Journal of Nursing Management, 2016, 24, E62–E69

Resilience, job satisfaction and anticipated turnover in nurse leaders TRACY ANN HUDGINS

DNP, RN, CNE, NE-BC

Associate Professor, Liberty University, Lynchburg, VA 24515, USA

Correspondence Tracy Ann Hudgins 1971 University Boulevard Lynchburg, VA 24515 E-mail: [email protected]

HUDGINS T.A.

(2016) Journal of Nursing Management 24, E62–E69. Resilience, job satisfaction and anticipated turnover in nurse leaders Aims The aim was to identify relationships between resilience, job satisfaction and anticipated turnover among nurse leaders. Background Despite the reported value of resilience, there is a lack of research on resilience in nurse leaders. This study examined how nurse leaders describe their resilience and the relationship it has with job satisfaction and anticipated turnover. Methods This quantitative study used a sample of 89 nurse leaders (bedside, department, division and organisational) from a multi-hospital health-care system in southwestern Virginia. Results There are significant relationships between resilience, job satisfaction and anticipated turnover. Additionally, it was found that the variables of job satisfaction and anticipated turnover significantly overlapped in their meaning and created a new construct of intent to remain (ITR) that has a statistically significant relationship with resilience. Implications for nursing management A stable nursing team has a positive impact on improving patient outcomes. To mitigate the impact of a nursing shortage, nurse leaders can enhance their own resilience and then recruit, hire and retain resilient staff nurses in an effort to improve nurses’ ITR. Conclusion With higher resilience, nurse leaders are more likely to intend to remain in their leadership positions. Keywords: nurse leader, resilience, retention, satisfaction

Accepted for publication: 6 January 2015

Introduction There is a looming crisis facing the health-care industry that has been projected to blossom over the next 10 years: another nursing shortage. Nursing shortages are defined by the inequities in the number of practising nurses and those entering and exiting the field at any given time compared with the number of nurses required to meet the needs of patients. The supply of nurses (i.e. the rate at which nurses are leaving and joining the profession) is driven by retirement, recruitment of new nurses into the profession and the success or failure to retain existing ones (Holmes 2004, Halfer E62

2007, Pine & Tart 2007). The demand for nurses is an increasing variable now due to broadening opportunities for nurses across the health-care industry as well as significant population growth (people are living longer and babies continue to be born) (Sigma Theta Tau International 2002, Ward & Saylor 2002, Upenieks 2003). Through age attrition, avoidance of the profession, poor recruitment efforts, inadequate numbers of nursing faculty, or attrition due to dissatisfaction with their career, the projected nursing shortage in the United States is estimated to peak by 2020 to over 1 200 000 nurses (American Association of Colleges of Nursing 2011, Bureau of Labor Statistics DOI: 10.1111/jonm.12289 ª 2015 John Wiley & Sons Ltd

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2012). Tangled in this shortage will be many nurse leaders who, for various reasons, leave their position, their company or the practice of nursing as a whole. Research related to the reasons those valued nurse leaders leave their positions and the role resilience plays in that decision to leave is limited. Effective nurse leadership is integral in increasing staff nurses’ satisfaction, thereby reducing the shortage (Sourdif 2004, Anthony et al. 2005, Apostolidis & Polifroni 2006). This fact demonstrates the importance of the retention of competent nurse leaders within the field of nursing as a starting point to mitigating a nursing shortage. Understanding how an individual nurse leader perceives resilience (Polk 1997), experiences job satisfaction (Judge et al. 1997), and when unsatisfied, plans to leave a leadership position (Hinshaw & Atwood 1982), is essential.

