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Intent to Stay: A Pilot Study of Baccalaureate Nurses and Hospital Nursing
INTENT TO STAY: A PILOT STUDY BACCALAUREATE NURSES AND HOSPITAL NURSING MARY JANE K. DIMATTIO, PHD, RN,⁎ PAULA ROE-PRIOR, PHD, RN,⁎ DONA RINALDI CARPENTER, EDD, RN⁎
OF
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Hospitals want to hire baccalaureate nurses. Even if there were sufficient numbers of baccalaureate nurses to fill hospital vacancies, however, it is unclear how long these nurses stay at the “bedside.” Until the profession can ascertain how many baccalaureate nurses stay in hospital nursing, simply preparing enough of them will not suffice. Because no published studies were identified that examined either how long baccalaureate nurses stay in hospital nursing or these nurses' reasons for leaving hospital nursing, we undertook a pilot study of our own baccalaureate graduates. Specifically, this comparative descriptive pilot study examined baccalaureate nurses' average number of years in hospital nursing and their reasons for leaving or intending to leave hospital nursing. Three hundred ninety graduates responded. Forty percent had left hospital nursing after an average of 6.4 years, with a median of 5 years. Just over 56% were still practicing hospital nursing, and of these, 81.8% were staff RNs, 26.9% of whom intended to leave hospital nursing in the next 3–5 years. Nurses who intended to leave were less satisfied in their jobs (P b .0001) than those who did not intend to leave. They were also more likely to disagree that RNs played a participatory role in hospital affairs (P = .048), that there were adequate staffing and resources (P = .041), and that RN–physician relationships were collegial (P = .048). The most frequent reasons for intent to leave were the following: to advance education or to take new positions (43%), stress/burnout, long hours, and lack of administrative support/respect (21%, respectively). Only 17% cited poor pay/benefits as a reason for intent to leave. Respondents who had already left hospital nursing cited similar reasons. Dissatisfaction with the practice environment results in baccalaureate nurses leaving hospital nursing at a time when there is a critical shortage of nurses in all practice settings, but especially hospitals. Considering the accumulating evidence of superior patient outcomes in hospitals well staffed by baccalaureate nurses, it is critical to identify and implement solutions to ensure that adequate numbers of experienced, baccalaureate nurses stay at the bedside. (Index words: Baccalaureate nurses; Hospital nurses; Personnel turnover) J Prof Nurs 26:278–286, 2010. © 2010 Elsevier Inc. All rights reserved.
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ACCALAUREATE NURSES ARE in demand. Many hospitals now prefer to hire them over nonbaccalaureate nurses (AMN Healthcare, 2007a; Burling, 2010), echoing earlier research that documented chief nursing officers' preference for hiring baccalaureate nurses in academic medical centers (Goode et al., 2001). Studies demonstrating superior patient outcomes
⁎The University of Scranton, Scranton, PA. Address correspondence to Dr. DiMattio: The University of Scranton, Department of Nursing, 800 Linden Street, Scranton, PA 18510. E-mails: [email protected], [email protected] 8755-7223/10/$ - see front matter 278 doi:10.1016/j.profnurs.2010.06.005
in hospitals employing large numbers of baccalaureate nurses have likely increased interest in this subgroup of the registered nurse workforce (Aiken, Clarke, Cheung, Sloane & Silber, 2003; Aiken, Clark, Sloane, Lake, & Cheney, 2008; Estabrooks, Midozi, Cummings, Ricker, & Giovannetti, 2005; Tourangeau et al., 2006). The studies validate the position that many have maintained for years: Baccalaureate nurses possess advanced critical thinking and problem-solving skills and hence are better prepared than nonbaccalaureate nurses for the “diagnostic and monitoring” (Benner, 1984) function of the nurse. The American Association of Colleges of Nursing (AACN) reports that enrollments in baccalaureate
Journal of Professional Nursing, Vol 26, No. 5 (September–October), 2010: pp 278–286 © 2010 Elsevier Inc. All rights reserved.
