Registered nurse turnover in the acute setting

About the author: Janine Ellison, RN, masters candidate, is a nurse educator in the professional development unit, older persons and rehabilitation, Waikato District Health Board, Hamilton, New Zealand. Her correspondence address is: [email protected]

---

Key words

nurse, attrition, retention, nurse turnover, acute care hospital

---

Aim

The aim of this integrative review was to explore the reasons behind nurse turnover in the hospital environment. The research question was: Why do registered nurses leave the acute setting?

Background

Increasing nurse turnover has become a major concern globally, with the World Health Organization (2016) insisting countries institute policies to stem the attrition of nurses. In the New Zealand context, with current district health board (DHB) debt, and the cost of nurse turnover, retaining nurses in the workplace is imperative. Nurses comprise 65 percent of the regulated health workforce in New Zealand (Huntington et al., 2011). New Zealand has some of the poorest statistics for nurse retention in the developed world, with a nurse turnover rate of 44.3 percent, nearly three times higher than Australia (Hughes, 2017). There is no turnover data related directly to the acute setting; however in 2017, 39 percent of New Zealand registered nurses (RNs) worked in the acute DHB environment (NCNZ, 2017). Thus most of the nursing workforce is employed in the acute setting, so understanding the reasons why nurses are leaving the acute workforce is important.

The start of nurse attrition from an area can cause a cascading effect, where staff that remain become overworked and they in turn leave – this is categorised as secondary turnover (Buffington et al., 2012; Rondeau & Wagar, 2016). Adverse patient events and medication errors increase in areas of high nurse turnover, and when this turnover leads to inadequate staffing, then patient mortality rates increase (Buffington et al., 2012; Fagerstrom et al., 2018; Hairr et al., 2014; Perrine, 2009). It is important that the health-care sector finds ways to improve retention of nurses, so patient safety is not compromised (Menella, 2018). The cost of nurse turnover in New Zealand is equal to half the salary of a nurse – approximately $30,000 – due to the hidden costs involved, such as advertising, training, temporary staffing and orientation periods (North et al., 2013). Better retention of nurses in New Zealand could save DHBs a substantial amount of money every year, therefore this should be a top priority for government and DHB policy. In the year to May 2019, 20 out of the 21 DHBs in New Zealand were in debt and the total debt across the DHBs was $423 million (Janic, 2019). Employing nurse-retention strategies could slow this attrition and save district health boards much-needed money.

Methods

The theoretical framework for this integrative review was based on Whittemore and Knafl’s (2005) updated methodology for integrative reviews. Integrative reviews analyse the findings of primary studies from a range of diverse methodologies, both qualitative and quantitative. There are five stages to the integrative review framework: problem identification, literature search, data evaluation, data analysis and presentation of findings. Search terms used were: tertiary, in-patient, acute, RN, nurse, leave, retention, stay, turnover and attrition, and the timeframe for the search was 2009-2019. Electronic databases searched included CINAHL Complete, Cochrane Library, ProQuest, PubMed, MEDLINE Complete, Clinical Key, Science Direct, Health Business Elite and Nursing Reference Center Plus. Thirty-six primary studies were evaluated, and 16 met the selection criteria for inclusion in the integrated review.

Findings

Three key themes were identified through an iterative approach to data evaluation and synthesis: support, workload and professional factors. The first theme to emerge concerned support, including organisational and manager support, appreciation and relationships with co-workers. A perceived lack of support or recognition from the employing organisation and its management was a major reason why nurses intended to leave their workplace. Nurse participants in these studies described how they felt unappreciated and their skills and knowledge unrecognised by managers and the organisation (Choi et al., 2011; Choi et al., 2012; El-Jardali et al., 2009; Tuckett et al., 2015). Nurse participants also reported how their self-esteem and sense of self-worth had been adversely affected by an unsupportive manager (Choi et al., 2011; Choi et al., 2012; El-Jardali et al., 2009; Hayward et al., 2016; Tuckett et al., 2015; Walker & Clendon, 2018).

