A systematic review of registered nurse turnover and retention in the United States

Nurse retention in peri- and post-COVID-19 work environments: a scoping review of factors, strategies and interventions

OBJECTIVES

The COVID-19 pandemic highlighted the deterioration of nurses' working conditions and a growing global nursing shortage. Little is known about the factors, strategies and interventions that could improve nurse retention in the peri- and post-COVID-19 period. An improved understanding of strategies that support and retain nurses will provide a foundation for developing informed approaches to sustaining the nursing workforce. The aim of this scoping review is to investigate and describe the (1) factors associated with nurse retention, (2) strategies to support nurse retention and (3) interventions that have been tested to support nurse retention, during and after the COVID-19 pandemic.

DESIGN

Scoping review.

DATA SOURCES

This scoping review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews. MEDLINE, Embase, CINAHL and Scopus databases were searched on 17 April 2024. The search was limited to a publication date of '2019 to present'.

ELIGIBILITY CRITERIA

Qualitative, quantitative, mixed-methods and grey literature studies of nurses (Registered Nurse (RN), Licenced Practical Nurse (LPN), Registered Practical Nurse (RPN), Publlic Health Nurse (PHN), including factors, strategies and/or interventions to support nurse retention in the peri- and post-COVID-19 period in English (or translated into English), were included. Systematic reviews, scoping reviews and meta-syntheses were excluded, but their reference lists were hand-screened for suitable studies.

DATA EXTRACTION AND SYNTHESIS

The following data items were extracted: title, journal, authors, year of publication, country of publication, setting, population (n=), factors that mitigate intent to leave (or other retention measure), strategies to address nurse retention, interventions that address nurse retention, tools that measure retention/turnover intention, retention rates and/or scores. Data were evaluated for quality and synthesised qualitatively to map the current available evidence.

RESULTS

Our search identified 130 studies for inclusion in the analysis. The majority measured some aspect of nurse retention. A number of factors were identified as impacting nurse retention including nurse demographics, safe staffing and work environments, psychological well-being and COVID-19-specific impacts. Nurse retention strategies included ensuring safe flexible staffing and quality work environments, enhancing organisational mental health and wellness supports, improved leadership and communication, more professional development and mentorship opportunities, and better compensation and incentives. Only nine interventions that address nurse retention were identified.

CONCLUSIONS

Given the importance of nurse retention for a variety of key outcomes, it is imperative that nursing leadership, healthcare organisations and governments work to develop and test interventions that address nurse retention.

Intuitive knowing for student nurses

ABSTRACT

"Intuitive knowing" is the ability to understand a clinical case instinctively without the need for conscious reasoning. This article examines the critical role of intuitive knowing in clinical decision-making among nurses, particularly in the context of increasingly complex patient care. Furthermore, the article offers recommendations for nursing educators to cultivate this essential skill in nursing students, ensuring they are equipped to effectively navigate the challenges of modern healthcare environments.

Interventions to retain emergency department nurses: A scoping review

INTRODUCTION

Globally, the nursing workforce is facing significant shortages, exacerbated by the COVID-19 pandemic. Emergency departments (ED) are dynamic environments that expose nurses to high levels of stress. Retention of existing nurses is vital, however the efficacy of interventions to improve the retention of ED nurses is limited. This review aimed to explore the evidence surrounding interventions focussed on addressing the retention of ED nurses.

METHOD

A scoping review of the literature was undertaken, guided by the Joanna Briggs Institute framework. A search of five electronic databases was conducted. Original research published between 2012 and 2023 regarding the population of nurses, the concept of interventions to decrease turnover/improve retention and the context of the emergency department were considered for inclusion.

RESULTS

Five articles met the criteria for inclusion; three evaluated educational programs to ease the transition to becoming ED nurses, two assessed locally developed 'ad hoc' interventions. All the transitional education programs reported an increase in retention rates, while the ad hoc interventions produced minimal to no improvement in retention or reduction of turnover intent. All studies were conducted in high-income countries.

CONCLUSION

There is a dearth of evidence for organisations to draw upon to increase the retention of ED nurses. Additional research is warranted, especially regarding the long-term effects of interventions aimed at improving ED nurse retention, as well as evaluating interventions implemented in a wider variety of contexts.

