An explorative study of nurses’ perception of turnover and retention

Nurse turnover is a global concern with important implications for patient safety. Below-target level staffing of nurses is associated with increased patient mortality, underlining the need to match staffing levels with patient needs [1]. However, turnover problems are complex [2]. Importantly, it has been shown that nurses experiencing lower levels of autonomy and less support from their peers increasingly consider leaving their job [3]. Turnover of nurses is costly for healthcare organisations, though studies have reached different conclusions regarding costs [4]. In general, nurse turnover is high in internal medical wards. However, an understanding of the reasons why nurses leave their job and what may encourage them stay are needed to inform and plan the necessary interventions. Although a large body of literature addresses the problem and its influencing factors, high turnover rates remain a problem [5]. Interactive methods, such as table-top simulation, have successfully been used to explore potential challenges and solutions in the preparation of surgical patients [6-8]. The researchers speculated that this interactive method may be used to explore the determinants of nurse turnover and reveal facilitators for nurse retention, potentially providing new insights and solutions. The aim of this study was to explore newly graduated nurses´(NGN), experienced nurses´ and nurse supervisors´ perceptions of determinants of nurse turnover and retention using table-top simulation.

METHODS

This explorative study was conducted at five University Hospitals in the Capital Region of Denmark.

Each Hospital Management selected one internal medicine ward to participate in the study. These wards had high nurse turnover rates and NGN were applicants for most of the available positions, resulting in a lack of experienced nurses. We invited nurses from each ward to participate based on three inclusion criteria, aiming for a total of 15 nurses in each group: three NGN, three experienced nurses and three nurse supervisors.

Study design

The study originates from a hermeneutical position in which the recorded reflections from the table-top simulations are used as data. The simulations took place in an undisturbed environment and lasted for 1.5 hours. The simulations were facilitated by HF and ABL who are trained facilitators. The set-up is illustrated in Figure 1 and was designed to help nurses reflect on typical patient-related tasks. The simulation started with the facilitators asking a few open questions, such as “What are your thoughts when you are on your way to work?”. The simulation illustrated arrival to work, patient-related activities during the day and patient handover. The questions guided the nurses to reflect on their patient-related tasks and on challenges and positive elements in relation to their clinical work. The facilitators asked questions to gain more insight into the elements mentioned by the participants. The participants took notes of their reflections, which were then discussed in a group. After the table-top simulation, the nurses and the researchers conducted an initial analysis to identify topics. This was done to ensure that the researchers continuously consolidated their initial assumptions together with the nurses, who selected the primary topics.

Data analysis

The simulations were audio-recorded and transcribed. The written notes were collected, and the citations were sorted for each group of nurses into subthemes and later into themes. An inductive content analysis of the transcripts of the audio-recording was conducted as described by Elo et al. [9]. The first step was to make sense of the data. All authors were involved in this step. The next steps, coding and grouping of the data, were conducted by HF and ABL. The last step involved categorisation of the data, which involved all authors. The themes were derived from the data by moving from specific to more general statements.

Ethical approval

Danish Law exempts this type of study from ethical approval. The nurses received written/verbal information and gave written consent.

Trial registration: not relevant.

RESULTS

A total of 15 simulations, including a total of 43 nurses, were conducted. See Table 1.

Newly graduated nurses

Four themes emerged from the simulations: core clinical competence, professionalism, organisation and culture. Table 2 shows these themes and provides example citations from NGN’ and their supervisors´ perceptions of NGN. NGN were interested in employment in wards with a well-organised introduction and formative evaluation of competence, including feedback. To supplement their training, courses are an attractive addition during the introduction period. The NGN were fully aware that they were novices and need training to provide safe care. The supervisors allocated the less complicated patients to NGN, which might be a good plan in the beginning, but not for long. A central topic was lack of competencies when on-call. In some wards, the NGN provided on-call service two months after joining a team. When they were on call, they were expected to be the most experienced nurse. The NGNs felt incompetent in this situation and expressed that it was very unpleasant to be given a task you cannot handle. They suggested evaluation of specific on-call competencies before assuming this function. The supervisors mentioned that as a student they would take care of 1-2 patients at a time, implying that NGNs did not possess the overview needed to be on-call.

The transition from taking care of simple cases to handling complex cases was difficult, especially if the experienced nurses typically handled the complex cases themselves. Specific courses covering these aspects after the introduction period were attractive to NGN. Interprofessional collaboration was considered important. However, knowledge of other professions´ competence was insufficient. The frequency of shifts was not mentioned as a challenge. Rather, the allocation of tasks according to level of competence was considered important by NGNs. This was supported by the supervisors. A learning culture and an understanding of the different learning needs are necessary. The NGN value social relations – developing a rapport with colleagues via social arrangements made it easier to ask for help. Overall, for the NGN, the internal medicine ward was a good starting point for developing their basic nursing skills.

Experienced nurses

The experienced nurses´ perspective on their own continuous professional development (CPD) is presented in Table 3. The same themes emerged but the subthemes differed. Lifelong learning was important, as were possibilities for working together, receiving feedback and working closer with specialists to improve their own competences. Task variation and daily clinical challenges were considered beneficial. Although they found it important to accompany the NGN, it was problematic to carry responsibility for same number of patients as usual during the supervision period. Good collaboration with colleagues and physicians was considered important, especially in relation to ethical decisions, such as when to discontinue treatment. Experienced nurses applied for positions on wards that offered a high degree of influence on tasks and flexible leaders capable of spotting the individual nurses´ potential and providing opportunities for CPD. The experienced nurses prioritised their family and considered overtime a challenge. The risk of being asked to cover for a nurse on-call could cause unease, even stomach ache at times. A sense of collegial community was a driver. The role of the nurse specialist, who may work in an office and develop guidelines, was mentioned as a prestigious opportunity. Patients in the ward often suffered from multiple co-morbidities, but to seek advice from another ward was not the custom. The nurses mentioned the differences in allocation of human resources and advocated allocation depending on the care intensity.