Nurses experienced a lack of support when there was poor communication between the employer organisation and nurses. “Nobody cares at the top about nurses” and staff are “drowning in policies” are examples of nurse views on this lack of support in an Australasian study conducted by Tuckett et al. (2015). Nurses equated poor organisational and coordination skills on the part of their direct manager, with chaos on the ward, and feelings of an overwhelming workload. Having a manager who didn’t offer help when staff were busy, was not visible on the ward, or was insensitive to staff needs was also identified as a reason staff intended to leave (Choi et al., 2011; Choi et al., 2012; El-Jardali et al., 2009; Tuckett et al.). Unapproachable managers who did not listen to staff needs or support staff when there were complaints led to nurses expressing an intention to leave. Some nurses might have stayed at their workplace if there had been support and positive leadership from their manager and more recognition of their skills (Heinen et al., 2013; Tuckett et al., 2015; Walker et al., 2018). Lack of support from colleagues was a further reason nurses intended to leave their workplace (Choi et al., 2011; El-Jardali et al., 2009; Labrague et al., 2018; Tuckett et al., 2015; Van Dam, Meewis & van der Heijden, 2012). Bullying, mistrust, fault-finding and disrespect among colleagues led to dissatisfaction with work and intent to leave (Choi et al., 2011; Choi et al., 2012; Walker et al., 2018). Some nurses felt that colleagues did want to provide support but were unable to due to high workloads and being “emotionally tired” from years of nursing (Tuckett et al., 2015).

The second theme related to workload, and included patient acuity, poor staffing and high nurse workload. Coupled with this workload theme was the perception that heath was treated as a business and was no longer patient-centred. Nurses suggested that patients were getting more complex, but the nurse-patient ratio remained the same, and working short-staffed was becoming more common. Increased patient acuity in the acute setting was identified as the reason many nurses intend to leave their workplace (Baernholdt & Mark, 2009; Choi et al., 2011; Hayward et al., 2016). More paperwork and documentation, with less time for patient care, left nurses feeling dissatisfied and with a sense that they had not provided quality care (Alasmari & Douglas, 2012; Choi et al., 2012; Hayward et al., 2016). The higher the nurse-patient ratio, the more likely nurses were to report their workplace only provided poor to fair patient care, and nurses who felt this way were also more likely to express an intention to leave (Aiken et al., 2012). Pressure and urgency at work was an important factor, and some felt this was why new staff left their workplace (Choi et al., 2011; Moloney et al., 2018). In one study, nearly half of New Zealand nurses who had left said they would have stayed in their workplace if there had been more staff on the wards (Walker et al., 2018). Inadequate staffing led to feelings of job dissatisfaction, emotional exhaustion and burnout, as staff had less time for patient care (Baernholdt et al., 2009; Choi et al., 2011; Dimattio et al., 2010; Hayward et al., 2016; Nantsupawat et al., 2016; Walker et al., 2018). Nurses felt understaffing led to greater risk of errors and vulnerability to stress and injury for nurses, as they had to complete tasks alone that normally required two people (Choi et al., 2011; Nantsupawat et al., 2016). A perception that health care had become business-focused was a reason some nurses intended to leave their workplace (Aiken et al., 2012; Tuckett et al., 2015), because they felt nursing was no longer patient-centred and this led to less personal satisfaction in their job. Nurses felt the real rewards in nursing were forming relationships with patients and providing quality care, which was no longer possible in the business-driven model of health care (Tuckett et al.).

