadequate meal breaks, and exposure to verbal or physical abuse [11], which may lead to decreased job satisfaction and increased turnover intention.
Furthermore, a healthy work environment plays a crucial role in shaping nurses’ work-life balance. Work-life balance, defined as the ability to maintain harmony between professional responsibilities and personal life, has recently emerged as a critical factor influencing job continuity and organizational choice [12]. Irregular working hours and excessive workloads can disrupt work-life balance, and such imbalance has been reported to reduce job satisfaction and organizational commitment while increasing turnover intention [13]. Therefore, a healthy work environment is expected to enhance work-life balance, which in turn may positively influence organizational commitment and retention intention [14].
In addition, need satisfaction and work-life balance, although conceptually related, represent distinct dimensions that should be differentiated. Need satisfaction reflects an individual's internal psychological state and the degree to which basic needs are fulfilled [15] whereas work-life balance reflects a contextual condition concerning the harmony between professional and personal life [16]. Accordingly, need satisfaction influences retention intention primarily through psychological stability and motivation, whereas work-life balance affects retention intention through sustainability of work and overall quality of life.
Taken together, a healthy work environment can influence retention intention through the mediating roles of need satisfaction and work-life balance at both psychological and contextual levels. However, most previous studies have examined only bivariate relationships among these variables, and research employing an integrated mediating model—particularly among nurses in tertiary hospitals—remains scarce. Therefore, this study aimed to examine the effects of the quality of healthy work environment on retention intention, with need satisfaction and work-life balance serving as mediating variables. The findings are expected to provide foundational evidence for developing effective workforce retention strategies and fostering a supportive organizational culture in nursing practice.
2. Purpose
This study aimed to assess nurses’ perceptions of the quality of healthy work environment, need satisfaction, work-life balance, and retention intention in tertiary hospitals, and to examine whether need satisfaction and work-life balance mediate the relationship between the quality of healthy work environment and retention intention. Its specific objectives are:
• To identify the respondents’ general characteristics, levels of the quality of healthy work environment, need satisfaction, work-life balance, and retention intention.
• To identify differences in the level of the quality of healthy work environment, need satisfaction, work-life balance, and retention intention according to the respondents’ general characteristics.
• To determine the correlations between respondents’ quality of healthy work environment, need satisfaction, work-life balance, and retention intention.
• To determine the mediating effects of need satisfaction and work-life balance on the relationship between respondents’ quality of healthy work environment and retention intention.
METHODS
1. Study Design
This descriptive survey study investigated the mediating effects of need satisfaction and work-life balance on the relationship between the quality of healthy work environment and retention intention among nurses working in tertiary hospitals.
2. Research Participants
Participants were nurses with at least one year of clinical experience recruited from multiple tertiary hospitals through an online-based open recruitment method. Due to the nature of the recruitment process, the exact number of institutions represented by the participants could not be specified. All participants understood the purpose of the study and voluntarily agreed to participate. Based on prior studies on nurses’ retention intention [8,17], a medium effect size was assumed for the sample size calculation. The required sample size was then calculated using G* Power version 3.1.9.7 for multiple regression analysis, assuming a medium effect size (f2=.15) based on Cohen's criteria, a significance level of .05, and a power of .95. This approach is commonly adopted in nursing research when estimating sample size for regression analysis. Based on a model including 12 predictors, the minimum required sample size was 184. A total of 187 nurses were recruited, and all collected data were included in the final analysis.
The initial sample size was estimated using G*Power based on multiple regression analysis. However, because the main analytic framework of this study was mediation analysis, sample size considerations for detecting indirect effects should also be acknowledged. Previous methodological work has shown that the sample size required to detect a mediated effect varies considerably depending on the magnitudes of the a and b paths and the method used to test mediation. In particular, Fritz and MacKinnon [18] demonstrated that mediation-specific sample size requirements may differ substantially from those based on simple regression. In the present study, indirect effects were tested using a bootstrap approach, which has been recommended for mediation analysis. Because the bootstrap confidence intervals for both indirect effects did not include zero, the obtained sample size was considered adequate to detect the indirect effects observed in this study. Nevertheless, this interpretation should be made cautiously, as mediation-specific power analysis was not conducted a priori.
