Joumal of Advanced Nursmg, 1992,17,1369-1376
Staff tumover among hospital nurses Stephen J Givanagh RGN PhD Professor of Nursing, Universtty of Wolverhampton, Wolverhampton, West Midlands, England
and Douglas A Cofifm RN PhD Asststant Professor, Lehman College, City University of New York, New York, USA
Accepted for publication 3 March 1992
CAVANAGH S J & COFFIN D A (1992) Journal of Advanced Nursmg 17, 1369-1376
Stafif tumover among hospital nurses Nursmg stafif tumover remams a fmanaal concem to public as well as pnvate mstitutions, and it has an impact on stafif morale and workmg practices Evidence suggests that staff tumover could also have a detrimental effect on patient care Numerous studies have exammed the reasons why staff leave their jobs, but these have often produced conflictmg findmgs and have frequently rebed upon bivanate correlation or multiple regression techniques The availability of analytical techniques such as structural modelhng provides an opportunity to examme several aspects of tumover behaviour simultaneously, and overcome some of the methodological difhculties encountered by pnor research This study involved 221 female nurses workmg full-time m hospitals to exanune aspects of the nursmg tumover model Usmg modellmg techniques, this current study found job satisfaction and participation at work to be important vanables m the tumover process This is m keepmg with other models of nursmg tumover BACKGROUND
methodological difidculties (Van der Merwe & Miller
The problems surrounding nursing tumover have been weU documented (Wandelt et al 1981, Cavanagh 1990) In particular, there are concems about the impact of himover on staff morale, pattems of commumcahon and workmg practices Tumover is also expensive m tenns of hmng, trammg, updatmg and mamtammg nursmg staff There is evidence that himover can have a detnmental psydiological effed on patient care (PhiUips 1987) and leads to mcreased tmie spent by patients m hospital (Revans 1964) While there is debate about the posihve mfluences (Cavanagh 1989), himover evokes pnmanly negahve . .
^971), there is bttle agreement amongst researdiers, for ^ ^ ^ P l ^ ' ^ow himover should be defmed, measured and ^^^'^ presented What has emerged is that the calculation °^ ^ ^^^''^8^ l^^g*^ °f '^'^'^^ '« ^ important and the '""st frequently quoted measure of nursmg himover The ^^^^^ge '^"g^h of stay is typicaUy computed by calculahon °^ ^^^ ™ ^ ^ ' ^ ^^^ ' " ^ ' ^ ^ °^ ^ dishibution of individuals ^^^^mg employment Pnce (1977) states that this method ^""^ ^^^ advantage that these measures are relahvely easy ^° ' ^ ' ^ ^ ^ ^ ^ ^ ^° ""^ " ^ ' l longihidinal data These measures of cenh-al tendency are also relahvely easy to calculate and understand m the context of tumover The design of tumover studies is an important issue Newman (1974) identifies the use of bivanate correlation studies as problemahc m the study of tumover because ^^ ^^^ over-simpbstic view of himover adopted by p p
Meas rement The shidy of himover behaviour has presented many
T!^^
\ L T . ^ ! : ^ U ! ! ! " " W ^ 1 ^r^^Jt
Wolverhampton 61-68 Uchfietd Street Wolverhampton, West Midlands WVl lDJ,
researdiers As a result there exists m the nursing him°
over bterature many mconsistent and conflidmg fmdmgs 1369
SJ Cavanagh and D A Coffin
Addihonally, mulhvanate studies have generally low values for explcimed vanance Nursmg tumover is more complex than such studies suggest The knowledge that bivanate and multivanate studies can lead to lncondusive findings has forced researchers to look at different ways of studying tumover One importjmt method is causal modeUmg This tedmique can permit the simultaneous use of factor analyhc techniques and regression models (Bentler 1989) An important example of this IS the work of Pnce & Mueller (1981) who developed a model of nursmg tumover m which an individual's perceived likelihood to stay m employment was the most important predictor of a nurse changing his or her job This study IS important m the nursing tumover literature because of its prospective design, sample size (n = 1091) and the modelbng techmques used The fmdmgs from this study make a powerful case for the existence of a complex relationship between vanables which may lead staff to change jobs Pnce and Mueller's work produces a plausible model for nursmg tumover worth lnvestigatmg further
The purpose of this study was to exanune aspects of the model of nursing tumover proposed by Pnce & MueUer (1981) using vanables known to have a relatively consistent and repeatable relahonship with tumover
