Impact of nursing unit turnover on patient outcomes in hospitals

The effects of work factors on nurses' job satisfaction, quality of care and turnover intentions in oncology

AIMS

We examined the effects of perceived supervisor support, value congruence and hospital nurse staffing on nurses' job satisfaction through the satisfaction of the three psychological needs for autonomy, competence and relatedness. Then, we examined the links between job satisfaction and quality of care as well as turnover intentions from the workplace.

BACKGROUND

There is growing interest in the relationships between work factors and nurses' job satisfaction. However, minimal research has investigated the effects of perceived supervisor support, value congruence and staffing on nurses' job satisfaction and the psychological mechanisms by which these factors lead to positive outcomes.

DESIGN

A cross-sectional questionnaire was distributed in 11 oncology units between September 2015 - February 2016.

METHOD

Data were collected from a sample of 144 French nurses who completed measures of perceived supervisor support, value congruence, staffing adequacy, psychological need satisfaction, job satisfaction, quality of care and turnover intentions.

RESULTS

The hypothesized model was tested with path analyses. Results revealed that psychological need satisfaction partially mediated the effects of perceived supervisor support, value congruence and hospital nurse staffing on job satisfaction. Moreover, job satisfaction was positively associated with quality of care and negatively linked to turnover intentions.

CONCLUSION

Overall, these findings provide insight into the influence of perceived supervisor support, value congruence and staffing on nurses' attitudes and behaviours.

Factors Influencing Job Satisfaction Among Long-Term Care Staff

OBJECTIVE

We assessed the intrapersonal, interpersonal, and organizational factors that predicted job satisfaction among long-term care employees.

METHODS

Baseline data were used to describe characteristics that influence job satisfaction. Using a forced linear regression model, while controlling for age and job title, we assessed if higher physical activity levels, fewer symptoms of depression, stress, and/or anxiety (ie, decreased mood), less back pain, stronger social support, and reports of low work demands were associated with higher job satisfaction.

RESULTS

Mood (β = -0.412, P = 0.003) explained 17% of the variance in job satisfaction.

CONCLUSION

This information can be used to guide facility wide programs and interventions aimed at increasing job satisfaction among all long-term care staff.

Exiting the Emergency Medical Services Profession and Characteristics Associated with Intent to Return to Practice

OBJECTIVE

Inadequate staffing of agencies, increasing attrition rates, and frequent turnover of personnel make employee retention an ongoing concern for Emergency Medical Services (EMS). Faced with increasing demand for EMS, understanding the causes underlying turnover is critical. The objectives of this study were to describe the proportion of individuals that left EMS, likelihood of returning to the profession, and key factors contributing to the decision to leave EMS.

METHODS

This was a cross-sectional study of nationally-certified EMS professionals who left EMS. Respondents to a census survey who reported not practicing EMS were directed to a subsection of items regarding their choice to leave EMS. Demographic and employment characteristics, likelihood of returning to EMS, and factors influencing the decision to leave EMS were assessed. Descriptive and comparative statistics (Chi-square and nonparametric test of trend [p-trend]) and univariable odds ratios were calculated.

RESULTS

The overall response rate for the full survey was 10% (n = 32,114). A total of 1247 (4%) respondents reported leaving the profession and completed the exit survey. The majority (72%) reported that they will likely return to EMS. A stepwise decrease in the reported likelihood of returning was seen with increasing years of EMS experience (e.g., 2 or less years of experience: 83%; 16 or more years: 52%; p-trend < 0.001) and months away from EMS (e.g., 0-2 months: 89%; more than 12 months: 57%; p-trend < 0.001). The most common factors reported to influence the decision to leave EMS included desire for better pay/benefits (65%), decision to pursue further education (60%), dissatisfaction with organization's management (54.7%), and desire for career change (54.1%).