3. Research Instruments
The general characteristics were assessed using 9 items, including gender, age, marital status, work department, total clinical experience, unpaid leave days related to the 2024 physicians’ collective action, average overtime minutes, monthly income, and work shift.
1) Quality of healthy work environment
The quality of healthy work environment was measured using the Quality of Healthy Work Environment Scale developed by Shin and Lee [19]. The scale comprises 23 items across five subdomains—namely, physical gratification (4 items), psychological stability (4 items), independent competency (5 items), collaborative relationships (5 items), and structural support (5 items). Each item is rated on a 5-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree), with higher scores indicating a higher perceived quality of the work environment. Cronbach's ⍺ for this scale was .85 in the original study [19] and .91 in this study.
2) Need satisfaction
Need satisfaction was assessed using the Nurse Needs Satisfaction Scale developed by Kim and Shin [15], based on Maslow's hierarchy of needs. The scale comprises 30 items, with six items in each of the five need domains: physiological, safety, belongingness, esteem, and self-actualization needs. Items are rated on a 5-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree), with higher scores indicating greater satisfaction of nurses’ needs. Cronbach's ⍺ for this scale was .90 in the original study [15] and .94 in this study.
Physiological needs encompass basic physical requirements necessary for sustaining nursing work, including adequate meals, rest, fatigue recovery and sleep. Example items include "I often skip meals due to nursing duties." Safety needs reflect protection from workplace hazards such as medical accidents, violence, and infection, as well as appropriate compensation and welfare benefits. Example items include "I am protected when medical accidents occur" and "My workplace responds appropriately to incidents of violence." Belongingness needs represent interpersonal relationships and a sense of affiliation within the organization, including communication, teamwork, and participation in decision-making. Example items include "I feel a sense of belonging in my department." Esteem needs refer to recognition, respect, and professional value, including social recognition, fair evaluation, and acknowledgment from others. Example items include "I believe nursing is a socially respected profession" and "My work performance is fairly evaluated." Self-actualization needs involve personal growth, achievement, and realization of one's potential, including professional development and the opportunity to utilize one's abilities. Example items include "I find my nursing work rewarding."
3) Work-life balance
Work-life balance was measured using the Work-Life Balance Scale developed by Kim and Park [16]. This scale comprises 29 items across four domains—namely, work-family balance (8 items), work-leisure balance (8 items), work-growth balance (9 items), and overall life evaluation (4 items). Items are rated on a 5-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree). All items are reverse-coded, with higher scores indicating greater satisfaction with work-life balance. Cronbach's ⍺ for this scale was .93 in the original study [16] and .95 in this study.
4) Retention intention
Retention intention was measured using the Nurses’ Retention Index developed by Cowin [6] and translated into Korean by Kim [17]. The scale comprises six items rated on an 8-point Likert scale ranging from 1 (strongly disagree) to 8 (strongly agree), with higher scores indicating stronger retention intention. Cronbach's ⍺ was .97 in the translated version [17] and .95 in this study.
4. Data Collection and Ethical Considerations
This study was conducted after obtaining approval from the Institutional Review Board of Asan Medical Center (IRB No. 2025-0111). Moreover, approval for participant recruitment was obtained from the nursing department. Recruitment notices were posted on nurse-only open chat rooms and Instagram-based social networking channels to encourage voluntary participation. All participants accessed the survey through an online link or QR code and completed a self-administered questionnaire.
Participants accessed the recruitment notice and independently reviewed the study information sheet and informed consent form via the provided URL or QR code. The information sheet outlined the study's purpose and methods, inclusion and exclusion criteria, voluntary participation, the right to withdraw at any time, and the confidentiality of personal information. Only participants who provided voluntary consent by selecting "yes" were allowed to proceed to the online self-administered questionnaire.
