An empirical analysis of nurse retention: what keeps RNs in nursing?

Key elements to support primary healthcare nurses to thrive at work: A mixed-methods sequential explanatory study

AIM

Develop evidence-based recommendations for managers to support primary healthcare nurses to thrive at work.

DESIGN

A mixed-methods sequential explanatory design.

METHODS

National data were collected in 2020 via an e-survey based on a meta-analysis of antecedents of thriving from 213 primary healthcare nurses across New Zealand. Structural equation modelling analysis identified the key factors supporting primary healthcare nurses to thrive. This informed a second open-ended e-survey in 2022 of 19 nurses from one primary healthcare organization. The thematic analysis provided recommendations for improving management strategies to support thriving primary healthcare nurses.

RESULTS

The vitality component of thriving significantly reduced burnout and intention to leave organization and profession. In contrast, the learning component of thriving had a significant positive effect on burnout. The key factors that support thriving at work are empowering leadership and perceived organizational supports (decreases burnout and intention to leave organization and profession through enhanced vitality). Recommendations for improving thriving were made in eight key areas: communication, effective management, professional development, scope of practice, autonomy, effective orientation, reward and work-life balance.

CONCLUSIONS

Vitality is important in reducing burnout and turnover intentions. While learning was identified as increasing burnout, professional development and training for managers were identified as essential. Hence, the vitality dimension of the thriving at work construct should be studied at the dimension level, but more research is needed into the impact of learning on thriving over time. Primary healthcare nurses have identified that empowering leadership and perceived organizational support are critical factors in supporting them to thrive, and they provide specific recommendations for managers to improve these factors in the clinical setting.

NO PATIENT OR PUBLIC CONTRIBUTION

This study collected data from Registered Nurses only.

WHAT IS ALREADY KNOWN

A plethora of existing research focuses on resilience in nurses rather than thriving at work. Enabling employees to thrive at work contributes to improved well-being and sustainable organizational performance.

WHAT THIS PAPER ADDS

Empowering leadership and perceived organizational support are the key factors that support primary healthcare nurses to thrive at work. The vitality dimension of the thriving at work construct should be studied at the dimension level, and further research is needed into the impact of learning on thriving over time. Primary healthcare nurses recommend that managers focus on improving communication, management efficiency, professional development, scope of practice, autonomy, orientation, reward and work-life balance.

Reducing Healthcare Employees' Burnout through Ethical Leadership: The Role of Altruism and Motivation

Globally, employee burnout (EBO) is a black swan in healthcare management. Previous organizational management literature shows that EBO was often misunderstood by assuming it as a personal issue. However, the new definition by the World Health Organization (WHO) clearly indicates that EBO is an occupational phenomenon that places responsibility on organizations to manage it. Although recent evidence suggests ethical leadership (ELP) style may be important to mitigate EBO, shockingly, such relationships were not tested in healthcare systems, especially in low- and middle-income countries. Filling this knowledge gap in the existing body of knowledge, this study aimed to investigate the ELP-EBO relationship. To explain the underlying mechanism of how ELP reduces EBO, this study included two psychological factors as a mediator and a moderator: altruism (AL) and intrinsic motivation (IM). The data were obtained from hospital employees via a self-administered questionnaire (n = 289, paper-pencil method). A hypothetical framework was designed and tested for empirical validation through structural equation modeling (SEM). Empirical evidence confirmed that ELP reduces the risk of burnout among hospital employees, and AL mediates this relationship. The results also confirmed the conditional indirect role of IM in the above proposed mediated relationship. This study's outcomes can help hospital administration deal with EBO's epidemic in an ELP framework. Other, different implications have also been discussed in detail.

Female Sex and Living in a Large City Moderate the Relationships between Nursing Students' Stress Level, Perception of Their Studies, and Intention to Practice Professionally: A Cross-Sectional Study

One way to increase nursing retention is to expand the number of nursing education programs; however, a more cost-effective initial step would be to ensure that each graduate will start a professional career. Nursing studies expose students to prolonged and uncontrolled stress that negatively affects their professional identity and health. Two hundred and fifty-four nursing students participated in this study. The data were obtained using the Perceived Stress Scale (PSS-10), a proprietary questionnaire on the students’ perception of their study, intention to practice in the future, and other metrics. Among our sample, a dozen students were unsure that they would enter the nursing profession. Stress levels in women were higher than in men. Respondents indicated that they were afraid of the return of the pandemic. This analysis was significant among people living in large cities. Based on our findings, five themes should be prioritised: favourable study environment and adequate competencies (including implementation of stress management techniques, especially among women and students living and studying in large cities), appropriate working hours, quality of practical classes, and quality of personal protective equipment.

