Shortage of Nurses - Turnover and Retention
In the history of nursing profession the crisis of nurses’ turnover remains a serious problem.
Nurse’s job satisfaction and retention are complex issues. Nurses are considered as the core of care and vital role in health care system. According to Institute for Health care Improvement (IHI), hundreds of hospitals in USA have struggled against nursing shortage that first took place during1990s. This shortage has been predominantly horrific in Carolina state of USA, and even worse in the countryside. Dynamic health workforces are current issue for leadership and management in nursing. Nurse Leaders and managers have the responsibility to manage limited resources, including human resources related to nursing service.
The turnover is caused by many factors including worker’s value systems and work environments. Nurse’s job satisfaction and retention strategies are areas that have not been studied broadly. To minimize the turnover is a priority for nurse administrators who face continuously this problem at their workplace. This paper will focus on description, analysis of issue through literature review, management along with leadership theory and recommendations to increase employee’s retention.
Description of issue
Nishtar Hospital Multan (NHM) is 1300 bedded, public, tertiary care mega hospital of South Punjab. It came into existence in 1954, and provides health care service to south-central Punjab as well as some part of Bulochistan. Hospital management has been facing hardship for last many years due to very high turnover rate 40% of nurses, during 2002 to 2007, 243 nurses were recruited, out of them 98 quitted their job (Telephonic information by Deputy Chief Nursing Superintendent, NHM, March 25, 2008).
Each unit of hospital consists of 50-60 patients, in case of emergency this number could be higher. The minimum nurse patient ratio in general ward is 1:30 that is very critical. Since 1998 Government of Punjab, Pakistan has been recruiting employees through contract policy. The situation is deteriorating day by day. The shortage of nurses is continuous problem by turnover of nurses at NHM.
Definition of Turnover
Huber, (2006) defines turnover as “the loss of an employee due to transfer, termination, or resignation” (, p.626). similarly Mrayyan ,( 2005) adds that “ the number of resignation or termination divided by the average of direct or indirect care of registered nurses full-time equivalent position for the same year” (p.42.).Moreover Sullivan& Decker (2004), declare that term turnover means when number of staff vacate a position. The employees choose to leave voluntarily. It is also defined as a situation in which employee quit job weather it is dysfunctional or functional.
Analysis of issue through literature
Literature review on nursing turnover guides about problems, and helps nurse leaders to minimize nursing shortage. There are several factors which could contribute for nursing turnover. The research- based literature illustrates the reasons why nurses quit their job willingly or against their will. According to The Health Department, Government of Punjab Contract Policy, the employees are not government servants. Their services are liable to be terminated at any time. They are less benefited as compare to government employees. For instance there is no opportunity for nurses to get deputation for higher education, study loan from the organization.
In Pakistan low salary is a hurdle for nurses to get advanced professional education at their own, limited chances for professional development. Similarly, they have less leave with pay as permanent nurses can avail 45 days leaves per year while contract employees have only 10 day per year. There are many young nurses who have the potentials and eagerness to enhance their education, but policy does not allow contract employees for deputation and scholarship. Prior to my joining at Aga Khan University I worked as nursing superintendent at NHM.
I contacted personally some of those nurses; the information that came to my knowledge is contract policy, work load, less facilities as compare to permanent workers, long night duty 12 hours, lack of support from seniors and non nursing duties. Huber (2006) believes that the nurses’ shortage is problem of every state and global trend. The reasons are comprehensive, that need to be observed separately. Factors are including nursing education that affect new graduates, and work environment to affect the ability of workplace which catch the attention of new nurse to preserve.
Likewise Taunton et al.1997,Sjoberg & Sverke 2000,as cited by Gardulf, Soderstrom, Orton, Eriksson, Arnetz, & Norstrom (2005),describe the association between an employee’s job satisfaction, working condition and the individual’s reason to leave. In the same way a study was conducted in Sweden by Halso-och sjukvardsrapport, 2000, 2001, as cited by Gardulf (2005) that revealed
Shortage of registered nurses and the high turnover rate. The number of beds in Sweden hospitals has decreased; outstanding to monetary problems and nursing shortage.10% of the positions of RNs at Heddinge University Hospital in Stockholm are vacant…. In 2002,201 positions for RNs out of 2000 were reported vacant and ward were being closed (p.330).
In USA, UK, Canada, different factors are identified for high turnover in nurses. Arnetz et al, 1995, Collin et al, 2000, Davidson, et al 1997 Wai Chi et al, 1998, cited by Gardulf et al (2005), believe that lack of career development, support from supervisors, frustration with internal management, less autonomy in workplace decision making. Moreover poor communication within organization, less time for complicated jobs, and lack of cooperation was also mentioned.
On the other hand, role ambiguity and low self-esteem are associated with organizational changes; hence 35% RNs were ready to give up their job. Another study was done by Fochsen, Sjogren, Josephson & Lagerstrom (2005), in Sweden, reveals the same factors that force the nurses to leave job. Low income, less professional growth, limited independence, unfriendly working environment; personal reasons and satisfaction are most significant factors to quit jobs.