MueUer (1981) observe that previous tumover research has focused on manufactunng or produdion areas, and not service areas such as hospitals The use of the hospitals, then, provides an opportumty to examme withm service settings, models developed within industry For-proftt and non-profit hospitals were mduded m the sample FuU-hme females nurses with a history of tumover were induded m this study, newly graduated nurses, or those who had not changed jobs, were exduded While there are many practiang male nurses, they constitute less than 10% of the USA's total registered nurse workforce (and less than 5% m the mshtutions partiapatmg in this study) The mclusion and analysis of this smaU proportion of male nurses could aeate a skewed dichotomous distnbuhon (male/female) which could distort the type 1 error rate, male nurses were therefore exduded from this study It IS acknowledged that there are a substanhal number of registered nurses workmg pairt-time withm hospitals (Pnce & MueUer (1981) reported that 38% of the registered nurses m their study worked part-time) In the institutions used m this study, many of the part-time staff were employed for only one or two shifts per week, these nurses were omitted from the study Staff workmg in general medical and surgical units were mduded, as most hospitals offer these services Specialized units, such as mtensive care, were exduded to eliminate the possibibty of unitspeafic tumover associated with high-technology or other factors All work shifts were included to maximize the availabibty of subjects
Sample
Vanables
METHODOLOGY Purpose
The vanables used in this study were identified m the The sample consisted of 221 female nurses workmg bterature by Pnce & MueUer (1981) as havmg a consistent full-time m hospitals on the west coast of the United States and repeatable relationship with tumover The vanables All subjects were mformed in wntmg about the purpose of mduded were intent to stay (the perceived likelihood of the study and of their nghts as human subjeds Specifically, an individual staying withm an organizahon), job satistheir responses would be anonymous and they could fadion, pay, promotion, opportunity (the potenhal for withdraw from the study at any hme without prejudice advancement withm an individual's chosen field of work Staff nurses constituted the largest (64 2%) part of the outside their current organization), kinship and family sample, with 35 8% bemg charge nurses or supervisors responsibilities, mstrumental commumcahon (the amount Most of the respondents (89 5%) were aged withm the of mformahon an individual receives from an employmg 29-59 range, with 8% less than 25 years and 2 5% older organizahon), routine (the perceived occurrence of repetithan 60 Fifty-three per cent of the sample eamed between hve work), educahon and trammg, and parhapation (the $25 000 and $34 000, with only 7% eammg less than amount of mvolvement an individual can apply to their $20 000 and 3% more than $40 000 The predominant shift work was days (38 2%), with 15 5% evenings, nights own working environment) 19 3%, and other shift pattems 27% Forty-seven per cent of subjects had xmdergraduate degrees and 11 2% Instrumentation possessed postgraduate awards Subjeds were required to complete two questionnaires Hospitals mduded m the sample were of medium size, The first obtamed demographic details and measured tumnamely, having between 100 and 650 beds Pnce & over rate This rebed on staff to examme their tumover 1370
Staff tumover
the model of nursmg tumover suggested by Price & Mueller (1981) Curry et al (1985), in their shidy of tumover, call those variables on the left of the model exogenous vanables, this convention will be used here Arrowed bnes mdicate the proposed relationships between Tumover vanables Several important features emerge from this model First, while the evidence for including vanables in this model can be found m nursing studies, strong evidence KiBstup icsponsibilitKs exists that these vanables are important in tumover behaviour in non-nursmg situations as weU This model suggests Education and training that nursing does not have any specific or unique vanables Figure 1 Pnce & Mueller's (1981) model of nursmg tumover associated with staff tumover Second, the model specifies (repnnted from Professional Tumover The Case for Nurses Iowa the foUowmg (a) those vanables that have a direct State University Press, Ames) influence on tumover (opportumty, education and traimng, and intent to stay), and (b) the effect of the exogenous charactenstics The second assessed respondent's scores vanables on tumover that may be mediated by mtervenmg on the selected variables, and was based upon work by vanables (job satisfachon and intent to stay) Third, the Pnce & MueUer (1981) These authors determmed the model permits a determmation to be made of the relative intemal consistency of this mstrument, the overall alpha importance of exogenous and mtervenmg vanables on was 0 83, while the range of mdividual subscales was 0 74 tumover to 0 90 Validity was determmed by usmg factor loadings, these ranged from 0 54 to 0 89