Effectiveness of Cognitive Behavioral Therapy in Reducing Psychological Distress in Nurses: A Systematic Review and Meta-Analysis of Experimental Studies

Work-related stress, a major contributor to physical and mental health issues of nurses, has a direct impact on patient safety and nurses' well-being. However, few studies have investigated the effectiveness of cognitive behavioral therapy in reducing psychological distress in nurses. Systematic search of six databases including CINAHL Plus with Full Text, Cochrane Library, Embase, Medline, PubMed, and Web of Science from their inception to February 27, 2024. The primary outcomes assessed were reductions in stress, anxiety, and depression following the implementation of cognitive behavioral therapy. A random effects model, accounting for study differences, was applied in the meta-analyses. Egger's regression test was utilized to assess potential publication bias in the pooled analyses. The meta-analysis included 10 studies that demonstrated the intervention's beneficial effects in reducing stress, anxiety, and depression among nurses. Despite the positive effects observed with cognitive behavioral therapy (CBT) in alleviating psychological distress among nurses, the generalizability of these findings may require further confirmation due to the diversity of cognitive behavioral therapies.

Registered nurses' experiences of the graduate nurse residency program: A qualitative study

BACKGROUND

The turnover of new graduate nurses is a critical issue worldwide. A key contributing factor is the highly stressful transition from student to registered nurse. Graduate nurse residency programs support new graduate nurses during this transition and facilitate professional development.

OBJECTIVE

This study aimed to gain insight into the experiences of registered nurses' in the graduate nurse residency program.

DESIGN

A descriptive qualitative study design using thematic analyses.

SETTING

This study was conducted in an academic tertiary hospital in Singapore.

PARTICIPANTS

Registered nurses who completed the graduate nurse residency program were selected using a purposive sampling approach.

METHODS

This study was conducted from September to December 2023. A total of 19 registered nurses were invited to an individual semi-structured interview. The interviews were either conducted online through Zoom or instant messaging. The Zoom interviews were audio- and video-recorded and transcribed verbatim. A six-step inductive thematic analysis was used for data analysis.

RESULTS

Two themes depicting nurses' experiences of the graduate nurse residency program were elucidated, (1) easing the shift from student to registered nurse; and (2) facilitating the transition to becoming a competent nurse. The participants alluded to the importance of the graduate nurse residency program in playing a supportive role in enabling their transition. The provision of technical and soft skills were valued by the participants. The graduate nurse residency program also aided in participants' professional development through evidence implementation and mentorship. The graduate nurse residency program was an enabler of participants' intent to stay in the nursing profession.

CONCLUSIONS

The findings of this study show that nurses viewed the graduate nurse residency program in a positive light. The provision of a multi-modal graduate nurse residency structured program focusing on building clinical competencies, mentorship, and evidence implementation projects can promote new graduate nurses' transition into professional practice. Further research is needed to examine the long term impacts of graduate nurse residency programs using cohort or randomized controlled trials.

Contemporary Factors Influencing Professional Identity in Acute Care Nurses: An Integrative Review

AIM

To explore the current state of the science on influencing factors of acute care nursing professional identity.

DESIGN

Integrative review.

METHODS

Data were collected and screened using Covidence systematic review software, adhering to pre-defined inclusion criteria. The Critical Appraisal Skills Programme checklist was used for critical appraisal, and content analysis was applied to analyse the data.

DATA SOURCES

CINAHL, PsycINFO and PubMed were utilised to search literature published between 2018 and 2023.

RESULTS

A total of 18 articles were included. Five themes were identified: (1) internal influences; (2) external influences; (3) externalisation of role; (4) early versus seasoned career experiences and (5) barriers to professional identity formation.

CONCLUSION

This review found evidence of multiple influencing factors, predominantly external, shaping acute care nurse professional identity. Research on the long-term impacts on practice, management, policy and education remains limited.

IMPLICATIONS

Enablers to forming professional identity foster empowerment, confidence, belonging and job satisfaction. Barriers to formation lead to hesitation, performance impediments, stress and exhaustion. Development of nurse professional identity may be instrumental in tackling acute care workforce challenges.

IMPACT

Review findings on professional identity formation can guide initiatives for enhancing healthy work environments and workforce retention. This exploration has international contemporary relevance for the nursing profession with suggestions for future research.

IMPACT STATEMENT

Existing literature underscores the significance of professional identity in nursing, yet the mechanisms underlying its integration and maintenance in the contemporary acute care workforce remain unclear. In the context of overwhelming workloads that adversely affect nurse mental health and retention, coupled with the escalating nursing shortage as we emerge from the pandemic, this examination of professional identity formation holds contemporary relevance for the evolving acute care landscape, offering implications for future research. The insights gleaned from this review may guide organisational leaders in developing new strategies addressing acute care nurse management, policy, education and retention.