Before commencing the survey, screening questions confirmed eligibility based on the inclusion criteria. Participants who satisfied the criteria could complete the survey, while those who did not were automatically excluded. To prevent duplicate responses, only one survey submission was allowed per account, and submission was permitted only after all items were completed.
Upon completion of the survey, participants received a modest incentive of approximately 5,000 KRW in the form of a mobile gift voucher as a token of appreciation. This incentive was provided at a level considered unlikely to exert undue influence on voluntary participation. Any contact information collected for compensation purposes was deleted immediately after distribution. All data were encrypted and stored on a password-protected computer accessible only to the research team. The study data will be retained for three years following study completion and permanently deleted thereafter. Because the survey was administered online with a forced-response format requiring all items to be completed before submission, there were no missing data in the dataset.
5. Data Analysis
Data analysis was conducted using IBM SPSS Statistics version 26.0 (IBM Corp., Armonk, NY, USA) and SPSS PROCESS Macro version 4.2.
First, descriptive statistics—including frequencies, percentages, means, and standard deviations—were employed to summarize participants’ general characteristics and the levels of the quality of healthy work environment, need satisfaction, work-life balance, and retention intention.
Second, differences in these variables based on participants’ general characteristics were examined using independent t-tests or one-way analysis of variance, with post hoc comparisons performed using the Scheffé test.
Third, relationships among the primary study variables were analyzed using Pearson's correlation coefficients.
Finally, the mediating effects of need satisfaction and work-life balance on the relationship between the quality of healthy work environment and retention intention were tested using Model 4 of the SPSS PROCESS Macro in a parallel multiple mediation model. Age, marital status, clinical experience, and monthly income—variables that exhibited significant differences in retention intention—were included as covariates. Direct, indirect, and total effects were estimated, and the significance of the indirect effects was evaluated using a bootstrapping procedure with 10,000 resamples.
RESULTS
1. Levels of the Quality of Healthy Work Environment, Need Satisfaction, Work-Life Balance, and Retention Intention
The levels of the quality of healthy work environment, need satisfaction, work-life balance, and retention intention are presented in Table 1. The overall mean score for the quality of healthy work environment was 3.38±0.52 (out of 5 points). Among the subdomains, independent competency showed the highest score, whereas physical gratification showed the lowest score. The overall mean score for need satisfaction was 3.04±0.57. Among the subdomains, esteem needs showed the highest score, whereas physiological needs showed the lowest score. The overall mean score for work-life balance was 2.89±0.69. Among the subdomains, overall life evaluation showed the highest score, whereas work-growth balance showed the lowest score. The mean score for retention intention was 4.88±1.88 (out of 8 points).
Table 1.
Levels of the Quality of Healthy Work Environment, Need Satisfaction, Work-Life Balance, and Retention Intention (N=187)
2. Differences in the Quality of Healthy Work Environment, Need Satisfaction, Work-Life Balance, and Retention Intention Based on Participants’ General Characteristics
Table 2 summarizes the participants’ general characteristics. Most participants were female (88.8%, n=166), with a mean age of 28.7±5.6 years. Most participants were unmarried (83.4%, n=156) and worked in medical or surgical wards. The mean clinical experience was 5.5±6.0 years, and over half reported an average overtime duration of less than 30 minutes per shift. Regarding monthly income, most participants earned less than 4 million KRW per month, while the majority worked a three-shift system.
Table 2.