Impact of COVID-19 on Intensive Care Unit Nurse Duty of Care and Professional Roles: A Qualitative Content Analysis

Background

Nurse duty of care, the balance between nursing occupational obligations to provide care, the personal costs for providing such care, and the reward for providing care, has been significantly altered by the COVID-19 pandemic. ICU nurses are increasingly burdened with higher personal costs to fulfill their jobs, but little additional reward for continuing to provide care.

Objectives

The purpose of this study was to examine the impact of the COVID-19 pandemic on the duty of care balance among ICU nurses who manage COVID-19 patients.

Design

This was a descriptive qualitative study using semi-structured interviews.

Methods

Nurses were recruited for a parent study on ICU nursing during COVID-19; this is a secondary analysis of the interviews that took place during the parent study. Content analysis was utilized to identify themes from interview transcripts.

Results

Thirteen nurses participated in interviews. Nurses reported betrayal at perceived breeches in their duty of care agreement by their employers, the general public, and national health authorities. They described alterations to previous standards of care such as significantly increased workloads, worsening understaffing, and changes to patient care expectations that were implemented for reasons other than betterment of patient care. Nurses reported they felt a moral obligation to provide care, however they experienced disempowerment and burnout that affected them both in and out of the workplace.

Conclusion

The COVID-19 pandemic has affected several aspects of the duty of care balance, resulting in a duty of care balance that is inequitable to nurses. Imbalance in the effort, risks, and rewards for nursing professionals may contribute to nurse burnout.

Relevance to Clinical Practice

This research highlights the need for healthcare administrators to consider resource allocation, nurse appreciation, and commensurate compensation for professional nurses.

Turnover Intention Among Nurses in Nurse Managers, Directors, and Executives: Developing a Tool for Measuring Environmental Factors

Background and Purpose

Turnover among nurse managers, directors, and executives is associated with staff nurse retention and patient outcomes. The purpose of this article is to describe the development of an instrument to evaluate factors associated with intent to leave among these leaders within acute care facilities.

Methods

The Nurse Leader Environment Support Survey (NLESS) was developed and evaluated using exploratory factor analysis and reliability testing (Cronbach's α). Data was obtained as part of a large nationwide electronic survey (N = 1,903).

Results

Factors converged into three major themes (organizational culture, professional vulnerability, and workplace relationships) which were consistent across all three leadership groups. Factor subscales exhibited Cronbach's α > .7.

Conclusions

The NLESS is a useful tool in comparing reasons for turnover among nursing leadership groups. Future refinement may prove useful in identifying and clarifying foundational causes of turnover.

The importance of organizational commitment in rural nurses' intent to leave

Aims

To examine determinants of intention to leave a nursing position in rural and remote areas within the next year, for Registered Nurses or Nurse Practitioners (RNs/NPs) and Licensed Practical Nurses (LPNs).

Design

A pan‐Canadian cross‐sectional survey.

Methods

The Nursing Practice in Rural and Remote Canada II survey (2014–2015) used stratified, systematic sampling and obtained two samples of questionnaire responses on intent to leave from 1,932 RNs/NPs and 1,133 LPNs. Separate logistic regression analyses were conducted for RNs/NPs and LPNs.

Results

For RNs/NPs, 19.8% of the variance on intent to leave was explained by 11 variables; and for LPNs, 16.9% of the variance was explained by seven variables. Organizational commitment was the only variable associated with intent to leave for both RNs/NPs and LPNs.

Conclusions

Enhancement of organizational commitment is important in reducing intent to leave and turnover. Since most variables associated with intent to leave differ between RNs/NPs and LPNs, the distinction of nurse type is critical for the development of rural‐specific turnover reduction strategies. Comparison of determinants of intent to leave in the current RNs/NPs analysis with the first pan‐Canadian study of rural and remote nurses (2001–2002) showed similarity of issues for RNs/NPs over time, suggesting that some issues addressing turnover remain unresolved.