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nursing programs are up despite persistent shortages of qualified faculty (AACN, 2009). The hospital sector, which remains the largest employer of nurses and stands to be hardest hit by the projected shortage of registered nurses, would welcome an influx of baccalaureate nurses. However, even if there were sufficient numbers of baccalaureate nurses, it remains unclear how long these nurses will continue to practice “bedside” or hospital nursing because there is evidence that baccalaureate nurses' careers are characterized by several position and job changes early on (Rambur, McIntosh, Palumbo, & Reineir, 2005). Certainly, recruitment of baccalaureate nurses is important, but retention of these same nurses as they become more experienced is also essential. The loss of experienced nurses from the hospital setting impacts not only patient care but also mentoring of new, less experienced nurses. Therefore, it is critical to understand intent to stay in hospital nursing as perceived by baccalaureate nurses and factors that contribute to intent to leave. The practice environment is, perhaps, one of the greatest challenges faced by hospitals in recruiting and retaining registered nurses in general. Hospitals are simply not considered good places to work (PricewatererhouseCoopers Health Research Institute, 2007, p. 32). Furthermore, opportunities for advanced practice are attractive to new nurses. Norman, Buerhaus, Donelan, McCloskey, and Dittus (2005) reported that inasmuch as 61% of their sample of baccalaureate and associate degree nursing students planned to work in hospitals after graduation, almost a quarter had their sights set on immediate graduate studies for advanced practice. If hospital nursing is increasingly viewed as a temporary place for registered nurses to work, particularly baccalaureate nurses, then benefits to hospitalized patients will be lost. The purpose of this pilot study was to begin to address the gaps in understanding the practice patterns of baccalaureate nurses with respect to hospital nursing. Data were collected and analyzed from graduates of one baccalaureate nursing program in northeastern Pennsylvania. The aims of the study were to determine (a) the number of baccalaureate graduates currently practicing hospital nursing; (b) the numbers who left and who intend to leave hospital nursing; (c) the average time graduates practice hospital nursing before leaving; and (d) factors that contribute to leaving or planning to leave hospital nursing. Hospital nursing was defined as nursing that is practiced in a hospital, involving direct care of individuals experiencing acute illnesses, life transitions (such as childbirth), or exacerbations of chronic health conditions, and that does not include nursing in an advanced practice role or in administration.
Review of Literature A search of the CINAHL database was undertaken for studies published between 2002 and 2008 on baccalaureate nurses, hospital nursing, and nurse practice patterns using the following search terms: baccalaureate
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nurse, hospital nurses, and personnel turnover. Additional studies were identified from reference lists. Finally, national reports and white papers were reviewed for findings on the major study concepts.
Education and Intent to Stay In a study of 1,853 New York State RN's, Ingersoll, Olsen, Drew-Cates, Devinney, and Davies (2002) found that baccalaureate nurses were more likely than nurses prepared at other levels to intend to change positions in 5 years. The researchers did not report the settings in which the baccalaureate nurses were employed, however. In two studies of hospital nurses, researchers found no difference in nurses' intent on leaving their positions according to educational level (Larrabee et al., 2003; Stone et al., 2006). Larrabee et al.'s study had a small sample of 90 nurses; Stone et al. had a large sample but only studied intensive care nurses. Studies have found that half of all new nurses leave or feel ready to leave their first jobs within 2 years (Kovner et al., 2007; PricewaterhouseCoopers, 2007). In other studies, nurses who were most likely to leave or who have the intent to leave their jobs were younger (Ingersoll et al., 2002), had fewer years in the job (Larrabee et al., 2003), or had fewer years in nursing (Bowles & Candela, 2005; Larrabee et al., 2003; Strachota, Nomandin, O'Brian, Clary, & Krukow, 2003) than those who did not intend to leave. None of the studies reviewed assessed intention to leave hospital nursing altogether.
Satisfaction and Intent to Stay Not surprisingly, satisfaction was a recurring concept in studies reviewed, and it appears that baccalaureate nurses are less satisfied in their jobs than master's and doctorally prepared nurses (Buerhaus et al., 2005; Ingersoll et al., 2002). Satisfaction is an important concept because it is linked with intent to stay. In a sample of 123 recent baccalaureate graduates, nurses intending to stay in their current positions for a year were significantly more satisfied on seven of the eight dimensions of a satisfaction survey than those who did not (Roberts, Jones, & Lynn, 2004). The study included nurses working in both hospitals and outpatient settings and did not define the term recent. Rambur, Palumbo, McIntosh, and Mongeon (2003) found that job dissatisfaction was the most frequent reason given by all registered nurses who planned to leave their jobs in the next 12 months, regardless of educational level, but more baccalaureate nurses were dissatisfied. Fifty-four percent of baccalaureate nurses compared to 41% of master's-prepared nurses cited job dissatisfaction over situational reasons or career advancement as their reason for intending to leave. These studies did not report practice settings but found that nurses working in hospitals and nursing homes were the least satisfied of nurses employed in all areas, consistent with trends identified in national samples of nurses working in hospitals and nursing homes (U.S. Department of Health and Human Services [USDHHS], 2006) and in
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direct care positions (Buerhaus et al., 2005). In keeping with all of these findings, Two studies (Larrabee et al., 2003; Lynn & Redman, 2005) reported that high job satisfaction was a negative predictor of hospital nurses' intent to leave. Zangaro & Soeken (2007) conducted a meta-analysis of studies addressing staff nurses' job satisfaction. Job satisfaction was most strongly and negatively correlated with job stress, followed by physician–nurse collaboration and autonomy. It is unclear if all of the studies included in the analysis were of hospital nurses. Ulrich, O'Donnell, Taylor, and Farrar (2007) studied the impact of the ethical climate in the workplace and its relationship to job satisfaction and intent to leave hospital nursing. Feelings of powerlessness, frustration, and fatigue when ethical issues cannot be resolved were related to job dissatisfaction and intent to leave.