Background Literature reveals that high quality nurse leaders are vital to staff nurses’ satisfaction and subsequent retention (Upenieks 2003, Han & Jekel 2011, Hill 2011). It is an inextricable fact that job satisfaction and anticipated turnover are woven together (Hinshaw et al. 1987, Anthony et al. 2005, Han & Jekel 2011). This same satisfaction leads to retention, which positively impacts patient outcomes (Aiken et al. 2011, Hill 2011). Despite the fact that resilience is consistently found to be a favourable personal characteristic, there is limited notable research on how resilience influences nurse leaders, their rate of anticipated turnover or job satisfaction. This article discusses the findings from this research study, which explored the relationships between resilience, job satisfaction and anticipated turnover. Additionally, guidance is offered on how a nurse leader can build personal resilience as well as a more resilient nursing team.

Resilience The word resilience has been in use since 1626, but does not have a clear definition in the literature (Oxford English Dictionary 2014). Richardson (2002) explains that the research related to resilience, which has spanned more than 60 years, has occurred in three waves: consideration of resilience qualities; understanding resilience as a process; and developing resilience as a vital skill in coping with adversity. Steps taken to provide clarity on the meaning of resilience included research describing resilience as a trait (Wagnild & Young 1993, Mandleco & Perry 2000, Lee ª 2015 John Wiley & Sons Ltd Journal of Nursing Management, 2016, 24, E62–E69

et al. 2004), process (Masten 2001), continuum (Rutter 1985, Ahern 2006) and cycle (Humphreys 2003, Black & Ford-Gilboe 2004, Aronowitz 2005). Polk’s (1997) synthesis of resilience research resulted in a clear theoretical definition of ‘the ability to transform disaster into a growth experience and move forward’. As a whole, the literature concludes that resilience is a protective quality during adversity.

Job satisfaction Nurse researchers have examined factors that contribute to the satisfaction of nurse leaders with their careers. Nurse leaders’ satisfaction was found to be influenced by the work climate and work relationships (Parson & Stonestreet 2003, Mackoff & Triolo 2008), their work schedule, professional recognition and autonomy (Krugman & Smith 2003), and role conflict and meaning (Van Bogaert et al. 2014). The perception of satisfaction may be enhanced by their personal degree of resilience.

Anticipated turnover The concepts of retention and turnover are terms that are used to research the same phenomenon from different ends of the same spectrum. Retention describes the activities surrounding employer efforts to keep valued employees within their organisations (Anthony et al. 2005). Turnover occurs when those efforts fail and nurses leave their place of employment (Jones 2008). Anticipated turnover is described as an individual’s plans to leave his/her current job during a given period of time (Hofmann 1981). Nurse leaders’ anticipated turnover is affected by the quality of work relationships, good administrative systems, a balanced work life (Parson & Stonestreet 2003), whether a job was overly complicated, the complexity of clerical work (Firth 2002), the level of organisational commitment, the degree of empowerment and the existence of positive relationships and trust in their leadership (Wilson 2005). When nurse leaders face work experiences that are not ideal, resilience plays a protective role in allowing the leader to endure the challenges and to persevere.

Theoretical framework Polk (1997) synthesised resilience literature to assemble a resilience model and mid-range nursing theory that is multi-dimensional and described by four patterns found in the resilience literature. Dispositional E63

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patterns are the ingrained psychosocial attributes that contribute to someone demonstrating resilience. Relational patterns consider the individual relationships that support resilience. Situational patterns are the experiences of an individual that create resilience opportunities. Lastly, the philosophical pattern involves the belief that one can find positive meaning in life experiences. Polk’s theory considers that the science of nursing and resilience share the theme that people are more than an aggregate sum of their individual parts (Polk 1997). Nurse leaders are an ideal sample to demonstrate Polk’s theory in action.