DATA ANALYSIS
Procedure Hospitals within the designated geographical location having general medical and surgical nursmg units were ldenhfied by usmg a hospital director (Amencan Hospital Association 1985) A letter of mtroduction was sent to the hospital's admmistrators outlining the proposed study and, whenever possible, a meeting was arranged Some hospitals permitted an on-site visit pnor to commencing the study to talk to potential respondents, while others only allowed the distnbution of questionnaires None of the seven facilities parhcipatmg m this study granted access to personnel records to venfy staff tumover details The questiormaires were distnbuted either in person, via the mtemal post, or with pay cheques to those wishing to participate A conveniently located box (usually m nursing units) was arranged for the coUection of completed questionnaires, and an envelope with the researcher's address was provided to ensure the anonymity of respondents A foUow-up visit was made, or reminder letters sent, after 2 weeks It should be noted that this procedure was different from that used by Pnce & Mueller (1981) m that they used a longitudinal study The proposed model The model m Figure I mdudes those vanables descnbed previously This arrangement of vanables is based upon
The retumed questionnaires were scored and the results tabulated Subjects received an interval level score on each mdependent vanable and a measure of their average length of employment was made The data were exammed for missmg values, outbers and skewed distnbutions Pnor to amalysis using the EQS program (Bentler 1990) a correlation matnx was prepjired from the data (Table 1)
RESULTS The average length of employment of respondents was 26 97 months, with a standard deviation of 25 5 months Information about vanables mduded m this model can be found m Table 2 A goodness of fit (chi-squared) analysis was performed on the data produced from the model (x^ = 31255, df = 3 3 , P = 0 554) The nuU hypothesis tested was that there was no statisticcdly significant difference between the model (Figure 1) and the data obtained from the study The non-significant chi-squared statistic can be interpreted as a rejection of the nuU hypothesis, and that there is a good fit between data and model As a further indicator of the goodness of fit, the Bentler-Bonnett fix index (Bentler 1990) was calculated as 0 983 Bentler considers that an index of 0 9 or better is an exceUent overall fit between proposed model and data Some covanance was found among vanables, with 1371
SJ Cavanagh and DA Coffin
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Staff tumover among hospital nurses Stephen J Givanagh RGN PhD Professor of Nursing, Universtty of Wolverhampton, Wolverhampton, West Midlands, England
and Douglas A Cofifm RN PhD Asststant Professor, Lehman College, City University of New York, New York, USA
Accepted for publication 3 March 1992
CAVANAGH S J & COFFIN D A (1992) Journal of Advanced Nursmg 17, 1369-1376
Stafif tumover among hospital nurses Nursmg stafif tumover remams a fmanaal concem to public as well as pnvate mstitutions, and it has an impact on stafif morale and workmg practices Evidence suggests that staff tumover could also have a detrimental effect on patient care Numerous studies have exammed the reasons why staff leave their jobs, but these have often produced conflictmg findmgs and have frequently rebed upon bivanate correlation or multiple regression techniques The availability of analytical techniques such as structural modelhng provides an opportunity to examme several aspects of tumover behaviour simultaneously, and overcome some of the methodological difhculties encountered by pnor research This study involved 221 female nurses workmg full-time m hospitals to exanune aspects of the nursmg tumover model Usmg modellmg techniques, this current study found job satisfaction and participation at work to be important vanables m the tumover process This is m keepmg with other models of nursmg tumover BACKGROUND
methodological difidculties (Van der Merwe & Miller
The problems surrounding nursing tumover have been weU documented (Wandelt et al 1981, Cavanagh 1990) In particular, there are concems about the impact of himover on staff morale, pattems of commumcahon and workmg practices Tumover is also expensive m tenns of hmng, trammg, updatmg and mamtammg nursmg staff There is evidence that himover can have a detnmental psydiological effed on patient care (PhiUips 1987) and leads to mcreased tmie spent by patients m hospital (Revans 1964) While there is debate about the posihve mfluences (Cavanagh 1989), himover evokes pnmanly negahve . .
