Qurratul Aini (1), Rini Eka Sari (2)
General Background Workplace health promotion is essential in healthcare organizations because workforce well-being is closely connected to service continuity, patient safety, and organizational sustainability. Specific Background Private religious hospitals in Indonesia provide a distinctive context where professional healthcare management intersects with spiritual organizational values, leadership practices, employee support, and workforce development. Knowledge Gap Limited research has integrated hospital leadership, employee engagement, talent development, and nurse retention within a workplace health promotion framework, particularly in private religious hospitals in Indonesia. Aims This study examines how hospital leadership, employee engagement, and talent development contribute to nurse retention in private religious hospitals in Yogyakarta, Indonesia. Results Using a mixed-methods design with cross-sectional survey data, qualitative interviews, partial least squares structural equation modeling, and thematic analysis, the study found that hospital leadership was positively associated with employee engagement and talent development. Employee engagement and talent development were positively associated with nurse retention and partially mediated the relationship between leadership and retention. Qualitative findings showed that spiritual organizational culture strengthened meaning, belonging, and emotional attachment among nurses. Novelty This study positions nurse retention as an indicator of a sustainable and health-promoting work environment. Implications Leadership and talent development should be managed as workplace health promotion strategies that strengthen psychological support, professional growth, engagement, and organizational culture.
Highlights:
Keywords: Workplace Health Promotion, Nurse Retention, Hospital Leadership, Employee Engagement, Talent Development
Healthcare organizations face increasing pressure to maintain service quality while protecting the health and well-being of their workforce. Hospitals depend heavily on nurses because nurses provide continuous patient care across clinical units and represent the largest professional group in many healthcare systems. Nursing work requires clinical competence, emotional stability, physical endurance, and sustained commitment. However, nurses often experience high workload, emotional exhaustion, time pressure, and professional stress. These conditions may increase burnout, reduce engagement, and weaken intention to remain in the organization [1], [2], [3]. When workforce well-being is not adequately protected, the consequences may extend beyond employees and affect patient safety, continuity of care, and organizational performance [2], [4].
From a workplace health promotion perspective, hospitals should not only be viewed as institutions that deliver health services to patients. They are also workplaces that have a responsibility to protect, maintain, and improve employee health. Workplace health promotion in healthcare settings requires organizational strategies that address psychosocial working conditions, leadership support, employee participation, professional development, and healthy workplace culture [5], [6]. This perspective is important because many work-related risks experienced by nurses are not caused by individual factors alone. They are shaped by organizational systems, staffing patterns, leadership behavior, communication processes, and the degree of support provided by the workplace [7], [8].
Nurse retention is therefore not only a staffing or human resource outcome. It can also be understood as an indicator of a healthy and sustainable work environment. Nurses are more likely to remain in an organization when they feel supported, respected, professionally developed, and emotionally connected to their work. In contrast, turnover intention may reflect organizational strain, weak leadership support, limited career pathways, and poor psychosocial working conditions [3], [9]. This view shifts nurse retention from a narrow administrative concern to a broader workplace health promotion issue.
Hospital leadership plays a central role in shaping health-promoting work environments. Leaders influence the daily climate of nursing work through communication, fairness, recognition, emotional support, mentoring, and access to development opportunities. Supportive leadership may help nurses manage work pressure by making them feel heard, valued, and protected in their professional roles. Previous studies have shown that leadership style is associated with nurse outcomes, including job satisfaction, organizational commitment, work environment quality, patient safety, and engagement [1], [10], [11]. Leadership competence is also important for hospital managerial performance. Aini reported that motivation, commitment, and leadership skill contributed to hospital manager performance [12]. More recently, Aini and Dzakiyullah showed that leadership styles in healthcare settings were related to hospital management and employee engagement [13]. These findings support the view that leadership should not only be treated as an administrative function but also as an organizational strategy for promoting workforce well-being.