In Pakistan study about job satisfaction and nurses’ intention to stay in private hospital by Jaffar (2003), report reveals that 24% nurses found dissatisfied. The reasons for dissatisfaction are work itself, working scheduling, and nurse-physician relationship. Further more Jalonen, Virtanen, Vahtera, (2006) speculate that in these days, many organizations avoid to hire permanent employees especially in public sectors due to monetary difficulty. During 1990, in USA, turnover rate was 6%-20%, while in Finland14%-18% .While in public and municipal sector, by the year 2001 it was 24%.
From the organizational point of view, employees’ commitment is important to resolve managerial problems, such as well- incorporated teams and people’s devotion. Less consideration to contract workers causes more turnovers. Job uncertainty is another perception that associated with provisional services. It can cause constant worry and frustration for extension of job. In contract employees there is a sense of isolation from regular employees, due to discrimination in rules and regulation like, no chance for profession growth and organizational recognition. Little work has been done for this sensitive issue. At NHM contract employees have the same feeling of deprivation.
Flanagan (2006) demonstrates an anticipated turnover model in her replicated study that relates turnover and job satisfaction. Other factors especially in psychiatric units, like prison environment, role uncertainty, type of client could be the factors for turnover. Andrew et al cited by Jasper (2005) states that “challenges of getting the right staff in the right place, whilst at nursing shortage. They present the results of a study exploring student opinions, of three initiatives to attract student nurses to local health care employment upon qualification” (p.280).According to Hadley 1990, Kinney 1994 cited by Rowe &Sherlock (2005), “verbal abuse; it is any statement to a victim that results in emotional damage, which limits her /his happiness and productivity” (p.24). Hospitals that have this problem face to increase in turnover of nurses. Occasionally it happens at NHM by senior nurses and doctors with serious consequences.
It is difficult to estimate the actual cost of nursing turnover. There are lots of operating cost required in hiring a new nurse ,for example, “recruiting, selection, orientation, on –the- job training and temporarily replacing a nurse who quit or fire”(Sullivan &Decker, 2004 p.303.).Nursing turnover is in the dire need to understand and control successfully. Moreover cost involves; advertisement, loss of experienced nurses, medication errors and impact on quality of patient care by novice nurses.
An estimate of “average replacement cost $92,442 for medical-surgical nurse while CCU nurse replacement cost $145,000 per annum” (Huber, 2006, p.638). In these days all over the world health care industry is facing serious problem regarding nurse’s shortage and turnover. Steers and Stone 1982 cited by Sullivan& Decker (2004), believe “the turnover involves real costs to the organization, turnover also can have undesirable effects on patients ...” (p.304).
Turnover at NHM is a leading point for other nurse who worked with departed nurses. It is quite possible that turnover could be an example for other nurses to detect a chance of better job in another place. Heavy burden on hospital budget for recruiting nurses as well as loosing experienced nurses. Use of temporary substitutes can cause difficulty as the workflow of the unit is disturbed. Turnover may cause the organization to delay to new projects. This situation creates high turnover especially in young nurses. Nurses are supposed to provide high quality and safe client care. This high turn over has a negative effect on patient care.
Integration of Transformational Leadership Theory
Many leadership theories are available to guide nurse leaders but I think transformational leadership theory could be appropriate to resolve the issue of nurses’ turnover. Burns, 1978, cited by Heidenthal, (2003) states that “it is a process in which leaders and followers raise one another to higher levels of motivation and morality” (p.172).Hein, (1998), defines that “Transformational leadership is moral leadership in that it has a transforming effect on both the leader and the follower, bringing out the best in each” (p72).This theory could be a guide line for nurse managers to explore the relationship between turnover and various factors.
Heidenthal, (2003) further suggests that transformational leaders stimulate others by performing in harmony with moral ethics, providing an image that reflects mutual standards and making others powerful to move ahead. Tichy and Devanna, 1986 as cited in Heidenthal, (2003) claim that “effective leaders identify themselves as change agents; are courageous; believe in people; are value driven; are life long learners; have the ability to deal with complexity, ambiguity, and uncertainty; and are visionaries” (p.173).At NHM the transformational theory could work effectively, here increased communication between administration and nurses might reduce the stress as it relates to workload demands.
IHI (2008) further suggested that they could review the literature on nurse staffing about the importance of rapid selecting of new nurse. A recruitment and reimbursement Committee, including a nurse leader could also be formed, to watch issues related to recruiting nurses, and to serve as an important link between nursing and the human resources department. In NHM, we have a very lethargic process to hire new nurses. Recruitment phase is as long as 3 to 4 month from the initial interview to selection and political interference. NHM management could focus on these points to fill vacant nursing positions, keen administrative support, and moving the process fast.
