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

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.

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.

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.

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.

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.

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.