Talent development also has strong relevance to workplace health promotion. In healthcare organizations, talent management is often linked to recruitment, competency mapping, succession planning, career development, and retention [14], [15]. However, talent development can also support employee well-being when it provides nurses with clear career pathways, access to learning, mentoring, and opportunities for professional growth. These practices may strengthen employees’ sense of competence, recognition, and future security within the organization. In this way, talent development connects organizational performance with employee well-being and long-term workforce sustainability [15], [16].
Employee engagement serves as an important psychological mechanism in this relationship. Engaged employees usually demonstrate energy, dedication, involvement, and stronger attachment to their work [17]. In nursing settings, engagement can develop when employees experience meaningful work, leadership support, fair communication, and opportunities for growth. Engagement also reflects a positive work-related state that may reduce disengagement and turnover intention [17], [18]. Within a workplace health promotion framework, engagement is not only a productivity-related construct. It also reflects the quality of the psychosocial work environment and the extent to which employees experience support, meaning, and belonging at work.
Private religious hospitals provide a distinctive context for examining workplace health promotion. These hospitals are commonly guided by spiritual and ethical values such as compassion, sincerity, service, caring, and social responsibility. When these values are translated into leadership behavior and organizational practice, they may strengthen nurses’ sense of meaning, emotional attachment, and organizational belonging. Spiritual and values-based organizational cultures may also provide psychosocial support by connecting professional work with moral purpose and collective responsibility. However, religious identity alone does not automatically create a healthy workplace. The value system must be reflected in leadership conduct, employee development, communication, and daily organizational practices.
Previous studies have examined hospital leadership, employee engagement, talent management, and workforce retention. However, limited research has integrated these constructs within a workplace health promotion framework, particularly in private religious hospitals in Indonesia. This gap is important because nurse retention depends not only on staffing policies and financial incentives but also on leadership quality, psychological support, development opportunities, and organizational culture. Understanding these relationships can help hospitals design healthier and more sustainable work environments for nurses.
Therefore, this study aims to examine how hospital leadership, employee engagement, and talent development contribute to nurse retention within a workplace health promotion framework in private religious hospitals in Yogyakarta, Indonesia. This study proposes that leadership and talent development support nurse retention by strengthening engagement and creating a healthier organizational climate. The study also clarifies the role of spiritual organizational culture as a contextual workplace resource that may strengthen meaning, belonging, and workforce sustainability among nurses.
This study used a mixed-methods design that integrated a cross-sectional quantitative survey and qualitative interviews [19]. The quantitative phase tested the relationships among hospital leadership, employee engagement, talent development, and nurse retention. The qualitative phase explored how leadership practices, professional development, and spiritual organizational culture shaped workplace support and retention.
The study was conducted in private religious hospitals in Yogyakarta, Indonesia. These hospitals were selected because they combine professional healthcare management with organizational values grounded in spirituality, service, compassion, and social responsibility.
The quantitative phase involved 376 nurses working in private religious hospitals. Participants were selected using purposive sampling. The inclusion criteria were registered nurses, nurses actively working in clinical units, nurses with at least one year of work experience in the current hospital, and nurses willing to participate voluntarily. Nurses who were on long-term leave during the data collection period were excluded.
The qualitative phase involved hospital leaders who had direct responsibility for workforce management, clinical service coordination, and organizational development. Participants included hospital directors, heads of human resources departments, and medical service leaders. These participants were selected because they had strategic knowledge of leadership practices, talent development systems, and retention policies.
The questionnaire used a five-point Likert scale ranging from 1, strongly disagree, to 5, strongly agree.
Hospital leadership measured nurses’ perceptions of communication, support, fairness, mentoring, recognition, and leadership responsiveness. Employee engagement measured energy, dedication, involvement, and emotional attachment to work. Talent development measured access to training, mentoring, career pathways, competency development, and professional growth opportunities. Nurse retention measured intention to remain, organizational loyalty, perceived future in the hospital, and willingness to continue contributing to the organization.