Differences in Quality of Healthy Work Environment, Need Satisfaction, Work-Life Balance, and Retention Intention According to Participants’ Characteristics (N=187)
| Characteristics | Categories | n (%) | Quality of healthy work environment | Need satisfaction | Work-life balance | e Retention intention | ||||
|---|---|---|---|---|---|---|---|---|---|---|
| M±SD | t or F (p) | M±SD | t or F (p) | M±SD | t or F (p) | M±SD | t or F (p) | |||
| Gender | Men | 21 (11.2) | 3.40±0.60 | 0.17 | 3.22±0.54 | 1.53 | 2.94±0.66 | 0.32 | 4.94±2.15 | 0.18 |
| Women | 166 (88.8) | 3.38±0.51 | (.863) | 3.02±0.57 | (.128) | 2.89±0.69 | (.747) | 4.87±1.86 | (.859) | |
| Age† (year) | ＜26a | 39 (20.9) | 3.36±0.39 | 4.28 | 2.95±0.39 | 2.35 | 2.82±0.77 | 0.99 | 4.25±1.77 | 6.75 |
| 26∼27b | 75 (40.1) | 3.26±0.56 | (.006) | 2.96±0.57 | (.074) | 2.87±0.68 | (.398) | 4.64±1.90 | (＜.001) | |
| 28∼30c | 44 (23.5) | 3.44±0.49 | b＜d | 3.16±0.47 | 2.88±0.65 | 5.00±1.86 a | a, b, c＜d | |||
| ≥31d | 29 (15.5) | 3.64±0.52 | 3.20±0.80 | 3.09±0.64 | 6.13±1.45 | |||||
| Marital status | Single | 156 (83.4) | 3.34±0.51 | -2.40 | 3.01±0.51 | -1.35 | 2.83±0.67 | -2.92 | 4.72±1.87 | -2.53 |
| Married | 31 (16.6) | 3.58±0.55 | (.018) | 3.21±0.77 | (.186) | 3.22±0.67 | (.004) | 5.65±1.78 | (.012) | |
| Work department | Medical/Surgical warda | 123 (65.8) | 3.41±0.50 | 0.48 | 3.02±0.56 | 1.58 | 2.86±0.71 | 0.52 | 4.86±1.94 | 1.48 |
| 34 (18.2) | 3.32±0.52 | (.622) | 3.00±0.43 | (.210) | 2.97±0.60 | (.593) | 4.52±1.85 | (.230) | ||
| ICU/ERb | 30 (16.0) | 3.34±0.60 | 3.21±0.68 | 2.96±0.68 | 5.33±1.64 | |||||
| OR/Otherc | ||||||||||
| Total clinical experience† (year) | ＜3a | 55 (29.4) | 3.33±0.50 | 2.33 | 3.02±0.47 | 1.65 | 2.81±0.75 | 1.29 | 4.49±1.90 | 9.13 |
| 3∼＜5b | 92 (49.2) | 3.35±0.53 | (.076) | 2.99±0.55 | (.179) | 2.87±0.65 | (.278) | 4.54±1.85 | (＜.001) | |
| 5∼＜7c | 9 (4.8) | 3.28±0.31 | 3.31±0.26 | 3.17±0.71 | 6.19±1.22 a | a, b＜c, d | ||||
| ≥7d | 31 (16.6) | 3.60±0.53 | 3.18±0.78 | 3.04±0.65 | 6.17±1.37 | |||||
| Unpaid leave days related to the 2024 physicians’ collective action (day) | None | 36 (19.2) | 3.40±0.60 | 0.03 | 3.09±0.68 | 0.22 | 3.07±0.67 | 1.58 | 4.75±1.93 | 0.16 |
| 1∼30 | 135 (72.2) | 3.38±0.50 | (.974) | 3.03±0.55 | (.800) | 2.86±0.69 | (.210) | 4.92±1.87 | (.854) | |
| ≥31 | 16 (8.6) | 3.38±0.56 | 3.08±0.45 | 2.78±0.63 | 4.76±2.03 | |||||
| Average overtime minutes† (minute) | Nonea | 30 (16.0) | 3.60±0.62 | 6.34 | 3.10±0.90 | 1.51 | 3.16±0.74 | 3.33 | 5.47±1.65 | 1.73 |
| ＜30b | 97 (51.9) | 3.45±0.47 | (＜.001) | 3.10±0.47 | (.214) | 2.93±0.65 | (.021) | 4.90±1.82 | (.163) | |
| 30∼＜60c | 51 (27.3) | 3.18±0.43 | c, d＜a | 2.91±0.46 | 2.68±0.70 | N/A | 4.58±1.95 | |||
| ≥60d | 9 (4.8) | 3.09±0.67 | 3.00±0.52 | 2.84±0.55 | 4.30±2.61 | |||||
| Monthly income† (10,000 won) | ＜400a | 120 (64.2) | 3.29±0.50 | 7.82 | 2.96±0.52 | 3.49 | 2.85±0.69 | 1.79 | 4.48±1.85 | 8.93 |
| 400∼＜500b | 53 (28.3) | 3.49±0.48 | (.001) | 3.20±0.47 | (.033) | 2.90±0.64 | (.169) | 5.42±1.71 | (＜.001) | |
| ≥500c | 14 (7.5) | 3.79±0.57 | a＜c | 3.14±1.04 | a＜b | 3.22±0.77 | 6.18±1.81 | a＜b, c | ||