REPORTING METHOD

Reporting adheres to the EQUATOR network, ENTREQ guidelines.

PATIENT OR PUBLIC CONTRIBUTION

None.

Retaining a Multicultural Nursing Workforce: A Self-Determination Theory Perspective

INTRODUCTION

The increased globalization of nurses has prompted organizations to explore innovative strategies to retain their workforce. However, due to cultural variations and increased workforce diversity, a one-size-fits-all retention strategy may not be effective.

METHODOLOGY

In this paper, we discuss nurse migration and retention to identify points of intersection and possible theories that can be applied.

RESULTS

Nurse migration and retention share a common motivation thread, indicating that a motivation theory could effectively integrate both concepts. Self-determination theory (SDT) is particularly relevant as it suggests that the needs for autonomy, competence, and relatedness influence motivation and retention and that these are universal, transcending cultural boundaries.

DISCUSSION

Addressing migrant nurse retention is crucial. The continued international recruitment poses a threat, as any intake by host countries further depletes the already scarce pool of nurses in some source countries. The perspective offered by the SDT may prove instrumental in developing effective strategies for retaining migrant nurses.

The Impact of Resilience and Leader-Member Exchange on Actual Turnover: A Prospective Study of Nurses in Acute Hospitals

BACKGROUND/OBJECTIVES

High nurse turnover has economic implications for healthcare organizations and impacts the quality of care. Individual, job-related, and organizational factors determine nurse turnover. This study, thus, aimed to investigate the impact of nurses' resilience and the quality of the relationship between staff nurses and nurse managers, defined as leader-member exchange (LMX), on actual nurse turnover.

METHODS

A prospective study was conducted from June to July 2022, targeting nurses from three advanced treatment hospitals in Japan. Data were collected through a self-administered questionnaire investigating the participants' actual turnover in April 2023. The data of 1130 nurses were analyzed in this study. A binary logistic regression analysis was performed using actual turnover as the dependent variable and nurse resilience and LMX as independent variables.

RESULTS

The results revealed that while LMX influenced actual turnover, nurse resilience had no statistically significant relationship with turnover.

CONCLUSIONS

The findings show that LMX needs to be improved if actual turnover is to be curbed.

Coping Measures for Hospital Nurses' Turnover: A Qualitative Meta-Aggregation (2018-2023)

AIM

To identify and synthesise the qualitative evidence that is available regarding reducing the turnover of hospital nurses from their own perspectives.

DESIGN

A qualitative systematic review using the meta-aggregation design.

DATA SOURCES

Qualitative studies either in English or in Chinese, dating from 2018 to 2023, were obtained from eight databases, including CINAHL, PubMed, Web of Science, Embase, Ovid, and Chinese National Knowledge Infrastructure (CNKI), Wanfang Database and the China Biomedical Database.

METHODS

Studies were screened using pre-determined inclusion and exclusion criteria. Quality assessment was done using the Joanna Briggs Institute Critical Appraisal Checklist for Qualitative Research. The study was reported according to the Enhancing Transparency in Reporting the Synthesis of Qualitative Research (ENTREQ) guidelines.

RESULTS

Sixteen papers were included that explored nurses' perspectives on enhancing their retention or reducing staff turnover. We developed three synthesised findings and 12 categories from 64 identified findings, including (1) individual adjustment strategy: professional pride, self-growth and psychological adjustment; (2) social support strategy: constructive workplace relationships, balancing work life and recognition of nursing and (3) organisational change strategy: embracing management and leadership, promote nursing professionalisation, workload management and support, flexible work patterns and opportunities, supporting personal career development and competitive salary.

CONCLUSION

This review provides an in-depth and meaningful understanding of nurses' own perceptions and suggestions for enhancing nursing turnover, which will call for a wide range of measures targeting the individual, social and organisational levels.

IMPLICATIONS FOR NURSING MANAGEMENT

This study contributes important knowledge to help improve hospital nurse's turnover, which can provide evidence to support nurse managers, other stakeholders and policymakers in correspondingly developing effective measures to address nurse turnover.

PATIENT OR PUBLIC CONTRIBUTION

There was no direct contribution from patient or caregiver to this study because the data of this study originated from published papers.