CONCLUSION

This cross-sectional study found an attrition rate of approximately 4% among nationally certified EMS professionals; however, the majority reported that they intended to return to the EMS profession. Intention to return to EMS decreased as years of experience and months away from the profession increased. Important factors in the decision to leave EMS included a desire for better pay and benefits and the decision to pursue further education. Targeting the factors identified as important in this study should be a priority for key stakeholders in improving recruitment and retention of EMS professionals.

Creating positive practice environments in a primary health care setting

AIM

The aim of this study was to explore and describe the perceptions of nurse managers, nurses, and a physician in the community health centre with the most positive practice environment in a province of South Africa.

METHODS

Ten (N = 10) semistructured individual interviews were conducted with personnel of the community health centre with the most positive practice environment.

RESULTS

Personnel cited the following as the most important characteristics of a positive practice environment in a primary health care setting: support, leadership and governance, collegial nurse-physician relationships, and quality of care.

CONCLUSION

In a primary health care setting, it is important to train, appoint, and support managers who in turn will be able to train and support their personnel. Furthermore, reciprocal community involvement must be encouraged between personnel of the community health centre and stakeholders in the community to improve the health status of the community. Finally, group cohesions between all health care workers and managers at different organisational levels should be encouraged, as this enhances teamwork and a culture of teaching-learning and improves the competence of all staff.

Dynamic workplace interactions for improving patient safety climate

Purpose

Employee engagement (EE), supervisor support (SS) and interprofessional collaboration (IPC) are important contributors to patient safety climate (PSC). The purpose of this paper is to propose and empirically test a model that suggests the presence of a three-way interaction effect between EE, IPC and SS in creating a stronger PSC.

Design/methodology/approach

Using validated tools to measure EE, SS, IPC and PSC data were collected from a questionnaire of 250 clinical and support staff in an Australian health service. Using a statistical package (SPSS) an exploratory factor analysis was conducted. Bivariate correlations between the derived variables were calculated and a hierarchical ordinary least squares analysis was used to examine the interaction between the variables.

Findings

This research finds that PSC emerges from synergies between EE, IPC and SS. Modelling demonstrates that the effect of IPC with PSC is the strongest when staff are highly engaged. While the authors expected SS to be an important predictor of PSC; EE has a stronger relationship to PSC.

Practical implications

These findings have important implications for the development of patient safety programmes that focus on developing excellent supervisors and enabling IPC.

Originality/value

The authors provide quantitative evidence relating to three of the often mentioned constructs in the typology of patient safety and how they work together to improve PSC. The authors believe this to be the first empirically based study that confirms the importance of IPC as a lead marker for improved patient safety.

Immunizations challenge healthcare personnel and affects immunization rates

PURPOSE

This study measured 1. medical office immunization rates and 2. health care personnel competency in managing vaccine practices before and after evidence-based immunization education was provided.

METHOD

This descriptive study compared 32 family medicine and pediatric offices and 178 medical assistants, licensed practical nurses, registered nurses, nurse practitioners, and physicians in knowledge-based testing pre-education, post-education, and 12-months post-education. Immunization rates were assessed before and 18-months post-education.

RESULTS

Immunization rates increased 10.3% - 18months post-education; knowledge increased 7.8% - 12months post-education. Family medicine offices, licensed practical nurses, and medical assistants showed significant knowledge deficits before and 12-months post-education. All demographic groups scored less in storage/handling 12-months post-education.

CONCLUSION

This study is one of the first studies to identify competency challenges in effective immunization delivery among medical assistants, licensed practical nurses, and family medicine offices. Formal and continuous education in immunization administration and storage/handling is recommended among these select groups.

Information exchange networks of health care providers and evidence-based cardiovascular risk management: an observational study

BACKGROUND

Although a wide range of preventive and clinical interventions has targeted cardiovascular risk management (CVRM), outcomes remain suboptimal. Therefore, the question is what additional determinants of CVRM and outcomes can be identified and addressed to optimize CVRM. In this study, we aimed to identify new perspectives for improving healthcare delivery and explored associations between information exchange networks of health care providers and evidence-based CVRM.