Methods This study aspired to identify nurse leaders who demonstrate resilience in the area of their disposition, have relational support, successfully navigate situations that are challenging and believe there is meaning in their profession. A quantitative and descriptive study design was used to investigate the relationship between the variables of resilience, job satisfaction and anticipated turnover. Using the G*Power analysis program (Erdfelder et al. 1996) to demonstrate a statistically relevant finding, a minimum sample size of approximately 82 respondents was recommended (alpha 0.05, power 0.80 and an effect size 0.30). Prior to the initiation of the research study, approval from the health-care organisation’s Institutional Review Board (IRB) was received. The role of the IRB is to ensure the protection of human subjects. This study received an expedited review and approval due to its minimal risk to survey respondents. A convenience sample of approximately 495 nurse leaders (bedside, department, division, and/or organisational level) employed by a multi-hospital healthcare organisation located in southwestern Virginia was sent an IRB approved survey link via email. This not-for-profit organisation is the largest provider of hospital and health-care services in western Virginia and southern West Virginia, serves 18 counties and six cities, and over 1 million patients are seen throughout the system each year. Nurse leaders were surveyed using a demographic data sheet, the ConnorDavidson resilience scale (CD-RISC), a single-item job satisfaction (JS) scale, and the anticipated turnover scale (ATS). Participation was voluntary and confidential. The electronic survey remained active for 14 days to allow time for completions to occur. Only completed surveys were included in data analyses. There were no reported IRB concerns. E64

The study variables included resilience, job satisfaction and anticipated turnover. The predictor variable of resilience was operationally defined as the total cumulative score on the Connor-Davidson resilience scale (CD-RISC). Respondents were asked to consider the past month when they responded to each item. The scale contains 25 items, each of which carries a five point range of responses from 0 to 4 (range 0–100), with 0 corresponding to ‘not true at all’, to 4 corresponding to ‘true nearly all of the time’. As the CD-RISC score increases, respondents are considered more resilient. Connor and Davidson (2003) define resilience as a raw score greater than 80, and high resilience as one standard deviation from the resilience score of 80 (score of 92). The second predictor variable, job satisfaction, was operationally defined as a respondents’ answer to the survey question, ‘Please rate your satisfaction with your current nurse leader job using the scale provided (1–5)’. This job satisfaction survey question had a Likert response from 1 (not satisfied) to 5 (highly satisfied). The outcome variable of anticipated turnover in nurse leaders was operationally defined as the total score on the anticipated turnover scale (ATS) (Hinshaw & Atwood 1980). Hinshaw and Atwood (1980) designed the 12 item, seven point Likert ATS scale to measure ‘anticipated turnover’, which they described as a nurse’s plan to leave his/her position (anticipated) and the eventual turnover from a current position. Response selections are on a continuum that ranges from ‘strongly disagree’ (0 points) to ‘agree strongly’ (7 points) with higher scores indicating a lower likelihood of anticipated turnover by the respondent (range 0–84). Half of the survey questions were reverse coded.

Results Descriptive statistics were used to analyse the demographic data. Frequency distributions were used to describe percentages of registered nurses for each categorical background variable (gender, race, highest degree held and organisational position). For each continuous descriptive variable, measure of central tendency (mean, median and mode) and variability (range and standard deviation) were used to describe the variable. A Cronbach alpha was conducted for the CD-RISC (0.92) and the ATS (0.83), with item reliability coefficients for the subscales in the range 83.38–84.43 and 50.54–52.69, respectively. These results are consistent with prior published literature ª 2015 John Wiley & Sons Ltd Journal of Nursing Management, 2016, 24, E62–E69