Against these conditions, during the past several years Institute of Health Improvement (2008), has worked to make stronger its nursing agenda and its ability to employ and preserve nurses. According to IHI persuasiveness could support the nurse in all phases at work. Nurse leaders can use the same methodology for nursing issues as to improve care for acute myocardial infarction patients to reduce medication errors and quality of care. Rely on evidence to find out what strategy can work, test ideas in small ways, and spread the successful strategies. Management of a NHM could follow the same strategy by giving priority to retain nurses. Welch (2005) believes that before hiring right people, check theirintegrity,intelligence and maturity.
IHI (2008) also believes that it is important to support local nursing schools, both economically and by providing training opportunities and faculty, In addition to make financial aid to both. This is a great recruiting opportunity, the student nurses are familiar with the system, and hospital management already knows them. NHM has a school of nursing, 250 student nurses are getting general nursing and midwifery training.
They are working there full time for four days a week that is an assistance to overcome the problem of shortage of nurses. The same strategy might be applied here at NHM. In addition, a nurse manager can serve as a link among the nursing schools and hospital to make sure that needs are being met for both organizations, and regularly obtain feedback about the working relationship through formal surveys and personal contact.
Huber (2006) emphasizes on retention policy of nurses by supporting and, encouraging job satisfaction and creating an atmosphere of regards and security in workplace. At NHM nurses feel insecure about their job and constantly work under stress. Permanent job could lessen the anxiety. Mrayyan, (2005) thinks that public hospital turnover rate is higher than private. As I have mentioned earlier that NHM is a public hospital, it seems true in my workplace. Mrayyan& Gardulf (2005) suggested that there is a dire need to take intervention to enhance nurses’ retention by, incentives, revision of salary, benefit package, less duty hours, child care facility at workplace.
In addition to these suggestions library and internet facility could be provided to learn and contribute in nursing research. If these facilities would be provided at NHM, I believe that turnover rate of nurses surely be declined. Rowe &Sherlock (2005) suggested that various techniques might be used to reduce verbal abuse like, involvement of nurses in policies and procedures, it will lessen exhaustion. Counseling of staff is necessary to boost up their morale. Nurse Managers could formulate strict policy for abuse and prompt report from victim and action accordingly. This harmony provides not only essential leadership support for unit nurses, but also educating, counseling, and role-modeling.
Fochsen, Sjogren, Josephson & Lagerstrom. (2005), in Sweden, warn the policy makers that low salaries as compare to workload reflects poor image of nursing. Same situation, nurses are facing at NHM. Furthermore Jalonen, Virtanen, Vahtera, (2006), find that change from provisional to permanent job could be effective to sustain organizational commitment. Continuity of care and care giver is essential. Flanagan (2006) reveals effective communication between management and staff; organizational support can reduce stress and job satisfaction.
At NHM nurse could have permanent job. Each nurse manager at her unit could watch and listen for problems and take appropriate action, by checking new nurses, making sure that she is available to them as a resource for information, guidance, and a friendly listener. Nurse Managers can observe new nurses to how they are doing. If they see a nurse is beginning to show signs of problem, like absenteeism, she could get involved in a silent way to see how she can help.
New nurses can turn to one another in small discussion groups. They might gossip about how to get out on time at the end of their shift, or how to control a helper who is older and more skilled. Some of these are questions they don’t feel comfortable asking their managers, nurse managers can guide and support them in their work. Nurse leaders can build a committee to focus on issues specific to the nursing personnel. They could meet regularly with the hospital management to present effort from the nurses, and take information, about nurse turnover and vacancy rates, from administration back to the units. I think with good information, in NHM, nurse managers on each unit would make good decisions about how to support nurses.
Government of Punjab health department could think over contract job policy and declare nursing as essential service like Pakistan army and police to appoint nurses on permanent job. IHI (2008) has analyzed that are the majority nurses expected to leave in their first few years of employment, and the threat is maximum at about 18 months. So nurse leaders could take some effective measures to retain by counseling a coaching and role modeling on each unit.
The nurses who are new to the profession need additional support. Adjustment in the practical world of nursing can be difficult; most new young nurses are deficient in life experience and professional. They are not only just novice to use technical skills, but also learning to deal with the emotional phase of being a nurse. Most important thing is how they can continue to develop as a nurse while maintaining an emotional control as human being.
I think to understand and help out these issues, the nurse leaders have to play a vital role to face these challenges. Kennedy cited by IHI. (2008) believes that nursing is a valuable work, but also demanding. Encouraging nurses is fine for nurses and for the institute, although most significantly for patients.
In conclusion Nurse Managers should analyze their institutions in the light of literature and seek guide line from transformational leadership style to retain their employees. Nursing leaders have to focus on improvements in two key areas: recruitment of new nurses, and retention of those staff. Theflexibility for long night duty hours or some incentive in form of extra money for night nurse could be helpful. Regular meeting with staff, leadership seminar might be a better idea to understand new strategies to decrease turnover. Contract might be turn into permanent job. Nurse Manager should improve their supervisory behavior, Clinical mentorship, and hire right people.
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