Nurses quietly quit their job more often than other healthcare workers: An alarming issue for healthcare services

AIM

To assess the level of quiet quitting among healthcare workers (HCWs) and identify possible differences between nurses, physicians, and other HCWs. We investigated the impact of sociodemographic variables, job burnout, and job satisfaction on quiet quitting levels.

BACKGROUND

The quiet-quitting phenomenon is not new but has been frequently discussed during the COVID-19 pandemic. Interestingly, the level of quiet quitting among HCWs has not been measured yet.

METHODS

We conducted a cross-sectional study with a convenience sample. We measured sociodemographic variables, job burnout, job satisfaction, and quiet quitting. We adhered to STROBE guidelines for cross-sectional studies.

FINDINGS

Among our sample, 67.4% of nurses were quiet quitters, while the prevalence of quiet quitting for physicians and other HCWs was 53.8% and 40.3%, respectively. Multivariable linear regression analysis identified that the levels of quiet quitting were higher among nurses than physicians and other HCWs. Moreover, greater job burnout contributed more to quiet quitting, while less satisfaction implied more quiet quitting. HCWs who work in shifts and those working in the private sector experienced higher levels of quiet quitting.

DISCUSSION

More than half of our HCWs were described as quit quitters. Levels of quiet quitting were higher among nurses. Job burnout and job dissatisfaction were associated with higher levels of quiet quitting.

IMPLICATIONS FOR NURSING PRACTICE AND NURSING POLICY

Measurement of quiet quitting and identification of risk factors are essential to prevent or reduce quiet quitting levels among HCWs. Our study provides information on this field helping managers and organizations to identify quiet quitters within HCWs. Policymakers and managers should develop and implement interventions both at an organizational level and at an individual level.

Association of Job Satisfaction, Intention to Stay, Organizational Commitment, and General Self-Efficacy Among Clinical Nurses in Riyadh, Saudi Arabia

Nurse turnover presents a significant challenge for healthcare organizations worldwide, impacting patient care quality and organizational stability. Understanding the determinants of nurse turnover, particularly job satisfaction, intention to stay, organizational commitment, and general self-efficacy, is crucial for developing effective retention strategies. This study aimed to explore the relationships among job satisfaction, intention to stay, organizational commitment, general self-efficacy, and demographic variables. A cross-sectional, correlational research design was employed, with data collected through validated questionnaires distributed to a total convenience sample of 227 clinical nurses in Riyadh, Saudi Arabia between July 2023 and August 2023. Validated measurement tools, including the Job Satisfaction Index, the Intent to Stay Scale, the Organizational Commitment Scale, and the General Self-Efficacy Scale, were utilized. Descriptive statistics were employed to summarize demographic information, and a correlation analysis was conducted to explore the relationships between the study variables. The findings revealed moderate levels of job satisfaction, intention to stay, organizational commitment, and general self-efficacy among the clinical nurses, with significant positive correlations observed among these variables as well as the nurses' sociodemographic characteristics. Notably, clinical nurses constituted a significant portion of the sample, suggesting the need for targeted interventions tailored to this demographic group as well as non-Saudi nurses (expatriate nurses), particularly in enhancing their organizational commitment and self-efficacy. The study found significant and positive associations between the four study variables and the nurses' demographic characteristics. Tailored interventions addressing job satisfaction, intent to stay, organizational commitment, self-efficacy, and demographic variables are essential for mitigating nurse turnover. By fostering a supportive work environment and implementing targeted retention strategies informed by demographic insights and determinants of turnover, healthcare organizations can enhance nurse retention rates and ensure a stable and fulfilled nursing workforce.

Attitudes and preferences about retention: A survey study of nursing home employees

OBJECTIVE

There is an anticipated surge in demand for nursing home staff associated with the doubling of Americans aged 65 and older by 2060. Nursing homes face alarming turnover rates, exacerbated by the COVID-19 pandemic. This study explores the attitudes and preferences of nursing home staff toward non-monetary perks to better understand perks' impact on employee retention.

METHODS

This cross-sectional survey study, conducted in a 115-bed nursing home in Pittsburgh area, assessed employee preferences toward non-monetary workplace incentives. Descriptive statistics were used to analyze multiple choice questions and thematic analysis was used to assess open-ended questions.

RESULTS

A total of 59 employees completed the survey. Participants indicated preferences for perks with monetary benefit, such as extra PTO for good work, gift cards, and classes. Thematic analysis revealed preferences for incentives such as equitable treatment.