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using these instruments (0.87 and 0.84, respectively). To analyse the relationships between continuous variables (resilience, job satisfaction and anticipated turnover), Pearson correlations were used. A regression analysis was conducted for the same variables to further examine the colinearity among resilience, job satisfaction and anticipated turnover. Finally, principal components were calculated to clarify the relationship. There were 89 completed surveys, resulting in a response rate of 17%, that were included in the analyses. Of the completed surveys, the vast majority of respondents were white (n = 78, 87.6%) females (n = 77, 86.5%). About one-third of these nurse leaders were educated at the bachelor’s degree level (n = 32, 36%) with their highest level of nursing education to the same level (n = 37, 41.6%). Regarding employment, the majority of respondents were employed full-time (n = 79, 88.8%), with an average of 19 years of nursing experience and an average of 8.5 years of nurse leader experience. All eight hospitals from the health-care organisation were represented in the sample, and a majority (n = 52, 58.4%) were employed at the organisation’s largest and only tertiary hospital. The respondents reported an average of 15 years of employment history with their current employer. Additionally, almost half the respondents described their current nursing position as bedside nurse leaders (n = 40, 44.9%) followed by a distant second of nurse director (n = 20, 22.5%). Table 1 provides a summary of this data analysis. To calculate resilience and anticipated turnover this study used the total score on the CD-RISC and the ATS, respectively. For the CD-RISC, scores may range from 0 to 100 and the ATS from 0 to 84. The sample responses were in the range 52–100 and 16–78, respectively. The mean CD-RISC score was 84.60 with a standard deviation of 11.13, and the mean score for the ATS was 59.87 with a standard deviation of 13.00. For CD-RISC, a higher score reflects a higher degree of resilience, while a higher ATS score reflects a lower likelihood of anticipated turnover. These results reflect a sample of nurse leaders who are more than likely not to remain in their current job and view themselves as highly resilient. The two-tailed Pearson correlation analysis shows a statistically significant relationship between resilience and anticipated turnover (r = 0.45). This sample reported a mean job satisfaction score of 3.5 on a five point Likert scale (SD = 1.14). The results showed that nurse leaders were satisfied with their job, but not highly satisfied. An additional Pearson correlation analysis for CD-RISC and JS was ª 2015 John Wiley & Sons Ltd Journal of Nursing Management, 2016, 24, E62–E69

Table 1 Demographics of survey respondents Categorical variable Race White Black or African American Asian American Indian/Alaska Native Native Hawaiian/Pacific Islander Two or more races Declined to answer Gender Male Female General education Associates Diploma Bachelors Masters Doctorate Declined to answer Nursing education Associates Diploma Bachelors Masters Doctorate Declined to answer Employment status Full-time Part-time Per diem/flex/as needed Declined to answer Current nurse leader position Clinical team leader Nurse manager Nurse supervisor Nurse director Nurse executive Nurse educator (graduate leadership courses) Consultant for nurse leaders or executives Declined to answer Continuous variables Age Years as a registered nurse Years employed by this employer Years as a nurse leader

n

%

78 1 0 0 0 1 9

87.6 1.1 0 0 0 1.1 10.1

3 77

3.4 86.5

15 8 32 19 3 12

16.9 9.0 36.0 21.3 3.4 13.5

19 2 37 18 3 10

21.3 2.2 41.6 20.2 3.4 11.2

79 1 0 9

88.8 1.1 0 10.1

40 14 1 20 2 1 0 11 Mean 47.33 19.14 15.21 8.58

44.9 15.7 1.1 22.5 2.2 1.1 0 12.4 SD 9.796 10.875 8.891 7.653

completed. The results reflect that there is a statistically significant relationship between resilience and job satisfaction (r = 0.51). For this sample of nurse leaders, the more resilient the leader was, the more satisfied he/she was with the leadership position. An additional correlation analysis for ATS and JS was completed as a final analysis to determine the correlation between the two variables. There is ample literature that has shown a direct relationship between job satisfaction and anticipated turnover. These results reflect that historical finding, with a statistically significant relationship between job satisfaction and anticipated turnover (r = 0.68). Simply stated, the more satisfied a nurse leader was, the less like the leader E65

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Table 2 Descriptive statistics for summed scales

ATS sum CDRISC sum JS sums

Mean

Standard deviation

n

59.87 84.60 3.5

13.00 11.13 1.14

78 73 78

Table 3 Correlation results for ATS, CD-RISC and JS ATS sums ATS sum CDRISC sum JS sums

Pearson correlation Sig. (two-tailed) Pearson correlation Sig. (two-tailed) Pearson correlation Sig. (two-tailed)

1 0.45** 0.00 0.68** 0.00

CDRISC sum 0.45** 0.00 1 0.51** 0.00

JS sums 0.68** 0.00 0.51** 0.00 1

porate e-mail system from the nursing research department, to the senior nursing directors, and then forwarded to front-line nurse leaders. This multistepped e-mail process may have decreased response rates to the survey. Due to the low survey response rate and high number of ‘decline to answer’ responses in the demographic data, results from this study should be viewed as preliminary and a replicated study should be considered to validate the current findings. The use of a single satisfaction survey question, while functional in its purpose, limited the depth in understanding nurse leaders’ job satisfaction. Future studies may consider the complexity of the job satisfaction construct and utilise a tool that has more precise satisfaction subscales.