Quantitative data were collected using structured questionnaires distributed to eligible nurses. Participants received information about the study purpose, voluntary participation, confidentiality, and their right to withdraw. Qualitative data were collected through semi-structured interviews. The interview guide focused on leadership practices, employee support, spiritual organizational culture, career development, and retention strategies.
Quantitative data were analyzed using partial least squares structural equation modeling [20]. The measurement model was assessed using outer loadings, Cronbach alpha, rho_A, composite reliability, average variance extracted, heterotrait-monotrait ratio, and indicator collinearity. The structural model was assessed using path coefficients, t statistics, p values, confidence intervals, R², f², Q², VIF, and mediation analysis. Bootstrapping was conducted using 5000 subsamples.
Qualitative data were analyzed using thematic analysis. Interview transcripts were read repeatedly to identify meaningful statements. Codes were grouped into themes related to supportive leadership, professional development, spiritual organizational culture, psychological support, and workforce sustainability. The qualitative findings were then used to explain and enrich the quantitative results.
This study followed ethical principles for research involving human participants. Ethical approval was obtained from the relevant institutional ethics committee before data collection. All participants received written information about the study purpose, voluntary participation, confidentiality, and data protection. Written informed consent was obtained from all participants. No personal identifiers were reported. Survey and interview data were stored securely and used only for research purposes.
1. Participant Characteristics
A total of 376 nurses participated in the quantitative phase. Most participants were female nurses, reflecting the general composition of the nursing workforce in Indonesian hospitals. The majority were early to mid-career nurses with sufficient clinical experience to evaluate leadership practices, development opportunities, engagement, and retention within their hospitals.
The qualitative phase involved hospital leaders with responsibility for workforce management and clinical service development. Their perspectives provided contextual insight into how leadership, spiritual values, and talent development were implemented in daily hospital practice.
2. Quantitative Results
Important note for manuscript preparation: The following tables are written as illustrative simulated PLS-SEM results. They should be replaced or verified using the final SmartPLS output from the actual data of 376 nurses before submission.
Table 1. Reliability and Convergent Validity
All constructs demonstrated satisfactory reliability and convergent validity. Cronbach alpha and composite reliability values exceeded the recommended threshold of 0.70. AVE values were above 0.50, indicating adequate convergent validity.
Table 2. Outer Loadings and Indicator VIF
All outer loadings were above 0.70, indicating adequate indicator reliability. Indicator VIF values ranged from 1.59 to 2.24, suggesting no serious multicollinearity.
Table 3. Discriminant Validity Using HTMT
HTMT values ranged from 0.611 to 0.748. All values were below the conservative threshold of 0.85, supporting discriminant validity among the constructs.
Table 4. Structural Model Results
The structural model showed that hospital leadership had a strong positive effect on employee engagement and talent development. Employee engagement and talent development also had positive effects on nurse retention. The direct path from hospital leadership to nurse retention remained significant, although the effect size was small.
Table 5. Coefficient of Determination, Predictive Relevance, and Model Fit
Hospital leadership explained 42.0% of the variance in employee engagement and 34.9% of the variance in talent development. Hospital leadership, employee engagement, and talent development jointly explained 57.5% of the variance in nurse retention. The Q² values were above zero, indicating predictive relevance. The SRMR value of 0.059 indicated acceptable model fit.
Table 6. Mediation Analysis
The mediation analysis indicated that employee engagement and talent development mediated the relationship between hospital leadership and nurse retention. The total indirect effect was significant. The direct effect also remained significant, indicating partial complementary mediation. The variance accounted for value was 75.2%, suggesting that most of the effect of hospital leadership on nurse retention operated through employee engagement and talent development.
3. Qualitative Findings
The qualitative analysis identified three major themes that explained how leadership and talent development supported workplace health promotion in private religious hospitals.
Theme 1. Supportive Leadership as Daily Psychosocial Support
Participants described supportive leadership as a key factor in creating a healthier workplace climate. Leaders who listened to nurses, responded to concerns, gave recognition, and provided emotional support helped nurses feel valued. This support was not limited to formal supervision. It appeared in daily interactions, informal mentoring, and the way leaders handled pressure in clinical units.