| Work shift† | 3 shiftsa | 152 (81.3) | 3.37±0.53 | 0.53 | 2.98±.54 | 5.58 | 2.86±0.70 | 0.83 | 4.72±1.90 | 2.68 |
| 2 shiftsb | 7 (3.7) | 3.37±0.24 | (.589) | 3.15±.30 | (.004) | 3.09±0.50 | (.439) | 5.48±1.61 | (.072) | |
| No shiftc | 28 (15.0) | 3.48±0.54 | 3.36±.66 | a, b＜c | 3.01±0.63 | 5.55±1.75 | ||||
Differences in the main study variables according to general characteristics were as follows: the quality of healthy work environment differed significantly by age (F=4.28, p=.006), marital status (t=-2.40, p=.018), average overtime minutes (F=6.34, p<.001), and monthly income (F=7.82, p=.001). Post hoc analysis revealed that participants aged 26∼27 years had significantly lower scores compared to those aged 31 years or older. Married participants reported significantly higher scores than unmarried participants. Participants with no overtime had significantly higher scores than those working 30∼60 minutes or more than 1 hour of overtime. Additionally, participants earning ≥5 million KRW per month had significantly higher scores than those earning < 4 million KRW.
Need satisfaction varied by monthly income (F=3.49, p=.033) and work shift (F=5.58, p=.004). Post hoc analysis indicated that participants earning 4∼5 million KRW had significantly higher need satisfaction than those earning < 4 million KRW. In terms of work shift, nurses working without shift rotations had significantly higher need satisfaction than those working two- or three-shift rotations.
Work-life balance differed by marital status (t=-2.92, p=.004) and average overtime minutes (F=3.33, p=.021). Married participants reported significantly higher work-life balance than unmarried participants. Although the difference according to overtime was statistically significant, post hoc analysis did not reveal significant differences between specific groups.
Retention intention differed significantly according to age (F=6.75, p<.001), marital status (t=-2.53, p=.012), total clinical experience (F=9.13, p<.001), and monthly income (F=8.93, p<.001). Post hoc analysis showed that participants aged 31 years or older had significantly higher retention intention than younger age groups. Married participants reported higher retention intention than unmarried participants. Participants with five or more years of clinical experience had significantly higher retention intention than those with less than five years of experience. Additionally, participants earning less than 4 million KRW had significantly lower retention intention than those earning 4 million KRW or more.
3. Correlations among the Variables
Table 3 presents the correlations among the study variables. The quality of healthy work environment was positively correlated with need satisfaction (r=.44, p<.001), work-life balance (r=.43, p<.001), and retention intention (r=.38, p<.001). Additionally, need satisfaction was positively correlated with work-life balance (r=.29, p<.001) and retention intention (r=.36, p<.001). Work-life balance exhibited a significant positive correlation with retention intention (r=.34, p<.001).