The third theme concerned professional factors, including career and professional development and participation in hospital affairs. Perceived poor education opportunities, along with limited possibilities to up-skill, were reasons nurses left their workplace. Nurses wanted more professional development opportunities from within the employing organisation. They wanted education that was directly related to the job they were employed to do, so when they couldn’t access this learning, they felt dissatisfied and this led to intent to leave (Abdulkareem, Chauhan & Kura, 2014; Alasmari et al., 2012; Dimattio et al., 2010; Nowrouzi et al., 2016; van Dam et al., 2012). Nurses also wanted more career and job advancement prospects and a greater chance for promotion (Alasmari et al., 2012; Dimattio et al., 2010; Nowrouzi et al., 2016). However, the opposite was true in one New Zealand study, where nurses who had left would have considered remaining if their organisation had been less demanding about them continuing with professional development (Walker et al., 2018). Nurses who felt they were not involved in hospital affairs were more likely to leave their workplace. Even though nurses were often the ones implementing policies, many felt they had no say in how these policies were made. Nurses were not involved in hospital decision-making and this lack of inclusion led them to consider leaving their workplace. Some nurses felt their employing hospital made decisions without consulting nursing staff and some of these decisions made it difficult for them to give quality patient care (Dimattio et al., 2010; Heinen et al., 2013; Nantsupawat et al., 2016). Nurses also wanted more open communication with hospital administrators and recognition of their knowledge and potential input into organisational-level decision-making (Nantsupawat et al., 2016).

Conclusion

This review identifies that a perceived lack of support from their employing organisation, management and colleagues; workload factors including acuity, nurse-patient ratio and poor staffing; and a lack of professional development opportunities along with limited potential for promotion or career advancement were all factors in nurses’ decision to leave the acute setting. There are many ways to retain these nurses, through positive leadership, adequate staffing, and professional development opportunities.

---

References

Abdulkareem, R., Chauhan, A., & Kura, K. (2014). Relationship between perceived organisational politics, organisational trust, human resource management practices and turnover intention among Nigerian nurses. International Journal of Business and Development Studies, 6(1), 53-82.

Aiken, L., Sermeus, W., Van den Heede, K., Sloane, D., Busse, R., McKee, M., Bruyneel, L., Rafferty, A., Griffiths, P., Moreno-Casbas, M., Tishelman, C., Scott, A., Brzostek, T., Kinnunen, J., Schwendimann, R., Heinen, M., Zikos, D., Sjetne, I., Smith, H., & Kutnery-Lee, A. (2012). Patient safety, satisfaction, and quality of hospital care: cross sectional surveys of nurses and patients in 12 countries in Europe and the United States. BMJ, 344, e1717.

Alasmari, H., & Douglas, C. (2012). job satisfaction and intention to leave among critical care nurses in Saudi Arabia. Middle East Journal of Nursing, 6(4), 3-12.

Baernholdt, M., & Mark, B. (2009). The nurse work environment, job satisfaction and turnover rates in rural and urban nursing units. Journal of Nursing Management, 17(8), 994-1001.

Buffington, A., Zwink, J., Fink, R., Devine, D., & Sanders, C. (2012). Factors affecting nurse retention at an academic Magnet® hospital. Journal of Nursing Administration, 42(5), 273-281.

Choi, S., Pang, S., Cheung, K., & Wong, T. (2011). Stabilizing and destabilizing forces in the nursing environment: A qualitative study on turnover intention. International Journal of Nursing Studies, 48(2011), 1290-1301.

Choi, S., Cheung, K., & Pang, S. (2013). Attributes of nursing work environment as predictors of registered nurses’ job satisfaction and intention to leave. Journal of Nursing Management, 21(3), 429–439.

Dimattio, M., Roe-Prior, P., & Carpenter, D. (2010). Intent to stay: A pilot study of baccalaureate nurses and hospital nursing. Journal of Professional Nursing, 26(5), 278-286.

Fagerstrom, L., Kinnunen, M., & Saarela, J. (2018). Nursing workload, patient safety incidents and mortality: An observational study from Finland. BMJ Open, 8(4).

Hairr, D., Salisbury, H., Johannsson, M., & Redfern-Vance, N. (2014). Nurse staffing and the relationship to job satisfaction and retention. Nursing Economic$, 32(3), 142-147.

Halter, M., Boiko, O., Pelone, F., Beighton, C., Harris, R., Gale, J., Gourley, S., & Drennan, V. (2017). The determinants and consequences of adult nursing staff turnover: A systematic review of systematic reviews. BMC Health Services Research, 17, 1-20.

Hayes, L., O’Brien-Pallas, L., & Duffield, C., Shamian, J., Buchan, J., … North, N. (2012). Nurse turnover: A literature review – An update. International Journal of Nursing Studies, 49(7), 887-905.