METHODS

This observational study was performed parallel to a randomized clinical trial which aimed to improve professional performance of practice nurses in the Netherlands. Information exchange on medical policy for CVRM ("general information networks") and CVRM for individual patients ("specific information networks") of 180 health professionals in 31 general practices was measured with personalized questionnaires. Medical record audit was performed concerning 1620 patients in these practices to document quality of care delivery and two risk factors (systolic blood pressure (SBP) and LDL cholesterol level). Hypothesized effects of five network characteristics (density, frequency of contact, centrality of CVRM-coordinators, homophily on positive attitudes for treatment target achievement, and presence of an opinion leader for CVRM) constructed on both general and specific information exchange networks were tested and controlled for practice and patient factors using logistic multilevel analyses.

RESULTS

Odds for adequate performance were enhanced in practices with an opinion leader for CVRM (OR 2.75, p < .05). Odds for achievement of SBP targets were reduced in practices who had networks with low homophily on positive attitudes for SBP and LDL targets (homophily for SBP targets OR 0.57, p < .05 and OR 0.60, p < .05, homophily for LDL targets OR 0.59, p < .05 and OR 0.61, p < .05 in general and specific information networks, respectively). No effects of network characteristics on cholesterol were found.

CONCLUSIONS

Delivery of evidence-based CVRM is associated with homophily of clinical attitudes and presence of opinion leaders in primary care teams. These results signal the potential of social networks to be taken into account in further attempts to improve the implementation of evidence-based care for CVRM. Future research is needed to identify and formulate optimal strategies for using opinion leaders to improve CVRM. Future interventions may be more effective if they target a common vision on CVRM within practices.

Standardizing Care and Parental Training to Improve Training Duration, Referral Frequency, and Length of Stay: Our Quality Improvement Project Experience

OBJECTIVES

At our institution, there is a six bed Pediatric Respiratory Care Unit for technology dependent infants and children with a tracheostomy tube. A lack of consistency in patient care and parent/guardian education prompted our group to critically evaluate the services we provided by revisiting our teaching protocol and instituting a new model of care in the Unit. The aims of this quality improvement (QI) project were to standardize care and skills proficiency training to parents of infants with a tracheostomy tube in preparation for discharge to home.

METHODS

After conducting a current state survey of key unit stakeholders, we initiated a multidisciplinary, QI project to answer the question: 'could a standardized approach to care and training lead to a decrease in parental/guardian training time, a decrease in length of stay, and/or an increase in developmental interventions for infants with tracheostomy tubes'? A convenience sample of infants with a tracheostomy tube admitted to the Pediatric Respiratory Care Unit were included in the study. Descriptive statistics were used to analyze the results.

RESULTS

Through this QI approach, we were able to decrease the time required by parents to achieve proficiency in the care of a technology dependent infant, the length of stay for these infants, and increase referral of the infants for developmental assessment.

CONCLUSIONS

These outcomes have implications for how to approach deficiencies in patient care and make changes that lead to sustained improvements.

Taken-for-granted assumptions about the clinical experience of newly graduated registered nurses from their pre-registration paid employment: A narrative inquiry

Paid employment within clinical setting, such as externships for undergraduate student, are used locally and globally to better prepare and retain new graduates for actual practice and facilitate their transition into becoming registered nurses. However, the influence of paid employment on the post-registration experience of such nurses remains unclear. Through the use of narrative inquiry, this study explores how the experience of pre-registration paid employment shapes the post-registration experience of newly graduated registered nurses. Repeated individual interviews were conducted with 18 new graduates, and focus group interviews were conducted with 11 preceptors and 10 stakeholders recruited from 8 public hospitals in Hong Kong. The data were subjected to narrative and paradigmatic analyses. Taken-for-granted assumptions about the knowledge and performance of graduates who worked in the same unit for their undergraduate paid work experience were uncovered. These assumptions affected the quantity and quality of support and time that other senior nurses provided to these graduates for their further development into competent nurses and patient advocates, which could have implications for patient safety. It is our hope that this narrative inquiry will heighten awareness of taken-for-granted assumptions, so as to help graduates transition to their new role and provide quality patient care.