DISCUSSION

These preliminary findings offer insights on increasing nursing home employee retention using non-monetary incentives.

Churning the tides of care: when nurse turnover makes waves in patient access to primary care

BACKGROUND

Team-based primary care (PC) enhances the quality of and access to health care. The Veterans Health Administration (VHA) implements team-based care through Patient Aligned Care Teams (PACTs), consisting of four core members: a primary care provider, registered nurse (RN) care manager, licensed vocational nurse, and scheduling clerk. RNs play a central role: they coordinate patient care, manage operational needs, and serve as a patient point of contact. Currently, it is not known how varying levels of RN staffing on primary care teams impact patient outcomes.

OBJECTIVE

This study aims to empirically assess how the stability of RN staffing within team-based primary care affects patient access to care.

METHODS

A retrospective database review using clinical and administrative data from the VHA over 24 months. Participants included 5,897 PC PACTs across 152 VHA healthcare facilities in the United States and its territories. The stability of personnel in the RN role was categorized as: RN continuous churn, RN staffing instability and RN vacancy. All 3 categories were compared to teams with RN stability (i.e., same person in the role for the entire 24-month period). Access measures included: average third-next-available appointment, established patient average wait time in days, urgent care utilization, emergency room utilization, and total inbound-to-outbound PC secure messages ratio.

RESULTS

RN continuous churn within PACTs had a significant impact on third-next-available appointment (b = 3.70, p < 0.01). However, RN staffing instability and vacancy had no significant relationship with any of the access measures. Several risk adjustment variables, including team full-time equivalency, team stability, relative team size, and average team size, were significantly associated with access to health care.

CONCLUSIONS

Teams are impacted by churn on the team. Adequate staffing and team stability significantly predict patient access primary care services. Healthcare organizations should focus on personnel retention and strategies to mitigate the impact(s) of continuous RN turnover. Future research should examine the relative impact of turnover and stability of other roles (e.g., clerks) and how team members adapt to personnel changes.

Hospital personnel perspectives on factors influencing acute care patient outcomes: a qualitative approach to model refinement

BACKGROUND

Health systems have long been interested in the best practices for staffing in the acute care setting. Studies on staffing often focus on registered nurses and nurse-to-patient staffing ratios. There were fewer studies on the relationship between interprofessional team members or contextual factors such as hospital and community characteristics and patient outcomes. This qualitative study aimed to refine an explanatory model by soliciting hospital personnel feedback on staffing and patient outcomes.

METHODS

We conducted a qualitative study using semi-structured interviews and thematic analysis to understand hospital personnel's perspectives and experiences of factors that affect acute care inpatient outcomes. Interviews were conducted in 2022 with 38 hospital personnel representing 19 hospitals across Washington state in the United States of America.

RESULTS

Findings support a model of characteristics impacting patient outcomes to include the complex and interconnected relationships between community, hospital, patient, and staffing characteristics. Within the model, patient characteristics were positioned into hospital characteristics, and in turn these were positioned within community characteristics to highlight the importance of setting and context when evaluating outcomes. Together, these factors influenced both staff characteristics and patient outcomes, but these two categories also share a direct relationship.

CONCLUSION

Findings can be applied to hospitals and health systems in a variety of contexts to examine how external factors such as community resource availability impact care delivery. Future research should expand on this work with specific attention to how staffing changes and interprofessional team composition can improve patient outcomes.

Answering the call: Experiences of nurses of color during COVID-19

In the years following the COVID-19 pandemic, issues such as high job demands, burnout, and turnover continue to influence the nursing workforce, with heavier impacts to marginalized groups. Understanding the work and life contexts of nurses of color can help guide strategies for workplace equity and meaningful support. This qualitative study explored the experiences of nurses of color in the United States during the pandemic, focusing on feelings about the profession and job decisions. The overarching theme was "answering the call," with subthemes of "COVID shone a light," "being consumed by COVID," and "is it worth it?" Participants shared how their racial identities shaped their perceptions and job decisions in positive and negative ways, noting how racism impacted many facets of their work and added to the stressors felt in the workplace and the community. Findings provide insight into the underrepresented perspectives of nurses of color and suggest strategies to eliminate racism in nursing.