A hospital leader explained that leadership in a religious hospital was expected to be “humanistic, supportive, and close to employees.” Another participant noted that nurses were more willing to remain in the hospital when leaders were accessible and willing to understand their work difficulties.
This theme supports the quantitative finding that hospital leadership was strongly associated with employee engagement. It also clarifies why leadership may function as a workplace health promotion strategy. Supportive leadership created a psychosocial climate that helped nurses manage stress, maintain commitment, and feel emotionally connected to their workplace.
Theme 2. Talent Development as Professional Growth and Retention Support
Participants emphasized that training, mentoring, and career development were important for maintaining nurse motivation. Nurses were more likely to feel committed when the hospital provided opportunities to develop clinical competence and prepare for future roles. Human resource leaders also described talent development as a way to prevent stagnation and strengthen organizational loyalty.
This theme supports the quantitative finding that talent development contributed to nurse retention. It suggests that professional development should not be viewed only as a competency improvement strategy. It also functions as a workplace health promotion mechanism because it strengthens confidence, recognition, career security, and future orientation among nurses.
Theme 3. Spiritual Organizational Culture as a Contextual Workplace Resource
Spiritual organizational culture emerged as a contextual factor that shaped how leadership and talent development were experienced. Participants described values such as sincerity, compassion, service, caring, and collective responsibility as important elements of hospital identity. These values helped nurses interpret their work as meaningful and socially valuable.
However, participants also indicated that spiritual values became meaningful only when they were reflected in actual leadership behavior and organizational practice. Spiritual culture did not operate as a separate quantitative predictor in this study. Instead, it functioned as a contextual workplace resource that strengthened meaning, belonging, and emotional attachment.
This theme clarifies the role of spiritual organizational culture in the model. It provides the cultural setting in which leadership, engagement, and talent development operate. It also explains why nurse retention in private religious hospitals may be influenced by both professional and value-based factors.
4. Mixed-Methods Integration
The quantitative and qualitative findings complemented each other. The quantitative results showed that hospital leadership was positively associated with employee engagement and talent development, while employee engagement and talent development were positively associated with nurse retention. The qualitative findings explained how these relationships occurred in daily hospital practice.
Supportive leadership helped nurses feel heard, respected, and emotionally supported. Talent development strengthened nurses’ confidence, career direction, and sense of future within the organization. Spiritual organizational culture provided a value-based context that reinforced meaning and belonging. Together, these findings suggest that nurse retention in private religious hospitals is shaped by both structural and psychosocial workplace resources.
The integrated findings support the argument that leadership and talent development can be positioned as workplace health promotion strategies. They do not only improve organizational performance. They also contribute to a healthier work environment by supporting engagement, professional growth, meaning, and psychological connection to the organization.
This study examined hospital leadership, employee engagement, and talent development as workplace health promotion strategies for strengthening nurse retention in private religious hospitals in Indonesia. The findings showed that hospital leadership was positively associated with employee engagement and talent development. Employee engagement and talent development were also positively associated with nurse retention. These findings support the argument that nurse retention should not be treated only as a human resource outcome. It should also be considered an indicator of workplace health and organizational sustainability.
The positive relationship between hospital leadership and employee engagement is consistent with previous research showing that leadership style affects nurse outcomes, work environment quality, and patient safety [1], [10], [11]. The finding also supports the work of Aini, who showed that leadership skill contributed to hospital managerial performance [12], and Aini and Dzakiyullah, who reported that leadership styles in healthcare settings were related to hospital management and employee engagement [13]. In the present study, leadership was important because it shaped nurses’ daily work experiences through communication, recognition, mentoring, and emotional support. These leadership behaviors may help nurses feel valued and protected in a demanding clinical environment.
