Title : Understanding burnout, motivation and retention among nurses: A constructivist grounded theory study of human resource management in healthcare

Background: Burnout among nurses has become a significant global healthcare challenge, contributing to reduced motivation, diminished job satisfaction, and increasing workforce shortages. Although burnout and nurse retention have been widely investigated, limited research has explored how human resource management (HRM) practices influence these phenomena within the professional nursing context. This study, informed by people sustainability theory and guided by a constructivist grounded theory methodology, aims to explore the relationship between HRM practices and nurse burnout, motivation, and retention i n Maltese healthcare settings.

Methods: A qualitative Constructivist Grounded Theory methodology, informed by Charmaz, was employed. Data were collected through semistructured interviews With 34 healthcare professionals from both public and private healthcare settings in Malta, including staff nurses, senior nurses, charge nurses, midwives, clinical psychologists, medical doctors, medical laboratory professionals, human resources directors, and a chief executive officer, providing diverse organisational perspectives. Data collection and analysis occurred concurrently using the constant comparative method. Theoretical sampling, memo writing, and iterative coding—including in vivo, focused, and theoretical—were conducted With the aid Of MAXQDA software to ensure data managernent and analysis rigour, until theoretical saturation was achieved.

Results: The findings indicate that burnout is strongly influenced by organisational rather than solely individual factors. Opportunities, leadership, effective communication, recognition, professional development, and adequate staffing strengthen nurses' commitment to their profession. In contrast, excessive workload, staffing shortages. emotional labour, limited resources, and perceived organisational silences contribute to emotional exhaustion, reduced professional fulfilment, and increased intentions to leave. Despite these challenges, many professionals demonstrate resilience and deep professional identity, remaining committed to patient care because of their intrinsic motivation. This resilience is sustained by substantive factors such as supportive workplaces, resilient engagement, growth, and retention intentions, which interact to enhance nurses' professional experiences and career decisions.

Conclusions: This study presents an original Constructivist Grounded Theory that advances understanding of the complex relationship between burnout, motivation, retention. and human resource management in the healthcare sector. By highlighting the key role Of HRM practices—such as leadership, recognition, workforce development' and employee wellbeing—and workplace factors in reduc ing burnout and improving nurse retention, the proposed theoretical framework provides practi cal and actionable insights for healthcare leaders, policymakers. and human resource professionals seeking to strengthen workforce sustainability and enhan the quality Of patient care.

Joshua Mercieca is a Human Resources Manager within the Maltese public healthcare sector and a lecturer in Human Resource Management at Global College Malta and the American University cf Malta. He holds a Master of Science in Human Resource Management and e Master Of Science in Management and is currently pursuing a Doctor of Philosophy (PhD) at the Malta College of Arts, Science and Technology. His doctoral research employs a constructivist grounded theory methodology to investigate the relationship between motivation, burnout, employee retention, and human resource management practices among healthcare professionals in Malta. His research interests include strategic human resource management, organisational behaviour, employee wellbeing, leadership, and healthcare workforce sustainability, and evaluative research methodologies.

Through his academic and professional roles, Joshua is committed to advancing evidence-based human resource practices that enhance organisational performance.