Implications for nurse leaders

**Correlation is significant at the 0.01 level (two-tailed).

was to leave his/her position. Tables 2 and 3 provide summary data related to this analysis. A regression analysis revealed that the relationship between JS and ATS was so strong (R2 = 0.47) that a principle components analysis (PCA) was used to explore the possibility that the two variables were measuring the same construct. The PCA produced a single component (eigenvalue = 1.68) accounting for more than 84% of the variance; the two variables measure the same construct, which was labelled intent to remain (ITR). CD-RISC correlated 0.53 with ITR, indicating that resilience has a significant relationship with a nurse leader’s intent to remain in a leadership position. Figure 1 reflects the relationships identified between resilience, job satisfaction, anticipated turnover and ITR.

Limitations The dissemination process for the survey may have limited responses by nurse leaders. To protect nurse leaders’ privacy, the survey was sent through the cor-

The results of this study provide evidence that resilience plays a vital role in enhancing job satisfaction and mitigating the anticipated turnover of nurse leaders. Additionally, there is anecdotal evidence to support the inherent value that resilience has for vulnerable nurses (Giordano 1997, Tusaie & Dyer 2004, Hodges et al. 2005). Resilient nurses may find their way through challenging work climates and situations, leading to a greater sense of job satisfaction that is directly related to job retention (Jackson et al. 2007). As another nursing shortage arrives at the doorstep of the health-care industry, nurse leaders will influence the shortage in two ways. First, they are part of the recruitment and retention efforts employed by hospitals to hire new talent or retain the talented nurses they currently employ. Second, as the general nursing shortage increases, woven in this shortage are nurse leaders who, like their staff nurse counterparts, are leaving the health-care industry. To mitigate the impact of this nursing shortage, nurse leaders must enhance their own resilience and then recruit, hire and retain resilient nurses within their department.

r=

0.

51

r = 0.68

Job satisfaction (JS)

Resilience (CD-RISC)

r = 0.53

r=

JS/ATS = PCA 84% = Intent to Remain (ITR)

0.4

5 Anticipated turnover (ATS)

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Intent to remain

Patient outcomes

Figure 1 Relationships between resilience, job satisfaction and anticipated turnover in nurse leaders. ª 2015 John Wiley & Sons Ltd Journal of Nursing Management, 2016, 24, E62–E69

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Development of resilience in nurse leaders

Dispositional pattern Focus on strengths Awareness of weaknesses Practice selfconfidence

Figure 2 Synthesis of Polk and Beeson’s resilience concepts for the development of resilience in nurse leaders.

Situational patterns Active coping Positive taxonomy Positive worldview Regulate emotions

Relational patterns Develop a positive professional and personal network Empower others through delegation

Philosophical patterns Find your passion Seek to serve others Explore personal faith and/or spiritual beliefs