Table 3.
Correlations of the Quality of Healthy Work Environment, Need Satisfaction, Work-Life Balance, and Retention Intention (N=187)
4. Mediating Effects of Need Satisfaction and Work-Life Balance on the Relationship between the Quality of Healthy Work Environment and Retention Intention
Table 4 presents the mediating effects of need satisfaction and work-life balance on the relationship between the quality of healthy work environment and retention intention. Mediation analyses were conducted while controlling for age, marital status, clinical experience, and monthly income, which were identified as covariates based on their significant associations with retention intention.
Table 4.
Mediating Effects of Need Satisfaction and Work-Life Balance in the Relationship between Quality of Healthy Work Environment and Retention Intention (N=187)
Before the regression analysis, the variance inflation factor to assess multicollinearity among the independent variables ranged from 1.31 to 1.53, which was less than 10, and the tolerance values ranged from .65 to .77, which were all above 0.1, indicating no multicollinearity. In addition, the Durbin-Watson statistic was 2.12, which was close to the standard value of 2.00, suggesting that autocorrelation was not a concern. To assess normality, the absolute values of skewness ranged from 0 to 1.24 (criterion < 2), and kurtosis ranged from 0 to 3.25 (criterion < 7), indicating that the assumption of normality was satisfied [20].
The quality of healthy work environment significantly positively impacted need satisfaction (β=.43, p<.001; R2= .23, F=6.47, p<.001) and work-life balance (β=.43, p<.001; R2=.23, F=6.48, p<.001). Further, it significantly positively impacted retention intention (β=.16, p =.037). Both need satisfaction (β=.19, p=.009) and work-life balance (β=.19, p=.008) significantly influenced retention intention (R2= .32, F=8.11, p<.001) (Figure 1). Bootstrapping with 95% confidence intervals confirmed the significance of the mediating effects (Table 5). The direct effect of the quality of healthy work environment on retention intention was significant (effect=0.59, SE=0.28, 95% confidence interval [CI] [0.04, 1.14]). The total indirect effect through need satisfaction and work-life balance was also significant (effect=0.59, SE=0.21, 95% CI [0.23, 1.06]). The specific indirect effect through need satisfaction was significant (effect=0.29, SE=0.19, 95% CI [0.05, 0.81]), as was the indirect effect through work-life balance (effect=0.30, SE=0.14, 95% CI [0.03, 0.60]). A comparison of the two indirect effects indicated no significant difference between them, as the 95% confidence interval for the difference included zero (95% CI [-0.43, 0.65]), suggesting that the magnitudes of the two mediating effects were comparable.
Table 5.
Total, Direct, Total Indirect, Specific Indirect Effects, and Difference between Indirect Effects (N=187)
DISCUSSION
This study examined the mediating roles of need satisfaction and work-life balance in the relationship between the quality of healthy work environment and retention intention among nurses working in tertiary hospitals.
The quality of healthy work environment demonstrated a statistically significant direct effect on retention intention, consistent with previous studies conducted among South Korean nurses [7,21]. Similarly, research involving nurses in Middle Eastern countries has identified a supportive work environment as an important factor associated with retention intention [22], highlighting the importance of organizational contexts that support nurses’ professional growth and development [7]. In addition, findings from a domestic study of dental hygienists further support the significant influence of work environment on retention intention [23]. Taken together, these results suggest that positive perceptions of the work environment may play an important role in promoting retention intention, underscoring the need for continuous monitoring and systematic management of workplace conditions within healthcare organizations [8].
However, the magnitude of the direct effect (β=.16), although statistically significant, was relatively modest. This indicates that while the quality of healthy work environment is an important factor associated with retention intention, it may be insufficient to fully explain retention intention as a single factor. Rather, these findings may reflect the multidimensional nature of retention intention, which may be influenced not only by organizational factors but also by individual psychological and life-related factors, such as need satisfaction and work-life balance. Therefore, efforts to promote retention intention may benefit from a comprehensive approach that considers both organizational and individual-level factors.