Impact

The geographic maldistribution of nurses requires focused attention on nurses' intent to leave. This research shows that healthcare organizations would do well to develop policies targeting specific variables associated with intent to leave for each type of nurse in the rural and remote context. Practical strategies could include specific continuing education initiatives, tailored mentoring programs, and the creation of career pathways for nurses in rural and remote settings. They would also include place‐based actions designed to enhance nurses' integration with their communities and which would be planned together with communities and nurses themselves.

Effect of preventive care interventions on pressure ulcer rates in a national sample of rural and urban nursing units: Longitudinal associations over 4 years

BACKGROUND

Pressure ulcer rates are persistently high despite years of research and practice policies focused on prevention. Prior research found crosssectional associations between care interventions, hospital and nursing unit characteristics and pressure ulcer rates. Whether these associations persist over time is unknown. Finally, comparisons of quality measures across rural and urban location have mixed findings.

OBJECTIVE

Our study examined effects of care interventions on unit-acquired pressure ulcer rates over 4 years controlling for community, hospital, and nursing unit characteristics in rural and urban locations.

DESIGN

Guided by contingency theory a longitudinal study was conducted to examine associations between context, staffing, care interventions, nurse outcomes, and pressure ulcer rates, using unit-level data from the National Database of Nursing Quality Indicators^Ⓡ 2010-2013 (16 quarters) augmented with data on rural classifications and case mix index. Ulcer rates were measured as percentage of patients with a nursing unit-acquired pressure ulcer. The three care interventions were unit-percentage of patients receiving skin assessment on admission, receiving risk assessment on admission, and receiving any risk assessment before the pressure ulcer. Nursing unit characteristics were RN staffing, education, and experience. Nurse outcomes were job satisfaction and intent-to-stay.

PARTICIPANTS

We included 5761 units (332 rural and 5429 urban) in 772 hospitals (89 rural and 683 urban) that reported ulcer rates in two or more quarters during the study period.

METHODS

Rural and urban units were examined separately using multilevel binomial regression in which within-unit changes in pressure ulcer rates were related to the within-unit changes in the explanatory variables, controlling for region, hospital size, unit type, case mix index, and percentage of patients at risk for pressure ulcers.

RESULTS

An increase in the three care interventions, RN skill mix, and the two nurse outcomes were associated with a decrease in unit-acquired pressure ulcers. For example, in rural units a 10% increase in unit-percentage of any risk assessment and in urban units a 10% increase in skin assessment on admission were associated with a 21% and 5% decrease in the odds of developing an ulcer. A 10% increase in RN skill mix was associated with 17-18% and 5-6% decrease in ulcer rates in rural and urban units respectively.

CONCLUSION

Hospitals aiming to improve pressure ulcer prevention should focus on organizational structures that support improved nurses work environments and workflow that will enhance nursing care interventions. Future studies should include both contextual and patient characteristics along with care interventions.

A cross-sectional study investigating the associations of person-organisation and person-group fit with staff outcomes in mental healthcare

OBJECTIVES

Organisational and workplace cultures are fundamental determinants of health systems performance; through better understanding of the dimensions of culture there is the potential to influence them, and subsequently improve safety and quality of care, as well as the experiences of both patients and staff. One promising conceptual framework for studying culture in healthcare is person-environment (P-E) fit. Comprising person-organisational (P-O) and person-group (P-G) components, P-E fit is defined as the extent to which individuals are compatible with their work environment. The aim of this study was to examine the associations of P-O and P-G fit with staff outcomes in mental healthcare.

SETTING AND PARTICIPANTS

Participants (n=213) were staff and volunteers at 31 primary mental health facilities across six states of Australia.

PRIMARY AND SECONDARY OUTCOME MEASURES

Staff outcomes, comprising burnout (depersonalisation and emotional exhaustion), job satisfaction and work stress.

DESIGN

A multidimensional survey tool was used to measure P-O and P-G fit, and staff outcomes. Multiple regression analyses were used to test the associations between fit and outcome measures.