The Effect of Nurse-Physician Collaboration on Job Satisfaction, Team Commitment, and Turnover Intention in Nurses

Voluntary turnover in nursing can lead to nursing shortages that affect both individuals and the entire hospital unit. We investigated the relationship between group- and individual-level variables by examining the association of nurses' job satisfaction and team commitment at the individual level, and nurse-physician collaboration at the group level, with individuals' intention to leave the unit at the individual level. A self-report questionnaire was administered to 1,024 nurses on 72 units in 3 Italian hospitals. At the individual level, affective commitment partially mediated the relationship between job satisfaction and nursing turnover intention. Moreover, a cross-level interaction was found. Nurses with high levels of job satisfaction showed high levels of identification with their team, and this relationship was stronger when the group perception of nurse-physician collaboration was high. Results suggested that managerial strategies to promote nurse-physician collaboration may be important to increase nurses' affective commitment to the team. At the individual level, job satisfaction and team affective commitment are important factors for retaining staff, and at the group level, good work collaboration with physicians is instrumental in developing nurses' affective identification with the team. © 2016 Wiley Periodicals, Inc.

Analysis of nurse staffing and patient outcomes using comprehensive nurse staffing characteristics in acute care nursing units

Associations between comprehensive nurse staffing characteristics and patient falls and pressure ulcers were examined using negative binomial regression modeling with hospital- and time-fixed effects. A convenience sample was collected from 35 nursing units in 3 hospitals. Rates of patient falls and injury falls were found to be greater with higher temporary registered nurse staffing levels but decreased with greater levels of licensed practical nursing care hours per patient day. Pressure ulcers were not related to any staffing characteristics.

Tides of change: improving glucometrics in a large multihospital health care system

BACKGROUND

This study explores the relationship between education for inpatient diabetes providers and the utilization of insulin order sets, inpatient glucometrics, and length of stay in a large health care system.

METHODS

The study included patients with and without the diagnosis of diabetes. An education campaign included provider-directed diabetes education administered via online learning modules and in-person presentations by trained individuals. Relationships among provider-attended diabetes education, order set usage, and inpatient glucometrics (hypo- and hyperglycemia) were analyzed, as well as length of stay.

RESULTS

Insulin use knowledge scores for all providers averaged 52%, and improved significantly to 93% (P < .001) by the end of the education intervention period. Likewise utilization of electronic basal-bolus order sets increased from a baseline of 20% for patients receiving insulin to 86% within 6 weeks (P < .01) of introduction of order sets. During the study, the incidence of hypoglycemia and hyperglycemia declined from 1.47% to 1.27% and from 23.21% to 17.80%, respectively. However, these improvements were not sustained beyond the completion of the education campaign.

CONCLUSIONS

Education of diabetes health care providers was provided in a large, multihospital system through the use of online learning modules. Adoption of standardized insulin order sets was associated with an improvement in glucometrics. This educational and quality initiative resulted in overall improvements in insulin knowledge, adherence to recommended order sets, inpatient glucometrics, and patient length of stay. These improvements were not sustained, reinforcing the need for repeated educational interventions for those involved in providing inpatient diabetes care.