Gratitude interventions to improve wellbeing and resilience of graduate nurses transitioning to practice: A scoping review

Background

New graduate nurses are the nursing cohort at greatest risk for turnover and attrition in every context internationally. This has possibly been heightened during the COVID-19 pandemic. Workplace conditions significantly impact nursing turnover; however, interventions under the positive psychology umbrella may have a mediating impact on the intention to leave. New graduate nurses are generally challenged most in their first three years of clinical practice, and the need for support to transition is widely accepted. Gratitude practice has been reported to improve individual control and resilient response to setbacks and, therefore, is of interest in testing if this intervention can impact turnover intention in the workforce.

Objective

To report on a scoping review undertaken to identify whether 'gratitude practice' as an intervention had the potential to improve new graduate nurses' wellbeing and resilience.

Methods

Arksey and O'Malley's scoping review approach. Primary research papers of any methodology, published in English between January 2010 and July 2022 were included. Literature was sourced from seven databases, including CINAHL PLUS, ERIC, MEDLINE, Professional Development Collection, APA PsychInfo, APA PsychArticles, and Psychological and Behavioural Sciences Collection.

Results

We identified 130 records, of which we selected 35 for inclusion. A large range of interventions were identified; most had some form of writing, journaling, or diarising. The next most common intervention was teaching gratitude strategies via workshops, and many interventions had some form of list or activity trigger for participants to complete. Five studies had complex combined interventions, while the rest were simple, easily reproducible interventions. Interventions were delivered both face-to-face or asynchronously, with some being online only and others sent out as a 'kit' for participants to work through.

Conclusion

Our review of existing literature shows a significant gap in research on gratitude practice and its impact on nursing populations. To ensure robust future studies, we suggest defining concepts clearly and selecting outcome measures and tools that are not closely related. Intervention design may not be as important as the choice of measures and tools to measure outcomes.

Assessment of Nursing Practice Environment and Its Influencing Factors: A Cross-Sectional Study at Shandong Province, Jinan

Objective

To investigate the current nursing practice environment in Jinan, Shandong Province, and to identify the factors influencing the practice environment.

Methods

This study is a cross-sectional study for nurses. From October to December 2022, using the clustering and stratified sampling methods, 2426 nurses from internal Medicine, Surgery, Obstetrics and Gynecology, Outpatient Department and Intensive Care Department of the Provincial Hospital of Shandong Medical University were selected and then investigated and analyzed using the revised Nurse Practice Environment Assessment Scale.

Results

The overall mean evaluation of the practice environment scored 75.13±19.87, with a minimum value of 59.74 and a maximum value of 95.82. The items with higher scores were "the hospital has systematic training for new nurses", "the work system is perfect", and "the hospital can provide continuing education for nurses in accordance with the needs of their positions". The items with lower scores were "nurses enjoy legal benefits", "nurses have the opportunity to participate in hospital management decisions", and "nurses have the opportunity to participate in hospital internal management". The results of the multiple linear regression analysis of the factors influencing nurses' practice environment showed that gender, education, position, and years of work were independent influences on nurses' practice environment scores (p < 0.05), and they explained 48.127% of the variation in the total scores of the nurses' practice environment scale. The estimated values (β) of sex, education, cheif nurse, nurses staff, work experience (year), and whether the only child variables were 3.141, 3.237, 2.713, 5.471, 2.074 and 0.732, respectively.

Conclusion

The nurse practice environment still needs to be improved, mainly in terms of hospital management participation, human resource allocation and salary distribution system.

The relationship between staffing and adverse events in Washington State hospitals: a cross-sectional study using linked hospital data

Objective

To quantify the relationship between staffing characteristics and patient outcomes in acute care hospitals in Washington state.

Methods

Retrospective cross-sectional time-series study of linked data from six sources on staffing and outcomes for Washington state hospitals. Key stakeholders provided input on data sources, measures, and outcomes in a four-phase participatory process. After data cleaning and linkage, we used a random effects Poisson regression model to examine the relationship between staffing levels or characteristics and adverse outcomes.

Results

The study included 263 hospital-years from 80 distinct hospitals, with 162 hospital-years from general acute care hospitals (n=46) and 101 hospital-years from critical access hospitals (n=34). In general acute care hospitals, a higher ratio of patients to care team staff is associated with a higher number of adverse events (adjusted RR, 1.36 per one SD increase; 95% UI 1.13-1.63), and a lower proportion of RNs on the care team staff is likely associated with a higher number of adverse events (adjusted RR, 1.16 per one SD increase; 95% UI, 0.97-1.39). In critical access hospitals, a lower proportion of RNs on the care team is associated with a higher number of adverse events (adjusted RR, 3.28 per one SD increase; 95% UI, 1.20-7.75). A counterfactual analysis indicated that if all general acute care hospitals had no more than the median staffing ratio of 1.2 patient hours per staff hour, the number of adverse events would be reduced by 10% (95% UI 2.7-16.8).