RESULTS

The regression analyses indicated that, based on a Bonferroni adjusted alpha value of α=00417, P-O fit accounted for 36.6% of the variability in satisfaction (F=8.951, p≤0.001); 27.7% in emotional exhaustion (F=6.766, p≤0.001); 32.8% in depersonalisation (F=8.646, p≤0.001); and 23.5% in work stress (F=5.439, p≤0.001). The P-G fit results were less conclusive, with P-G fit accounting for 15.8% of the variability in satisfaction (F=4.184, p≤0.001); 10.0% in emotional exhaustion (F=2.488, p=0.014); 28.6% in depersonalisation (F=8.945, p≤0.001); and 10.4% in work stress (F=2.590, p=0.032). There was no statistically significant increase in the variability accounted for when the interaction term of P-O and P-G fit was added to the regression.

CONCLUSIONS

The findings highlight that staff's perception of their workplace and organisational culture can have implications for staff well-being.

Concept analysis of nurse retention

Nurse retention is widely acknowledged as a crucial international workforce issue, yet the concept remains ambiguous. This study focuses on a concept analysis in an effort to clarify the attributes of nurse retention, including its antecedents and consequences. The Walker and Avant approach was applied to analyze the concept of nurse retention. Four key attributes of nurse retention were identified in the analysis, specifically motivation, intention, and individual decision; strategy and intervention; geographic context; and attachment to work. Antecedents of nurse retention included the healthcare system at the macro level, the health care facility, health personnel, and living conditions. Retention has consequences for individual nurses, the healthcare organization, and the overall health system. Our concept analysis provides clarification to better understand nurse retention along with its implications for the healthcare workforce. The analysis further emphasizes the importance of retention as a comprehensive priority issue for human resources when recruiting and maintaining the nursing workforce internationally.

How people fit in at work: systematic review of the association between person-organisation and person-group fit with staff outcomes in healthcare

OBJECTIVES

People interact with their work environment through being, to a greater or lesser extent, compatible with aspects of their setting. This interaction between person and environment is particularly relevant in healthcare settings where compatibility affects not only the healthcare professionals, but also potentially the patient. One way to examine this association is to investigate person-organisation (P-O) fit and person-group (P-G) fit. This systematic review aimed to identify and synthesise knowledge on both P-O fit and P-G fit in healthcare to determine their association with staff outcomes. It was hypothesised that there would be a positive relationship between fit and staff outcomes, such that the experience of compatibility and 'fitting in' would be associated with better staff outcomes.

DESIGN

A systematic review was conducted based on an extensive search strategy guided by Preferred Reporting Items for Systematic review and Meta-Analyses to identify relevant literature.

DATA SOURCES

CINAHL Complete, EMBASE, Ovid MEDLINE, PsycINFO and Scopus.

ELIGIBILITY CRITERIA

Articles were included if they were empirical studies, published in peer-reviewed journals in English language, set in a healthcare context and addressed the association that staff outcomes have with P-O and/or P-G fit.

DATA EXTRACTION AND SYNTHESIS

Included texts were examined for study characteristics, fit constructs examined and types of staff outcomes assessed. The Quality Assessment Tool was used to assess risk of bias.

RESULTS

Twenty-eight articles were included in the review. Of these, 96.4% (27/28) reported a significant, positive association between perception of fit and staff outcomes in healthcare contexts, such that a sense of compatibility had various positive implications for staff, including job satisfaction and retention.

CONCLUSION

Although the results, as with all systematic reviews, are prone to bias and definitional ambiguity, they are still informative. Generally, the evidence suggests an association between employees' perceived compatibility with the workplace or organisation and a variety of staff outcomes in healthcare settings.

Job satisfaction, work stress, and turnover intentions among rural health workers: a cross-sectional study in 11 western provinces of China

BACKGROUND

Health workforce turnover remains a global concern, particularly in rural and remote areas. Western rural areas are the least developed in China, where it faces the serious challenge on the rural health worker (RHW) management. This study aimed to investigate job satisfaction, work stress, and turnover intentions of RHWs, and to explore prominent factors associated with turnover intentions of RHWs in rural western China.

METHODS

From June to September 2013, based on a three-stage random sampling method, a cross-sectional survey was conducted among RHWs in 11 western provinces in China. A brief, structured questionnaire filled in by RHWs was used for data collection. A total of 5046 RHWs participated in the study. The response rate was approximately 93.1%. Exploratory factor analyses, Pearson's chi-squared tests, one-way ANOVA, binary logistic regression analyses, and mediating effect tests were performed for data analyses.