Group cohesion and organizational commitment: protective factors for nurse residents' job satisfaction, compassion fatigue, compassion satisfaction, and burnout

Stress can have detrimental effects on nurse residents' levels of job satisfaction, compassion, fatigue, and burnout. This can lead to high turnover rates and poor quality of care among novice nurses. Therefore, it is critical to identify protective factors to prevent the onset of negative nurse outcomes (compassion fatigue, burnout, and job dissatisfaction) and to promote positive nurse outcomes (job satisfaction, compassion satisfaction). This study aimed to determine whether factors such as group cohesion and organizational commitment would be protective and moderate the association between stress exposure and posttraumatic stress symptoms and other negative nurse outcomes, thus facilitating positive outcomes. Findings showed that group cohesion was effective in moderating the negative effects of current stress exposure and posttraumatic stress symptoms on negative nurse outcomes, specifically on increased compassion fatigue and burnout, and reduced compassion satisfaction. In addition, organizational commitment was determined to promote positive nurse outcomes such as job satisfaction and compassion satisfaction. The study findings are promising, as retention of quality nurses is a significant problem for hospitals. Nurse managers and hospital administrators should be aware of the benefits of group cohesion and organizational commitment and strive to make the promotion of these factors a priority.

Evaluating the intervening factors in patient safety: focusing on hospital nursing staff

OBJECTIVE To evaluate intervening factors in patient safety, focusing on hospital nursing staff. METHOD The study is descriptive, with qualitative approach, excerpt from a larger study with analytical nature. It was undertaken in a public hospital in Fortaleza, CE, Brazil, between January and June 2013, with semi-structured interviews to 70 nurses, using Thematic Content Analysis. RESULTS The principal intervening factors in patient safety related to hospital nursing staff were staff dimensioning and workload, professional qualification and training, team work, being contracted to the institution, turnover and lack of job security, and bad practice/disruptive behaviors. These aspects severely interfere with the establishment of a safety culture in the hospital analyzed. CONCLUSION It is necessary for managers to invest in nursing staff, so that these workers may be valued as fundamental in the promotion of patient safety, making it possible to develop competences for taking decisions with focus on the improvement of quality care.

What does nurse turnover rate mean and what is the rate?

Registered nurse turnover is an important indicator of the nurse job market. Despite its wide use as a measure for health-care system analysis, there is a lack of consistency in the definition of turnover. Some definitions include any nurse leaving an organization; others may include involuntary and voluntary leaving. These inconsistent definitions also result in various turnover rates. The RN Work Project is a 10-year panel study of new nurses. Data were collected from the new nurses, rather than from a specific organization. About 17.5% of new nurses leave their first job within 1 year of starting their jobs. Consistent and accurate measurement of turnover is an important step in addressing organizational work environments and policies about the nursing workforce.

Concurrent and lagged effects of registered nurse turnover and staffing on unit-acquired pressure ulcers

OBJECTIVE

We examined the concurrent and lagged effects of registered nurse (RN) turnover on unit-acquired pressure ulcer rates and whether RN staffing mediated the effects.

DATA SOURCES/SETTING

Quarterly unit-level data were obtained from the National Database of Nursing Quality Indicators for 2008 to 2010. A total of 10,935 unit-quarter observations (2,294 units, 465 hospitals) were analyzed.

METHODS

This longitudinal study used multilevel regressions and tested time-lagged effects of study variables on outcomes.

FINDINGS

The lagged effect of RN turnover on unit-acquired pressure ulcers was significant, while there was no concurrent effect. For every 10 percentage-point increase in RN turnover in a quarter, the odds of a patient having a pressure ulcer increased by 4 percent in the next quarter. Higher RN turnover in a quarter was associated with lower RN staffing in the current and subsequent quarters. Higher RN staffing was associated with lower pressure ulcer rates, but it did not mediate the relationship between turnover and pressure ulcers.

CONCLUSIONS

We suggest that RN turnover is an important factor that affects pressure ulcer rates and RN staffing needed for high-quality patient care. Given the high RN turnover rates, hospital and nursing administrators should prepare for its negative effect on patient outcomes.

A multilevel investigation on nursing turnover intention: the cross-level role of leader-member exchange

AIM

To analyse nursing turnover intention from the unit by using multilevel approach, examining at the individual level, the relationships between job characteristics, job satisfaction and turnover intention, and at the group level the role of leader-member exchange.