Increase in resilience

Developing resilience

Building a resilient team

Resilience is a trait that can be taught and developed with practice (Masten 2001). A nurse leader who struggles to bounce back after adversity (work or personal) can develop resilience behaviours that will become protective during future challenges. A synthesis of Polk’s (1997) mid-range theory for patterns of resilience and Beeson’s (2012) traits of resilient people provide a strong framework for nurse leaders to enhance their resilience. The first step in this process is for the nurse leader to complete a self-assessment of his/her general disposition. The nurse leader should consider if she/he tends to be optimistic, happy and generally content. Or does he/she tend to be pessimistic, negative and wait for the proverbial shoe to fall? The nurse leader who is aware of weakness and actively seeks new ways to focus on strengths is likely to experience a higher degree of self-confidence – an essential building block of resilience. A nurse leader can address the situational pattern of resilience through practising healthy coping strategies, using a positive taxonomy, adopting a positive worldview, regulating his/her emotions, focusing on his/her strengths and being aware of his/her weakness and practising self-confidence. To enhance the relational pattern of resilience, the nurse leaders can develop a professional and personal network of positive mentors and cheerleaders. Additionally, the nurse leader can use empowerment of others to decrease work demands and to develop the leaders’ nursing team. Finally, to develop the philosophical pattern of resilience, the nurse leader can define (or re-define) his/her passions, consider the value of serving others, and explore personal faith and/or spiritual beliefs. Data support that a belief in something greater than oneself is a protective quality leading to resilience (Beeson 2012). With each of these steps, resilience skills are enhanced and integrated in behaviours can then influence others. Figure 2 reflects the process of building resilience in the nurse leader.

Nurse leaders can foster and develop resilience in their existing team by offering training related to the resiliencebuilding strategies explored in this article. Additionally, the nurse leader can support an active hiring process that identifies resilient nurses during interviews through the use of behavioural interview techniques. The nurse leader will want the interviewee to be able to explore critical thinking skills in the framework of resilience. This is effectively done by presenting interview questions that are targeted at resilience skills. There are four interview questions that will help screen for these skills: 1 Relational pattern question: Building a rapport is sometimes a very challenging thing to do. Give an example of a time when you were able to build a rapport with someone at work, even when the situation was difficult. 2 Dispositional pattern question: It is essential to be aware of your strengths and weakness in a professional setting. Give an example of how you used your strengths to compensate for your weakness to achieve a specific goal. 3 Situational pattern question: Give me an example of a time at work when you had to deal with unreasonable exceptions of you. What coping strategies did you use to remain positive? 4 Philosophical pattern question: Give an example of how you used your leadership skills to serve the needs of others (Behavioral Technology, Inc. 1995).

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Raising the resilient nurse leader Much like the proverb ‘it takes a village to raise a child’, nurses and nurse leaders can be nurtured by their ‘village’ of nurse educators and human resource personnel in a way that fosters resilience development. Each new nurse is a potential nurse leader and should have his/her resilience supported at the earliest possible opportunity. Nurse educators have an opportunity to assist

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graduating nursing students to develop resilience through increasing awareness of their own protective factors and learning how to operationalise these protective factors when coping with the challenges of their first nursing position (Stephens 2013). Once in practice, new nurses can participate in preceptorship programmes that facilitate increased self-awareness related to triggers that lead to distress, how and why the nurse responds to the trigger, and ways to alter the response so nurses are able to regulate their emotions and behaviour. This development has the potential to improve resilience, personally and professionally (Sergeant & Laws-Chapman 2012). Any nurse who has an interest in leadership will benefit from an organisational commitment to professional development activities targeted at the development of resilience. This can include cognitive education, counselling, and environmental changes (e.g. quiet places for breaks at work) (Grafton et al. 2010). Ultimately, a nurse and nurse leader has accountability for his/her own resilience, but organisational support can be an essential component in supporting individual efforts.

Conclusion There is a difference between being ‘strong’ in the face adversity and demonstrating resilience. Being ‘strong’ simply means that one can endure a tough situation and still be standing when it is over. Resilience capitalises on that strength, but has the added benefit of learning life lessons during the adversity. This empowers a person to experience future challenges with new insights. Nurses who have the privilege of leading others understand that a leadership role is often fraught with adversity. The same nurses know that with each adversity, we can teach ourselves and those we serve valuable professional lessons. Resilience is a key skill in successful leadership and should be fostered, mentored and taught to all nurses. If we can help our nurses bounce, maybe fewer will roll away.

Source of Funding No funding.

Ethical Approval This study was submitted to Carilion Clinic’s Institutional Review Board and was given an expedited review and approval.

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Resilience, job satisfaction and anticipated turnover in nurse leaders.

The aim was to identify relationships between resilience, job satisfaction and anticipated turnover among nurse leaders...
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