Conclusion

RN staffing is an indisputable component of safe, high quality patient care, and other factors such as availability of care team staff, hospital features, and patient characteristics also impact patient outcomes. This study highlights the utility of merging diverse data sources to provide a comprehensive analysis of the relationships between staffing and patient outcomes.

Stakeholder perspectives on factors influencing acute care patient outcomes: A qualitative approach to model refinement

Background

Health systems have long been interested in the best practices for staffing in the acute care setting. Studies on staffing often focus on registered nurses and nurse-to-patient staffing ratios. There are fewer studies on the relationship between interprofessional team members or contextual factors such as hospital and community characteristics and patient outcomes. This qualitative study aimed to refine a causal model by soliciting hospital stakeholder feedback on staffing and patient outcomes.

Methods

We conducted a qualitative study using semi-structured interviews and thematic analysis to understand hospital stakeholder perspectives and their experiences of factors that affect acute care inpatient outcomes. Interviews were conducted in 2022 with 38 hospital stakeholders representing 19 hospitals across Washington State.

Results

Findings support a model of characteristics impacting patient outcomes to include the complex and interconnected relationships between community, hospital, patient, and staffing characteristics. Within the model, patient characteristics are nested into hospital characteristics, and in turn these were nested within community characteristics to highlight the importance of setting and context when evaluating outcomes. Together, these factors influenced both staff characteristics and patient outcomes, while these two categories also share a direct relationship.

Conclusion

Findings can be applied to hospitals and health systems across the globe to examine how external factors such as community resource availability impact care delivery. Future research should expand on this work with specific attention to how staffing changes and interprofessional team composition can improve patient outcomes.

Emergency Department Volume, Severity, and Crowding Since the Onset of the Coronavirus Disease 2019 Pandemic

STUDY OBJECTIVE

We describe emergency department (ED) visit volume, illness severity, and crowding metrics from the onset of the coronavirus disease 2019 (COVID-19) pandemic through mid-2022.

METHODS

We tabulated monthly data from 14 million ED visits on ED volumes and measures of illness severity and crowding from March 2020 through August 2022 compared with the same months in 2019 in 111 EDs staffed by a national ED practice group in 18 states.

RESULTS

Average monthly ED volumes fell in the early pandemic, partially recovered in 2022, but remained below 2019 levels (915 per ED in 2019 to 826.6 in 2022 for admitted patients; 3,026.9 to 2,478.5 for discharged patients). The proportion of visits assessed as critical care increased from 7.9% in 2019 to 11.0% in 2022, whereas the number of visits decreased (318,802 to 264,350). Visits billed as 99285 (the highest-acuity Evaluation and Management code for noncritical care visits) increased from 35.4% of visits in 2019 to 40.0% in 2022, whereas the number of visits decreased (1,434,454 to 952,422). Median and median of 90th percentile length of stay for admitted patients rose 32% (5.2 to 6.9 hours) and 47% (11.7 to 17.4 hours) in 2022 versus 2019. Patients leaving without treatment rose 86% (2.9% to 5.4%). For admitted psychiatric patients, the 90th percentile length of stay increased from 20 hours to more than 1 day.

CONCLUSION

ED visit volumes fell early in the pandemic and have only partly recovered. Despite lower volumes, ED crowding has increased. This issue is magnified in psychiatric patients.

Motivations and expectations of generation Z nursing students: A post-pandemic career choice qualitative analysis

BACKGROUND

The global nursing shortage is a growing concern so recruiting and retaining Generation Z (Gen Z) students is vital to the sustainability of the profession.

PURPOSE

To explore the perceptions and expectations of first-year nursing students regarding the nursing profession, its working conditions, and how these factors influenced their career choices.

METHOD

Descriptive qualitative research design, employing an interpretive research approach and content analysis conducted following Graneheim & Lundman's method. Our study involved 105 Generation Z nursing degree students enrolled in first year at the Mar Nursing School in Barcelona, Spain in 2021. Data collection included voluntary written narratives about their career choice and questionnaires of demographic information and their healthcare experiences.