Hayward, D., Bungay, V., Wolff, A., & MacDonald, V. (2016). A qualitative study of experienced nurses’ voluntary turnover: learning from their perspectives. Journal of Clinical Nursing, 25(9-10), 1336-1345.

Heinen, M., van Achterberg, T., Schwendimann, R., Zander, B., Mathews, A., Kozka, M., Ensio, A., Sjetne, I., Casbas, T., Ball, J., & Schoonhoven, L. (2013). Nurses’ intention to leave their profession: A cross sectional observational study in 10 European countries. International Journal of Nursing Studies, 50(2013), 174-184.

Hughes, V. (2017). Leadership strategies to promote nurse retention. Scientific Journal of Nursing & Practice, 1(11), 001-005.

Huntington, A., Gilmour, J., Tuckett, A., Neville, S., Wilson, D., & Turner, C. (2011). Is anybody listening? A qualitative study of nurses’ reflections on practice. Journal of Clinical Nursing, 20, 1413-1422.

Jancic, B. (2019, 2 August). DHB deficit explodes to $423 million, more than double last year. New Zealand Herald.

Labrague, L., Gloe, D., McEnroe, D., Konstanitinos, K., & Colet, P. (2018). Factors influencing turnover intention among registered nurses in Samar Philippines. Applied Nursing Research, 39(2018), 200-206.

Lartey, S., Cummings, G., & Profetto-McGrath, J. (2014). Interventions that promote retention of experienced registered nurses in health care settings: a systematic review. Journal of Nursing Management, 22(2014), 1027-1041.

Lu, H., Barriball, L., Zhang, X., & While, A. (2012). Job satisfaction among hospital nurses revisited: A systematic review. International Journal of Nursing Studies, 49(2012), 1017-1038.

Menella, H. (2018). Retention of healthcare personnel: retaining older nurses. CINAHL Nursing Guide.

Ministry of Health. (2016). Health of the health workforce 2015.

Moloney, W., Gorman, D., Parsons, M., & Cheung, G. (2018). How to keep registered nurses working in New Zealand even as economic conditions improve. BMC, 16(45).

Nantsupawat, A., Kunaviktikul, W., Nantsupawat, R., Wichaikhum, O., Thienthong, H., & Poghosyan, L. (2016). Effects of nurse work environment on job dissatisfaction, burnout, intention to leave. International Nursing Review, 64, 91-98.

North, N., Leung, W., Ashton, T., Rasmussen, E., Hughes, F., & Finlayson, M. (2013). Nurse turnover in New Zealand: costs and relationships with staffing practises and patient outcomes. Journal of Nursing Management, 21, 419-428.

Nowrouzi, B., Rukholm, E., Lariviere, M., Carter, L., Koran, I., Mian, O., & Giddens, E. (2016). An examination of retention factors among registered nurses in Northeastern Ontario, Canada: Nurses intent to stay in their current position. Work, 54(1), 51-58.

Nursing Council of New Zealand. (2017). The New Zealand nursing workforce: A profile of nurse practitioners, registered nurses and enrolled nurses 2016¬2017.

Perrine, J. (2009). Recruitment and Retention Report. Strategies to boost RN retention. Nursing Management, 40(4), 20-22.

Rondeau, K., & Wagar, T. (2016). Human resource management practices and nursing turnover. Journal of Nursing Education and Practice, 6(10), 101-109.

Tuckett, A., Winters-Chang, P., Bogossian, F., & Wood, M. (2014). ‘Why nurses are leaving the profession . . . lack of support from managers’: What nurses from an e-cohort study said. International Journal of Nursing Practice, 21(4), 359-366.

Van Dam, K., Meewis, M., van der Heijden, B. (2012). Securing intensive care: towards a better understanding of intensive care nurses’ perceived work pressure and turnover intention. Journal of Advanced Nursing, 69(1), 31-40.

Whittemore, R., & Knafl, K. (2005). The integrative review: Updated methodology. Journal of Advanced Nursing, 52(5), 546-553.

World Health Organization. (2016). Global strategic directions for strengthening nursing and midwifery 2016–2022.