BACKGROUND

Research on nursing turnover has given little attention to the effects of multilevel factors.

METHOD

Aggregated data of 935 nurses nested within 74 teams of four Italian hospitals were collected in 2009 via a self-administered questionnaire.

RESULTS

Hierarchical linear modelling showed that job satisfaction mediated the relationship between job characteristics and intention to leave at the individual level. At the unit level, leader-member exchange was directly linked to intention to leave. Furthermore, cross-level interaction revealed that leader-member exchange moderated the relationship between job characteristics and job satisfaction.

CONCLUSION

This study supported previous research in single-level turnover studies concerning the key role of job satisfaction, providing evidence that job characteristics are important in creating motivating and satisfying jobs. At the unit-level, leader-member exchange offers an approach to understand the role of unit-specific conditions created by leaders on nurses' workplace wellbeing.

IMPLICATIONS FOR NURSING MANAGEMENT

This study showed that it is important for nursing managers to recognise the relevance of implementing management practices that foster healthy workplaces centred on high-quality nurse-supervisor relationships.

Incivility, retention and new graduate nurses: an integrated review of the literature

AIM

To evaluate the influence of incivility on the new graduate nurse transition experience.

BACKGROUND

Incivility in the work environment is a major source of dissatisfaction and new graduate nurses are especially vulnerable. Incivility contributes to the high levels of turnover associated within the first 2 years of new graduate nurse employment.

EVALUATION

An integrated review of the literature was conducted using MEDLINE-EBSCOhost, PsycInfo and CINAHL databases. Relevant articles were reviewed for appropriateness related to inclusion/exclusion criteria and for quality using established criteria. Sixteen studies were included in the final analysis.

KEY ISSUES

Themes that emerged included workplace incivility, nurse residency programmes, mentoring through preceptors and empowerment/work environment. Findings indicated that incivility in the workplace was a significant predictor of low job satisfaction in new graduate nurses transitioning into practice.

CONCLUSIONS

While graduate nurse transition programmes are associated with improved satisfaction and retention, they appear to address incivility by acculturating new graduate nurses to the experience of incivility. There is little evidence that the culture of incivility has been addressed.

IMPLICATIONS FOR NURSING MANAGEMENT

Nurse managers have the responsibility to be aware of the prevalence of incivility, assess for its occurrence, and implement strategies which eliminate workplace incivility and tolerance for uncivil behaviours.

Nurse retention and satisfaction in Ecuador: implications for nursing administration

AIM

This study explores the characteristics of professional nursing work environments that may affect nursing turnover and satisfaction within a large Ecuadorian hospital.

BACKGROUND

Nursing turnover is a challenge and may compromise patient care. Work dissatisfaction contributes to high turnover. Improving nurse satisfaction can contribute to better patient outcomes.

METHOD

Eighty-eight nurses participated in a quantitative and qualitative survey focusing on nursing satisfaction, turnover and selected organisation characteristics.

RESULTS

Issues that may affect nurse satisfaction and turnover were identified using questions from the Nursing Work Index: pay, insufficient number of nurses, undervaluing of nurses by public and the medical team, limited advancement opportunities, lack of autonomy and inflexibility in schedule. Other themes identified from qualitative data are reported.

CONCLUSIONS

The top factor of decreased satisfaction was low pay as indicated by the Nursing Work Index. The qualitative results showed that low pay was the factor for nurse turnover. Additional factors related to nursing satisfaction can be addressed to improve nurse retention.

IMPLICATIONS FOR NURSING MANAGEMENT

Along with increasing nursing pay, strategies to consider in decreasing turnover and increasing satisfaction included: providing opportunities for nursing advancement, promoting the value of nursing, creating clinical protocols and enhancing autonomy. This study adds to knowledge about nursing needs and satisfaction in South America.