In this study, need satisfaction was identified as a significant mediator in the relationship between the quality of healthy work environment and retention intention. This finding suggests that a healthy work environment may contribute to nurses’ motivation to remain in their organization by supporting the fulfillment of their needs. It is consistent with prior research indicating that positive perceptions of the nursing work environment are associated with higher levels of need satisfaction, which in turn are related to lower turnover intention [10]. Moreover, previous studies have demonstrated that need satisfaction is positively associated with retention intention [24].
When examining need satisfaction by subdomain, physiological and safety needs were found to be relatively low, consistent with findings from prior studies involving nurses in general and university hospitals [25]. This suggests that, regardless of hospital type, nurses may experience insufficient fulfillment of basic needs. Previous research has suggested that this may be related to demanding working conditions, including rotating shifts, sleep deprivation, and limited opportunities for adequate meal breaks and rest [25,26]. According to Maslow's hierarchy of needs, unmet basic needs may hinder the fulfillment of higher-level needs [27]. Accordingly, institutional and environmental efforts that support nurses’ physical health and workplace safety may be beneficial. These may include reducing excessive workloads, securing adequate staffing, and providing meal and rest breaks during working hours [26]. In addition, establishing protective systems against workplace violence and occupational hazards, along with comprehensive preventive measures and compensation for infectious disease exposure, may help improve perceptions of workplace safety. Reinforcing safety protocols and providing regular training may further support nurses’ awareness and proactive engagement in maintaining workplace safety.
In contrast, esteem needs showed the highest level among the five need domains, suggesting that nurses in tertiary hospitals perceive their professional roles and expertise as relatively well recognized within their organizations. Previous studies have suggested that the fulfillment of esteem needs may be positively associated with retention intention among nurses [24,25]. According to Maslow's hierarchy of needs, the fulfillment of esteem needs provides a foundation for the pursuit of self-actualization. However, despite the high level of esteem needs observed in this study, self-actualization needs were relatively low, which may suggest that while systems for external recognition and evaluation are relatively well established, opportunities for personal growth and self-development may be insufficient.
In other words, although nurses may feel recognized for their professional roles, they may experience limited opportunities to realize their full potential. Given the high-intensity workload and shift-based structure of tertiary hospitals, opportunities for self-development may be constrained, which may be associated with lower levels of self-actualization needs. Previous research has also highlighted that continuous professional development has been found to be closely associated with organizational support and work environment [28]. Therefore, supporting self-actualization among nurses may be facilitated by structured educational programs, career development systems, and expanded opportunities for professional growth, along with organizational strategies that support nurses in planning their future roles and professional trajectories.
Work-life balance was also identified as a significant mediator in the relationship between the quality of healthy work environment and retention intention. This finding is consistent with prior studies demonstrating that a positive work environment is associated with improved work-life balance, which in turn is related to lower turnover intention and higher retention intention [13,29].
In the present study, the overall level of work-life balance was moderate and comparable to previous findings. Among its subdomains, overall life evaluation was the highest, whereas work-growth balance was the lowest. This pattern suggests that while nurses generally perceive their overall lives positively, they may have limited time and opportunity to engage in work-related growth and self-development activities due to the demanding conditions of tertiary hospital settings.
In particular, the low level of work-growth balance suggests the importance of considering professional development as an integral component of work-life balance. Given the high workload and shift-based schedules in tertiary hospitals, nurses may have limited time and psychological resources to engage in self-development activities.
Therefore, improving work-growth balance may be important not only for enhancing work-life balance but also for supporting long-term retention and professional development. Organizational strategies tailored to the context of tertiary hospitals may include providing flexible, online-based educational programs that can be accessed during irregular schedules, ensuring protected learning time within shifts, and implementing structured, competency-based career development programs aligned with clinical expertise levels. Additionally, integrating career planning support into organizational systems may help nurses set and achieve professional goals, thereby supporting both individual development and retention intention.