RESULTS

Approximately 29.1% of the 5046 RHWs indicated turnover intentions. Most of the RHWs disclosed low educational levels, income levels, and professional technical titles. The RHWs expressed slight job satisfaction (mean 3.20) and moderate work stress (mean 3.22). Age, income, medical institution, and job satisfaction (i.e., organizational management, reward, and occupation satisfaction) were significant predictors of the RHWs' turnover intentions. The RHWs, who were younger (less than 41 years), receiving an income of $326.8-$490.1 per month, working in township hospitals, and having low job satisfaction, were more likely to have turnover intentions. Work stress had an indirect and positive effect on RHWs' turnover intentions. Job satisfaction weakened the positive effect of work stress on turnover intentions of RHWs by playing a total mediating role. Reward satisfaction was the strongest mediator.

CONCLUSIONS

The turnover intentions of RHWs in western China are significantly associated with job satisfaction, work stress, age, income, and medical institution. Appropriate strategies should be implemented to improve RHWs' job satisfaction and reduce their work stress. Meanwhile, providing more attractive wages and non-monetary support, improving working conditions, etc. could be effective to reduction in RHWs' turnover intentions.

Nursing work environment, value congruence and their relationships with nurses' work outcomes

AIMS

To explore the relationships between work environment, value congruence and nurses' work outcomes; as well as to test the moderating effects of value congruence.

BACKGROUND

A poor nursing work environment in most of mainland China has negatively influenced nurses' job satisfaction, burnout and turnover intention. New insights such as improving nurses' value congruence should be proposed to better foster nurses.

METHODS

Cross-sectional data were selected from the Chinese Nurses' Environment of Work Status study. In total, 19149 valid samples were collected. Hierarchical regression analyses and simple slope analyses were performed.

RESULTS

The correlation coefficients of the variables were all significant (p < .01) and in the expected direction. Value congruence moderated the relationship between nursing work environment and burnout (emotional exhaustion: β = 0.106, p < .01; depersonalization: β = 0.111, p < .01).

CONCLUSIONS

Nursing work environment and value congruence were positively related to job satisfaction, and negatively related to burnout and turnover intention. The adverse impact of poor work environment on nurses' burnout can be buffered if nurses' value congruence is compatible with that of the organisation.

IMPLICATIONS FOR NURSING MANAGEMENT

Except for improving the organisational characteristics, value congruence is a useful concept that managers can leverage to improve positive outcomes for both the organisation and its nurses.

How to keep registered nurses working in New Zealand even as economic conditions improve

BACKGROUND

Many registered nurses (RNs) increased their participation in the New Zealand health workforce during the Global Financial Crisis (GFC), resulting in low vacancy rates. However, based on the documented impact of improving economies, a mean RN age of about 50, and just-agreed substantive increases in RN pay rates, it is likely that many will soon leave or reduce the hours they work. This study aims to investigate whether improved financial security will encourage RNs to leave or reduce their work commitment and to identify the factors that influence such intentions.

METHODS

An exploratory study using a cross-sectional survey design. Data were collected in 2014-2015 via an e-survey of 2,910 RNs in New Zealand. Data were analysed by regression.

RESULTS

We found that due to "burnout" and low "work engagement", both of which are strongly affected by workload and work-life interference, 22.6% of the RNs surveyed plan to leave work altogether and a further 32% plan to reduce their workforce participation when their financial situations improve.

CONCLUSIONS

The findings justify the urgent cooperative development, implementation and evaluation of a comprehensive suite of RN 'retention' measures involving national nursing organisations, the RN regulator and health system employers and funders.

The Cost of Caring: An Exploration of Compassion Fatigue, Compassion Satisfaction, and Job Satisfaction in Pediatric Nurses

PURPOSE

The purpose of this study was to describe levels of compassion satisfaction, compassion fatigue, and job satisfaction among pediatric nurses in the United States and determine if there was a relationship among these constructs.