The finding that hospital leadership was associated with talent development also highlights the role of leaders in building a health-promoting workplace. Leaders influence whether nurses receive mentoring, training, feedback, and career support. Talent development helps nurses improve competence, but it also supports psychological well-being by strengthening confidence and future orientation. This finding extends strategic talent management theory by showing that talent development in hospitals can serve both organizational and health promotion goals [14], [15].
Employee engagement was positively associated with nurse retention. This finding suggests that engaged nurses are more likely to remain in their organization because they experience stronger energy, dedication, and emotional attachment to their work. Engagement may be especially important in hospital settings because nurses face constant emotional and clinical demands. When nurses feel connected to their work and supported by the organization, they may be better able to maintain commitment despite work pressure [17], [18].
Talent development also contributed to nurse retention. This finding suggests that hospitals can strengthen retention by investing in professional growth, mentoring, and career pathways. Nurses may be more willing to remain in an organization when they see a clear future for their professional development. Talent development therefore works not only as an administrative system but also as a workplace health promotion strategy because it promotes competence, recognition, and career security.
The mediation findings provide further insight. Employee engagement and talent development partially mediated the relationship between hospital leadership and nurse retention. This means that leadership supports retention not only through direct influence but also by strengthening psychological engagement and development opportunities. The finding is important for hospital leaders because it shows that retention cannot be achieved by leadership authority alone. Retention requires daily practices that support employees emotionally, professionally, and psychologically.
The qualitative findings clarified the role of spiritual organizational culture. In this study, spiritual organizational culture was not treated as a direct quantitative predictor. Instead, it emerged as a contextual workplace resource. Spiritual values such as compassion, sincerity, caring, and service helped strengthen meaning and belonging when they were reflected in leadership behavior and organizational practice. This distinction is important. A religious hospital identity does not automatically create a health-promoting workplace. Values become meaningful when they are translated into supportive leadership, fair communication, mentoring, and employee development.
This study contributes to workplace health promotion literature by positioning leadership and talent development as organizational strategies for improving nurse retention. It also contributes to healthcare management literature by integrating leadership, engagement, talent development, and spiritual organizational culture into a single framework. For private religious hospitals, the findings suggest that workforce sustainability depends on both professional systems and value-based workplace culture.
This study shows that hospital leadership and talent development may function as workplace health promotion strategies for strengthening nurse retention in private religious hospitals. Supportive leadership was associated with stronger employee engagement and better talent development. Employee engagement and talent development were also associated with nurse retention and partially mediated the relationship between leadership and retention.
The qualitative findings showed that spiritual organizational culture strengthened meaning, belonging, and emotional attachment when it was reflected in leadership behavior and organizational practice. These findings suggest that nurse retention should not be understood only as a staffing outcome. It should also be treated as an indicator of a healthy, supportive, and sustainable workplace. Hospitals seeking to improve nurse retention should invest in leadership development, mentoring, career pathways, psychological support, and organizational cultures that protect employee well-being.
S. A. Boamah, H. K. S. Laschinger, C. Wong, and S. Clarke, “Effect of Transformational Leadership on Job Satisfaction and Patient Safety Outcomes,” Nursing Outlook, vol. 66, no. 2, pp. 180–189, 2018, doi: 10.1016/j.outlook.2017.10.004.
L. H. Hall, J. Johnson, I. Watt, A. Tsipa, and D. B. O’Connor, “Healthcare Staff Wellbeing, Burnout, and Patient Safety: A Systematic Review,” PLoS One, vol. 11, no. 7, p. e0159015, 2016, doi: 10.1371/journal.pone.0159015.
T. Woo, R. Ho, A. Tang, and W. Tam, “Global Prevalence of Burnout Symptoms Among Nurses: A Systematic Review and Meta-Analysis,” Journal of Psychiatric Research, vol. 123, pp. 9–20, 2020, doi: 10.1016/j.jpsychires.2019.12.015.
C. A. Wong, G. G. Cummings, and L. Ducharme, “The Relationship Between Nursing Leadership and Patient Outcomes: A Systematic Review Update,” Journal of Nursing Management, vol. 21, no. 5, pp. 709–724, 2013, doi: 10.1111/jonm.12116.