Furthermore, improving work-life balance may involve attention not only to work-growth balance but also to work-family and work-leisure balance. Previous studies have suggested that family support and family-friendly organizational cultures may contribute to better work-life balance among nurses [14,30]. Accordingly, organizational efforts to provide family-friendly programs and supportive resources may help promote work-family balance. Flexible scheduling and adequate rest may also support work-leisure balance [31]. In addition, organizational programs that promote leisure, health, and stress management may provide practical support for maintaining overall work-life balance.
Taken together, the mediating roles of need satisfaction and work-life balance underscore the value of an integrated interpretive framework. The present study offers empirical support for an integrated framework linking the quality of healthy work environment, need satisfaction, work-life balance, and retention intention. Previous research has shown that organizational factors such as the work environment influence nurses’ psychological states and work experiences, which in turn affect behavioral outcomes such as retention intention [10,21]. Consistent with this perspective, the present study found that the quality of healthy work environment may be associated with retention intention through both need satisfaction and work-life balance. Need satisfaction may function as a psychological pathway related to intrinsic motivation and the fulfillment of basic needs, whereas work-life balance may reflect a contextual pathway related to the harmony between professional and personal life. These findings may extend previous research by offering empirical support for a dual mediating mechanism through which psychological and contextual factors jointly influence retention intention.
Importantly, the two mediating pathways identified in this study should not be interpreted as operating independently, but rather as complementary mechanisms that together may shape retention intention. A healthy work environment may simultaneously support nurses’ psychological stability and intrinsic motivation through needs fulfillment, while also potentially contributing to sustainability in work and overall quality of life through improved work-life balance. When considered together, these pathways may provide a more comprehensive and integrative explanation of retention intention than either pathway alone, suggesting that the combined influence of psychological and contextual factors may offer additional explanatory value beyond single-path models.
In addition, although both need satisfaction and work-life balance were identified as significant mediators, no significant difference was found between their mediating effects. This finding suggests that both psychological and contextual pathways may contribute to retention intention at a comparable level. Al Yahyaei [32] reported that nurses’ retention intention is a multidimensional construct that cannot be sufficiently explained by a single factor, and the findings of the present study are consistent with this perspective. From a practical standpoint, these findings suggest that organizational strategies addressing both nurses’ psychological needs and work-life balance may be more beneficial than focusing on a single dimension.
This study has several limitations. First, all variables were collected at a single time point using self-reported questionnaires, which may have introduced response bias and potential common method bias. Although anonymity and voluntary participation were ensured, the possibility of bias cannot be completely excluded, and the findings should be interpreted with caution. Second, the cross-sectional design limits the ability to establish causal relationships among variables. Third, the study was conducted among nurses working in tertiary hospitals, which may limit the generalizability of the findings. In addition, although data were collected from multiple institutions, the exact number of participating institutions could not be clearly specified due to the nature of the recruitment process. Furthermore, as participants were recruited through online communities, the possibility of self-selection bias cannot be excluded, which may further limit the representativeness of the sample.
CONCLUSION
This study demonstrated that the quality of healthy work environment perceived by nurses in tertiary hospitals influences retention intention through the mediating roles of need satisfaction and work-life balance. These findings suggest that understanding nurses’ retention intention may be more comprehensively understood through an integrated perspective that considers not only organizational factors but also individual psychological and life-related factors. In particular, the significant mediating effects of need satisfaction and work-life balance support the notion that strategies to enhance retention intention should adopt a multidimensional approach rather than focusing on a single factor.
Future research should employ longitudinal designs to clarify causal relationships among variables. In addition, studies including diverse hospital types and institutional settings are needed to enhance the generalizability of the findings. Furthermore, based on the mediating roles identified in this study, future research should examine the effectiveness of interventions targeting need satisfaction and work-life balance.
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