Nursing churn and turnover in Australian hospitals: nurses perceptions and suggestions for supportive strategies

Background
This study aimed to reveal nurses’ experiences and perceptions of turnover in Australian hospitals and identify strategies to improve retention, performance and job satisfaction. Nursing turnover is a serious issue that can compromise patient safety, increase health care costs and impact on staff morale. A qualitative design was used to analyze responses from 362 nurses collected from a national survey of nurses from medical and surgical nursing units across 3 Australian States/Territories.

Method
A qualitative design was used to analyze responses from 362 nurses collected from a national survey of nurses from medical and surgical nursing units across 3 Australian States/Territories.

Discussion
Our study found that nurses working in hospital wards in Australia consider limited career opportunities, poor staff support, recognition and attitudes of co-workers to be particularly influential in deciding to remain in their current job and the profession. This was linked to poor work environments characterized by inadequate skill-mix, low nurse-to-patient ratios and reduced physical resources, accompanied by a lack of involvement in decision making, constant changes, issues related to leave and shifts, poor staff relationships and patient expectations.

A number of suggestions were made to encourage retention. Interestingly, these focused on non-financial incentives emphasizing the recognition of staff achievements, the provision of appropriate career and professional development opportunities, and the need to clarify roles, engage with staff and model leadership. Nurses also highlighted the need for flexible employment options.

These self-reported factors are consistent with the literature. The importance of recognizing staff achievement is identified in studies in several countries where offering praise for a job well done was found to contribute to staff satisfaction [7,35,36]. Other research has found that strategies suggested by the nurses in our study have made an impact upon retention. Hunter and Nicol [37] found evidence that training and development, continued education, and professional growth opportunities improve recruitment and retention for occupational therapists. In our study, a lack of support for staff was regarded as a factor that contributed to nursing turnover, and participants highlighted the need for quality preceptorship for new graduates. Chenoweth et al. [38] have found that effective clinical supervision had a positive influence on recruitment and retention and worked best when there was a good supervisor-mentee relationship. In terms of the flexible working options requested by nurses in our study, other research has found that options such as self-scheduling system, flexibility in schedules, family-friendly policies and social hours improve health care provider retention [37-39]. Patterson et al. [40] also reported a positive influence between nurse staffing models and turnover although others have not found any evidence to suggest that having the right staff skill mix is effective in retaining health care providers.

Implications for nursing management
A range of interventions have been found to address potential turnover and improve retention. The recognition of staff achievements and improving self-efficacy and participation in the workplace could be realized through improved performance management and flexible work design particularly in this Australian hospital context.

Performance management
Performance management (PM) for nursing staff may deserve focus as it provides processes for joint review that enable nurse and supervisor to plan for professional development and career advancement, recognise and reward staff achievements [41,42] and improve morale [43]. PM processes that provide such opportunities may improve job satisfaction and retention [42,44] and help to address factors that contribute to nursing turnover. PM enables the achievement of accomplishment-based performance indicators to be negotiated in line with nurse’s job descriptions, standards and outcomes at the individual team and hospital levels. This process should engage staff members themselves in appraising their performance and planning and evaluating appropriate career and professional development activities [45,46]. Enhancing PM systems alongside building nurse manager-nurse relationships can also provide the support and mentoring that participants in our study described as necessary to plan and achieve promotion. Additionally, managers offering praise when high quality clinical practice is observed may help to reinforce the occurrence of such practice, and ensure that nursing staff feel that their work is appreciated and valued.

Nurses in our study also identified a need for clinical preceptorship for overseas qualified nurses and new graduates, the latter group being of particular concern in relation to turnover in Australia[47] and overseas [20,48]. The difficulties of overseas qualified nurses in Australia noted in our study have been found in other research [49,50]. A PM process could also include appraisal of cultural competency [51] and identify professional development interventions to address cultural and language issues [52-54]. In this way, early identification of learning needs may enable managers to ensure that overseas qualified nurses and new graduates can receive appropriate training before taking on shifts in the ward.

Work design
In our study participants highlighted poor skill-mix and issues with shifts that could be addressed by the provision of a range of employment options and flexible shifts. Flexible scheduling has been found to be an important part of a quality work environment because nurse satisfaction is connected with having a certain level of influence on decisions pertaining to the hours they work[55]. However, challenges to flexibility include nurse shortages and complex staffing arrangements. Nonetheless, Hirschkorn and others [56] have identified lessons which could potentially be applied to the nursing context such as flexible work environments and phased retirement options, which may benefit working parents and carers as well as an aging workforce.

Role of nursing unit manager and nursing executive
The effective leadership of the nursing unit managers (NUMs) is critical to improving staff retention and reducing turnover, as well as improving nurse satisfaction and the provision of a positive a working environment [7]. However, building the leadership capacity of NUMs in order to strengthen performance management and introduce flexible work design tailored to address the different context of hospital wards [57] requires organisational support from nursing executives. This nursing executive must itself be stable and have opportunities for growth within its mandate [58]. The recommendations of the public enquiry into the Mid Staffordshire Trust in the UK provides clear evidence of the importance of nursing leadership and management in creating positive work environments, recognising nurses’ contributions and addressing morale [59].

Limitations
There are a number of limitations that may affect the interpretation and transferability of the findings of this study. The response rate in this qualitative study (n = 362) reflects 22% of the total population (n = 1655) included in the larger survey. There may be the possibility that participants who answered the open-ended question were not typical of many nurses’ perspectives which may limit data quality. The findings reflect the voices of nurses who were highly motivated to contribute their views. However those that chose not to complete the long answer question may not have wanted to add additional material, did not have the time or may have not been confident to share their feelings and experiences. Member checking to confirm understanding and ensure that the themes adequately represented the expressions of the participants was not possible due to the fact that the surveys were completed anonymously making to follow up difficult. In addition the written response does not allow for further probing or clarification of responses as one would be able to achieve in a face to face interview.

Conclusion
Positive solutions must be found and nurses engaged in designing, implementing and evaluating them if we wish to decrease clinical nursing staff turnover. Enhancing performance management and flexible employment options require changes in workplace culture to ensure that nurses don’t view nursing as a “dead end job”. Nurses need to feel empowered to help steer their career and contribute to decisions that progress the delivery of quality health care on the hospital wards in which they work.

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This article is adapted from Angela J Dawson, Helen Stasa, Michael A Roche, Caroline S E Homer and Christine Duffield, Nursing churn and turnover in Australian hospitals: nurses perceptions and suggestions for supportive strategies. Source article. This work is licensed under a Creative Commons Attribution 3.0 License.