^971), there is bttle agreement amongst researdiers, for ^ ^ ^ P l ^ ' ^ow himover should be defmed, measured and ^^^'^ presented What has emerged is that the calculation °^ ^ ^^^''^8^ l^^g*^ °f '^'^'^^ '« ^ important and the '""st frequently quoted measure of nursmg himover The ^^^^^ge '^"g^h of stay is typicaUy computed by calculahon °^ ^^^ ™ ^ ^ ' ^ ^^^ ' " ^ ' ^ ^ °^ ^ dishibution of individuals ^^^^mg employment Pnce (1977) states that this method ^""^ ^^^ advantage that these measures are relahvely easy ^° ' ^ ' ^ ^ ^ ^ ^ ^ ^° ""^ " ^ ' l longihidinal data These measures of cenh-al tendency are also relahvely easy to calculate and understand m the context of tumover The design of tumover studies is an important issue Newman (1974) identifies the use of bivanate correlation studies as problemahc m the study of tumover because ^^ ^^^ over-simpbstic view of himover adopted by p p
Meas rement The shidy of himover behaviour has presented many
T!^^
\ L T . ^ ! : ^ U ! ! ! " " W ^ 1 ^r^^Jt
Wolverhampton 61-68 Uchfietd Street Wolverhampton, West Midlands WVl lDJ,
researdiers As a result there exists m the nursing him°
over bterature many mconsistent and conflidmg fmdmgs 1369
SJ Cavanagh and D A Coffin
Addihonally, mulhvanate studies have generally low values for explcimed vanance Nursmg tumover is more complex than such studies suggest The knowledge that bivanate and multivanate studies can lead to lncondusive findings has forced researchers to look at different ways of studying tumover One importjmt method is causal modeUmg This tedmique can permit the simultaneous use of factor analyhc techniques and regression models (Bentler 1989) An important example of this IS the work of Pnce & Mueller (1981) who developed a model of nursmg tumover m which an individual's perceived likelihood to stay m employment was the most important predictor of a nurse changing his or her job This study IS important m the nursing tumover literature because of its prospective design, sample size (n = 1091) and the modelbng techmques used The fmdmgs from this study make a powerful case for the existence of a complex relationship between vanables which may lead staff to change jobs Pnce and Mueller's work produces a plausible model for nursmg tumover worth lnvestigatmg further
The purpose of this study was to exanune aspects of the model of nursing tumover proposed by Pnce & MueUer (1981) using vanables known to have a relatively consistent and repeatable relahonship with tumover
MueUer (1981) observe that previous tumover research has focused on manufactunng or produdion areas, and not service areas such as hospitals The use of the hospitals, then, provides an opportumty to examme withm service settings, models developed within industry For-proftt and non-profit hospitals were mduded m the sample FuU-hme females nurses with a history of tumover were induded m this study, newly graduated nurses, or those who had not changed jobs, were exduded While there are many practiang male nurses, they constitute less than 10% of the USA's total registered nurse workforce (and less than 5% m the mshtutions partiapatmg in this study) The mclusion and analysis of this smaU proportion of male nurses could aeate a skewed dichotomous distnbuhon (male/female) which could distort the type 1 error rate, male nurses were therefore exduded from this study It IS acknowledged that there are a substanhal number of registered nurses workmg pairt-time withm hospitals (Pnce & MueUer (1981) reported that 38% of the registered nurses m their study worked part-time) In the institutions used m this study, many of the part-time staff were employed for only one or two shifts per week, these nurses were omitted from the study Staff workmg in general medical and surgical units were mduded, as most hospitals offer these services Specialized units, such as mtensive care, were exduded to eliminate the possibibty of unitspeafic tumover associated with high-technology or other factors All work shifts were included to maximize the availabibty of subjects
Sample
Vanables
METHODOLOGY Purpose
The vanables used in this study were identified m the The sample consisted of 221 female nurses workmg bterature by Pnce & MueUer (1981) as havmg a consistent full-time m hospitals on the west coast of the United States and repeatable relationship with tumover The vanables All subjects were mformed in wntmg about the purpose of mduded were intent to stay (the perceived likelihood of the study and of their nghts as human subjeds Specifically, an individual staying withm an organizahon), job satistheir responses would be anonymous and they could fadion, pay, promotion, opportunity (the potenhal for withdraw from the study at any hme without prejudice advancement withm an individual's chosen field of work Staff nurses constituted the largest (64 2%) part of the outside their current organization), kinship and family sample, with 35 8% bemg charge nurses or supervisors responsibilities, mstrumental commumcahon (the amount Most of the respondents (89 5%) were aged withm the of mformahon an individual receives from an employmg 29-59 range, with 