DISCUSSION

Our findings provided valuable insights into the nurses´ perspectives of determinants of nurse turnover and retention in internal medicine wards. Four themes were identified: core clinical competence, professionalism, organisation and culture. The NGN focused on competence evaluation to overcome their feeling of incompetence, whereas the experienced nurses focused on lifelong learning and planning for CPD. In addition, the importance of a good learning culture, as well as social and organizational factors, was mentioned. Overall, we found that the wards had less focus on how to reduce nurse turnover than on introducing NGN.

Although the wards were aware of the importance of a thorough NGN introduction programme, the simulations illustrated the NGN’s fear of being incompetent and endangering patients. Competence evaluation followed by feedback in the workplace are the basis of competency-based education. Feedback is considered the most important part of the learning process [10-12]. The NGN can follow their own progression, the supervisor can delegate tasks according to competence level and the patient receives safe care. Such competence evaluations provide the NGN with the possibility to avoid tasks they are unqualified to do until the necessary competence has been achieved. It was brought into question whether the NGNs may reject a task if they felt incompetent [13]. A safe learning environment is a prerequisite to healthcare professionals speaking up [14]. The experienced nurses were aware of the importance of life-long learning and asked for possibilities to work with and receive feedback from colleagues and physicians. This aligns with the paradigm shift towards workplace-based learning as part of CPD [14] and with a study showing that a positive nurse-physician relation is an essential part of a safe learning environment [15]. Our data showed that the quality of work, collaboration with colleagues and physicians, and the culture were important for nurses. This is supported by a multi-centre study reporting that a favourable nurse-physician relation makes nurses less likely to leave the profession [13]. An interesting finding was the mentioning of the on-call teams´ collective competence. It can be challenging for both the team and for patient safety if both the nurse and the physician are newly graduated, but this is only seldomly reflected in work schedules.

The organisation of everyday work was mentioned by all groups. Allocation of patients should depend on the individual nurse´s competence. Assigning an NGN several patients and, over time, allowing him or her to care for more complex patients is necessary. In contrast to the NGN, the experienced nurses favoured limited on-call duties, prioritised family over work and applied for positions in wards with flexible planning and influence on work-related tasks. This reflects the findings of another study showing that job variety and the degree to which employees are given the opportunity to act independently are important factors [2]. The experienced nurses asked for daily challenges and highlighted their focus on quality of care. If this focus was lacking, the nurses considered leaving their current role and seeking a new job. Our findings align with a study showing that the quality of the nurse practice is significantly associated with their intention to leave current employment [16]. A study of the importance of the work environment on hospital outcomes supported this finding [17].

Retention and turnover problems are complex, and no single solution can solve these challenges [2]. We need to address the gap between what is learned at a pre-graduate level and the competences needed for clinical work and to establish interprofessional activities for students. Pre-graduate education should encompass competencies such as being responsible for more than one patient and having the ability to speak up if one needs help to solve a task. In addition, we need to address organisational issues and issues related to the local culture. As a minimum, an introduction programme including both mentoring and courses for NGNs should be in place during the first six months. Programmes with a time frame of at least 12 months are slightly more effective [18]. Assessment of competence and feedback are the major ingredients for such a programme, which involves the clinical nurse specialist at the bed site. Including the newly graduated nurse in the team is essential; hence, social activities are important.

A nurse’s decision to change job is influenced by personal and work environment factors [19]. A lower job satisfaction may be due to long working hours, too many on-call shifts and working with less support from peers and supervisors [3]. The turnover rate of the more experienced nurses is a challenge that may be addressed by ensuring a focus on life-long learning and enhancing collaboration with physicians. The clinical nurse specialist is mentioned as an important element for the quality of patient care and has to participate in clinical work, not office work only. Influence on one’s own work tasks is an important factor for the nurse turnover rate [3, 20]. Leaders and colleagues have an important role in changing these premises. High performing hospitals are characterised by a flat organisational structure with staff involvement in organisational development, an active policy regarding lifelong learning, structured educational programmes and career opportunities [16].

Discussion of the methods used

Table-top simulation with artefacts and facilitation provided an opportunity for nurses to reflect in an involving manner on barriers to and aids assisting working as both an NGN and an experienced nurse. The nurses found that the method was useful. The head of the hospital selected the wards, and the ward chair selected the nurses. This may potentially have introduced a bias. However, nurse turnover is a general problem in medical wards, and the number of nurses involved in the simulations was representative. The data represent individual-level perspectives and are vulnerable to social desirability bias. However, we believe that the use of notes minimised that risk. Data were collected in a single Danish region, which may influence the transferability of our findings.

We could have chosen to ask nurses who have resigned about their reasons for leaving their position. In contrast, we chose to ask current nurses what would make them stay to make it possible for leaders of departments to initiate a dialogue with the nurses about their suggestions. In addition, this approach involves the nurses in reducing turnover.

CONCLUSIONS

The table-top simulations provided valuable insights into the nurses´ perspectives of nurse turnover and retention in internal medicine wards. The NGN focused on evaluation of core clinical competence to be able to provide safe care to the patient. The experienced nurses favoured influence on their own work and a CPD plan. In addition, the importance of a good learning culture, as well as collegial and social factors, was mentioned by both groups of nurses. Overall, the wards have focused most on recruitment and less on how to reduce the nurse turnover rate.