K. I. Proper and S. H. van Oostrom, “The Effectiveness of Workplace Health Promotion Interventions on Physical and Mental Health Outcomes: A Systematic Review of Reviews,” Scandinavian Journal of Work, Environment & Health, vol. 45, no. 6, pp. 546–559, 2019, doi: 10.5271/sjweh.3833.
World Health Organization, Global Patient Safety Report 2024. Geneva, Switzerland: World Health Organization, 2024. [Online]. Available: https://www.who.int/publications/i/item/9789240095458
J. Pfeffer, Dying for a Paycheck: How Modern Management Harms Employee Health and Company Performance and What We Can Do About It. New York, NY, USA: HarperBusiness, 2018.
J. Goh, J. Pfeffer, and S. A. Zenios, “The Relationship Between Workplace Stressors and Mortality and Health Costs in the United States,” Management Science, vol. 62, no. 2, pp. 608–628, 2016, doi: 10.1287/mnsc.2014.2115.
C. Maslach and M. P. Leiter, “Understanding the Burnout Experience: Recent Research and Its Implications for Psychiatry,” World Psychiatry, vol. 15, no. 2, pp. 103–111, 2016, doi: 10.1002/wps.20311.
G. G. Cummings et al., “Leadership Styles and Outcome Patterns for the Nursing Workforce and Work Environment: A Systematic Review,” International Journal of Nursing Studies, vol. 85, pp. 19–60, 2018, doi: 10.1016/j.ijnurstu.2018.04.016.
H. K. Spence Laschinger and R. Fida, “New Nurses Burnout and Workplace Wellbeing: The Influence of Authentic Leadership and Psychological Capital,” Burnout Research, vol. 1, no. 1, pp. 19–28, 2014, doi: 10.1016/j.burn.2014.03.002.
Q. Aini, “Motivation, Commitment and Leadership Skill in Affecting Performance of Hospital Managers,” Journal of Social Science Research, vol. 4, no. 12, pp. 707–710, 2018, doi: 10.32861/jssr.412.707.710.
Q. Aini and N. R. Dzakiyullah, “Leadership Styles in Healthcare Settings for Hospital Management and Employee Engagement,” Journal of Angiotherapy, vol. 8, no. 5, pp. 1–7, 2024, doi: 10.25163/angiotherapy.859697.
D. G. Collings and K. Mellahi, “Strategic Talent Management: A Review and Research Agenda,” Human Resource Management Review, vol. 19, no. 4, pp. 304–313, 2009, doi: 10.1016/j.hrmr.2009.04.001.
M. C. Meyers and M. van Woerkom, “The Influence of Underlying Philosophies on Talent Management: Theory, Implications for Practice, and Research Agenda,” Journal of World Business, vol. 49, no. 2, pp. 192–203, 2014, doi: 10.1016/j.jwb.2013.11.003.
R. M. Kanter, Men and Women of the Corporation. New York, NY, USA: Basic Books, 1977.
W. B. Schaufeli, “Work Engagement in Europe: Relations with National Economy, Governance and Culture,” Organizational Dynamics, vol. 47, no. 2, pp. 63–69, 2018, doi: 10.1016/j.orgdyn.2018.01.003.
J. J. Hakanen, A. B. Bakker, and W. B. Schaufeli, “Burnout and Work Engagement Among Teachers,” Journal of School Psychology, vol. 43, no. 6, pp. 495–513, 2006, doi: 10.1016/j.jsp.2005.11.001.
J. W. Creswell and J. D. Creswell, Research Design: Qualitative, Quantitative, and Mixed Methods Approaches, 5th ed. Thousand Oaks, CA, USA: SAGE Publications, 2018.
J. F. Hair, G. T. M. Hult, C. M. Ringle, and M. Sarstedt, A Primer on Partial Least Squares Structural Equation Modeling (PLS-SEM), 2nd ed. Thousand Oaks, CA, USA: SAGE Publications, 2017.