DESIGN AND METHODS

All members Society of Pediatric Nurses were sent an electronic invitation to participate, and those who consented received three measures; a demographic questionnaire, the Job Satisfaction Survey (JSS) and the Professional Quality of Life (ProQOL) measure.

RESULTS

Three hundred eighteen (10.6%) of members of the Society of Pediatric Nurses participated in the study: Over three quarters (245, 76%) of the sample had another career before nursing. The sample's mean job satisfaction level was 149.8 (SD=29.74), which was significantly higher than published reported means for nurses. Bivariate analyses revealed a significant relationship between gender and the compassion satisfaction, in that women were more likely to evidence compassion satisfaction than men (t=1.967, p=.05, df=298). No other significant relationships were found.

CONCLUSIONS

The majority of nurses had high levels of compassion satisfaction and job satisfaction; further, female gender was associated with higher levels of compassion satisfaction.

PRACTICE IMPLICATIONS

This current study had a very high response from second-career nurses (n=245, 76.8%) and overall, the sample had higher levels of compassion satisfaction. It is possible that second career nurses are better equipped in some way that helps them mediate negative responses of caring as a pediatric nurse and future research should explore this. Due to the significant financial costs to institutions of having nurses who have low levels of job satisfaction and high levels on compassion fatigue, it is imperative for hospital administrators to develop infrastructures to support employees.

Wage Inequity: Within-Market Comparative Analysis of Salary for Public Health Nurses and Hospital Nurses

The labor market perspective focuses on supply and demand for registered nurses (RNs) as employees. This perspective contrasts with beliefs in the public health sector that RNs working in local health departments (LHD) as public health nurses (PHNs) accept lower wages because of factors other than market demand. This study sought to describe the extent to which hourly wages of RNs working in LHDs are competitive with hospital RN wages within the same county market. A repeated measures survey design was used in collecting 2010 and 2014 data. The unit of analysis was the county, as an RN labor market for LHDs and hospitals. Survey questions captured factors common in human resources benefits and wage packages, such as differential pay, hourly rate pay based on years of experience, components of benefit packages (eg, sick and vacation leave), and reimbursement for education. Within each county, the LHD and all hospitals constituted a "market," yielding a potential 12 markets in our study sample. Human resources representatives from each of the 12 LHDs and from all hospitals within those 12 counties were invited to participate. We conducted comparisons with survey data using t test of mean differences on mean RN wages across years of experience. On average, LHDs paid significantly less than hospitals in their markets, at all levels of RN experience, and this gap increased with RN experience in the sample markets. Salary compression was evident in 2010 and worsened for PHNs in 2014, when compared with hospital RNs. In 2014, 100% of the sample LHDs offered reimbursements for continuing education for PHNs compared with 89% of hospitals providing this benefit. This study contributes to our understanding of the human resources challenges faced by LHDs and provides evidence elucidating resources issues that need to be addressed in order to improve recruitment and retention of PHNs.

Factors predicting Registered Nurses' intentions to leave their organization and profession: A job demands-resources framework

AIMS

To develop a comprehensive model of nursing turnover intention by examining the effects of job demands, job resources, personal demands and personal resources on burnout and work engagement and subsequently on the intention to leave the organization and profession.

BACKGROUND

The ageing population and a growing prevalence of multimorbidity are placing increasing strain on an ageing nursing workforce. Solutions that address the anticipated nursing shortage should focus on reducing burnout and enhancing the engagement of Registered Nurses (RNs) to improve retention.

DESIGN

A cross-sectional survey design.

METHOD

Data were collected in 2014-2015 via an e-survey from 2,876 RNs working in New Zealand. Data were analysed with structural equation modelling.

RESULTS

Higher engagement results in lower intention to leave the organization and profession. Burnout has significant effects on intentions to leave through lower engagement. While most of the demands and resources' variables (except professional development) have effects on intentions to leave, greater workload and greater work-life interference result in higher burnout and are the strongest predictors of intentions to leave. Greater emotional demands (challenges) and greater self-efficacy also have strong effects in lowering intentions to leave through higher engagement.

CONCLUSIONS

Employee burnout and work engagement play an important role in transmitting the impacts of job demands, job resources, personal demands and personal resources into RN intention to leave the organization and profession. Work-life interference and high workloads are major threats to nursing retention while challenge demands and higher levels of self-efficacy support better retention.