8% less than 25 years and 2 5% older organizahon), routine (the perceived occurrence of repetithan 60 Fifty-three per cent of the sample eamed between hve work), educahon and trammg, and parhapation (the $25 000 and $34 000, with only 7% eammg less than amount of mvolvement an individual can apply to their $20 000 and 3% more than $40 000 The predominant shift work was days (38 2%), with 15 5% evenings, nights own working environment) 19 3%, and other shift pattems 27% Forty-seven per cent of subjects had xmdergraduate degrees and 11 2% Instrumentation possessed postgraduate awards Subjeds were required to complete two questionnaires Hospitals mduded m the sample were of medium size, The first obtamed demographic details and measured tumnamely, having between 100 and 650 beds Pnce & over rate This rebed on staff to examme their tumover 1370
Staff tumover
the model of nursmg tumover suggested by Price & Mueller (1981) Curry et al (1985), in their shidy of tumover, call those variables on the left of the model exogenous vanables, this convention will be used here Arrowed bnes mdicate the proposed relationships between Tumover vanables Several important features emerge from this model First, while the evidence for including vanables in this model can be found m nursing studies, strong evidence KiBstup icsponsibilitKs exists that these vanables are important in tumover behaviour in non-nursmg situations as weU This model suggests Education and training that nursing does not have any specific or unique vanables Figure 1 Pnce & Mueller's (1981) model of nursmg tumover associated with staff tumover Second, the model specifies (repnnted from Professional Tumover The Case for Nurses Iowa the foUowmg (a) those vanables that have a direct State University Press, Ames) influence on tumover (opportumty, education and traimng, and intent to stay), and (b) the effect of the exogenous charactenstics The second assessed respondent's scores vanables on tumover that may be mediated by mtervenmg on the selected variables, and was based upon work by vanables (job satisfachon and intent to stay) Third, the Pnce & MueUer (1981) These authors determmed the model permits a determmation to be made of the relative intemal consistency of this mstrument, the overall alpha importance of exogenous and mtervenmg vanables on was 0 83, while the range of mdividual subscales was 0 74 tumover to 0 90 Validity was determmed by usmg factor loadings, these ranged from 0 54 to 0 89
DATA ANALYSIS
Procedure Hospitals within the designated geographical location having general medical and surgical nursmg units were ldenhfied by usmg a hospital director (Amencan Hospital Association 1985) A letter of mtroduction was sent to the hospital's admmistrators outlining the proposed study and, whenever possible, a meeting was arranged Some hospitals permitted an on-site visit pnor to commencing the study to talk to potential respondents, while others only allowed the distnbution of questionnaires None of the seven facilities parhcipatmg m this study granted access to personnel records to venfy staff tumover details The questiormaires were distnbuted either in person, via the mtemal post, or with pay cheques to those wishing to participate A conveniently located box (usually m nursing units) was arranged for the coUection of completed questionnaires, and an envelope with the researcher's address was provided to ensure the anonymity of respondents A foUow-up visit was made, or reminder letters sent, after 2 weeks It should be noted that this procedure was different from that used by Pnce & Mueller (1981) m that they used a longitudinal study The proposed model The model m Figure I mdudes those vanables descnbed previously This arrangement of vanables is based upon
The retumed questionnaires were scored and the results tabulated Subjects received an interval level score on each mdependent vanable and a measure of their average length of employment was made The data were exammed for missmg values, outbers and skewed distnbutions Pnor to amalysis using the EQS program (Bentler 1990) a correlation matnx was prepjired from the data (Table 1)
RESULTS The average length of employment of respondents was 26 97 months, with a standard deviation of 25 5 months Information about vanables mduded m this model can be found m Table 2 A goodness of fit (chi-squared) analysis was performed on the data produced from the model (x^ = 31255, df = 3 3 , P = 0 554) The nuU hypothesis tested was that there was no statisticcdly significant difference between the model (Figure 1) and the data obtained from the study The non-significant chi-squared statistic can be interpreted as a rejection of the nuU hypothesis, and that there is a good fit between data and model As a further indicator of the goodness of fit, the Bentler-Bonnett fix index (Bentler 1990) was calculated as 0 983 Bentler considers that an index of 0 9 or better is an exceUent overall fit between proposed model and data Some covanance was found among vanables, with 1371
SJ Cavanagh and DA Coffin
a.
I
I
o
8
I E
u
I 1
I
I o
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