RESULTS

It became evident that Generation Z students' perceptions and expectations of nursing don't align with the actual professional experience. This mismatch could lead to disillusionment and attrition among these students.

CONCLUSIONS

Several factors (economic, aspirational, perception of nursing during the COVID-19, or gender) influence new students' career choice. These factors shape their expectations and often do not match actual working conditions in nursing. Educational institutions must prepare students by transferring cross-cutting competencies to effectively meet these challenges and avoid potential dropout from the profession.

How local, first-line nurse leaders can positively influence nurse intent to stay and retention: A realist review

AIMS AND OBJECTIVES

To explore evidence on how local nurse leaders can positively influence nurse retention.

BACKGROUND

Nurse turnover and retention is a wicked problem with multiple interrelated factors and no one solution. Local nurse leadership has the potential to positively influence nurse intent to stay directly or via various factors.

DESIGN

A realist review.

METHODS

Having designed a search strategy based on a tentive programme theory, 1386 initial hits in three databases were screened and reduced to 48 research articles published between 2010-2021. The articles' content were coded for findings that supported, refined or contradicted four ContextMechanismOutcome configurations.

RESULTS

Sufficient evidence was found to support four guiding lights encouraging local nurse leaders to: (1) foster relational connectedness; (2) enable professional practice autonomy; (3) cultivate healthful workplace cultures; (4) support professional growth and development. Mutuality and reciprocity is also key if leaders themselves are to experience wellbeing and growth.

CONCLUSIONS

Person-centred, transformational and resonant local nurse leaders can positively influence nurse intent to stay within the workplace or organisation.

REPORTING METHOD

Conform JCN guideline 'What to cover in the main tekst by article type' for reviews.

PATIENT OR PUBLIC CONTRIBUTION

No Patient or Public Contribution.

A Contemporary Model for Improving RN Job Outcomes

The pandemic has highlighted three critical nursing workforce issues: turnover, wellbeing, and equity. A comprehensive framework is needed to understand the interactions between these concepts. This paper proposes a model that allows for more inclusive understanding of professional outcomes for RNs, with attention not just to job outcomes, but also to equity for underrepresented groups in the workforce and individual wellbeing. The model highlights the importance of systems and societal elements, contextual elements, and individual responses to the dynamic conditions of work and life, and can be used to advance research and practice to create effective retention and support strategies.

Closing the Workforce Staffing Chasm by Breaking Boundaries: Innovative Partnerships and Strategies Between Recruitment and Nursing

As hospitals are experiencing a nursing shortage, nursing leaders must build innovative partnerships and strategies between nursing and recruitment to close the workforce gap. One large health care system was experiencing a high vacancy rate. To improve recruitment and retention efforts, nursing leaders partnered with the recruitment department and other key stakeholders to develop strategies. Together, they designed a candidate-centric recruiting and hiring process, designed innovative recruitment campaigns including recruiting former employed nurses, recruitment of traveling nurses into employees, increased graduate nurse recruitment efforts, and implementation of a registered nurse (RN) Ambassador program. The team improved work process efficiency for recruiters and candidates. Retention efforts focused on engaging nurses in the work environment, decreasing nurse leader workload to allow a focus on staff relationships, and improving exit processes in an effort to retain the nurse. The actual vacancy rate was as high as 20.9% in July 2021 to 8% in September 2022, indicating the system is closing the vacancy rate and nearing the goal of 5%.

Research Topic Trends on Turnover Intention among Korean Registered Nurses: An Analysis Using Topic Modeling

This study aimed to explore research topic trends on turnover intention among Korean hospital nurses by analyzing the keywords and topics of related articles. Methods: This text-mining study collected, processed, and analyzed text data from 390 nursing articles published between 1 January 2010 and 30 June 2021 that were collected via search engines. The collected unstructured text data were preprocessed, and the NetMiner program was used to perform keyword analysis and topic modeling. Results: The word with the highest degree centrality was "job satisfaction", the word with the highest betweenness centrality was "job satisfaction", and the word with the highest closeness centrality and frequency was "job stress". The top 10 keywords in both the frequency analysis and the 3 centrality analyses included "job stress", "burnout", "organizational commitment", "emotional labor", "job", and "job embeddedness". The 676 preprocessed key words were categorized into five topics: "job", "burnout", "workplace bullying", "job stress", and "emotional labor". Since many individual-level factors have already been thoroughly investigated, future research should concentrate on enabling successful organizational interventions that extend beyond the microsystem.