Practice Environment and Intent to Stay Satisfaction and, subsequently, intent to stay are linked to issues in the practice environment, which is defined as the “organizational characteristics of a work setting that facilitate or constrain professional nursing practice” (Lake, 2002, p. 178). Hospital nurses have reported being unable to “imagine” to continue working in inpatient settings unless work conditions improved (Kimball & O'Neil, 2003, p. 44). Other hospital nurses reported that scheduling, pay, poor staffing, unsupportive management, unhappy coworkers, and high patient acuity were among their reasons for terminating their employment or changing to per diem status (Strachota et al., 2003). Conversely, transformational leadership, nurse–physician collaboration, and group cohesiveness were predictors of psychological empowerment, which negatively predicted job dissatisfaction among hospital nurses (Larrabee et al., 2003). Dimensions of the practice environment also figured prominently in nurses' reasons for leaving their first jobs and included high acuity, inadequate staffing, unsafe patient care, lack of support and guidance from management, and too much responsibility (Bowles & Candela, 2005). Of the 352 nurses in the study, 93% worked in hospitals. Nurse practice patterns have been positively influenced by the practice environment in magnet hospitals. There is evidence to suggest that nurses employed in hospitals with magnet recognition experience greater satisfaction with the work environment, which links positively with retention (Cimiotti et al., 2005; Upenieks, 2003; Brady-Schwartz, 2005). Practically speaking it should be a goal to not only prepare baccalaureate nurses but also retain them at the bedside. Constant turnover has implications for jeopardizing patient care because the experience that is necessary to provide expert care is lost (Benner, 1984; Hatcher et al., 2006). No studies were identified on the length of time baccalaureate nurses remain in hospital nursing. Data from the Health Resources and Services Administration show that beginning in their early 30s, baccalaureate nurses have lower workforce participation rates than
diploma/associate nurses, and this trend continues through their early 50s when their rates of workforce participation begin to match those of diploma/associate nurses with all showing a sharp decline. Workforce participation is defined as providing nursing services or seeking employment in nursing (USDHHS, 2006). Whereas these findings are not broken down by setting, they do not bode well for hospitals seeking to employ baccalaureate nurses. In contrast, a study of Vermont nurses found that baccalaureate nurses were employed longer and had held more jobs than associate degree nurses. Statistically, more associate degree nurses worked in hospitals and direct patient care (Rambur et al., 2005). Hence, the latter study lends support to the idea that the baccalaureate degree provides for career mobility away from the direct care of patients in hospitals. In summary, the literature shows that nurses do not stay long in their first jobs; nurses in direct care roles and who have less than a master's degree are less satisfied in their jobs than those with more education, and nurses who are dissatisfied intend to leave their jobs. Factors contributing to dissatisfaction and intent to leave are related to the practice environment and include job stress related to patient acuity, inadequate staffing, inadequate support from management, and lack of collaboration with physicians. It is unclear, however, if all of these findings hold true for the subset of baccalaureate nurses and how long baccalaureate nurses stay in hospital nursing.
Methodology Design and Sample This cross-sectional, comparative descriptive pilot study surveyed baccalaureate nurses who graduated from a university in northeastern Pennsylvania. The program, which prepares traditional students in addition to offering RN and LPN to baccalaureate completion tracks, primarily draws students from Pennsylvania, New York, New Jersey, and Connecticut and has graduated more than 700 baccalaureate nurses in 26 years. There is also a graduate nursing program with several tracks at the university; however, graduates from this program were not included in the study.
Procedure Prior to data collection, approval for the pilot study was obtained from the appropriate institutional review board. With the assistance of the alumni office, a postcard was mailed to all baccalaureate graduates (n = 720) describing the study and alerting them to the arrival of a survey packet within 4 weeks receipt of the postcard. The packet contained a cover letter describing the study, assuring human subjects' protections, and requesting participation. Participants were asked to refrain from placing identifying information on the surveys and to return them in a postage-paid envelope. Because there was no system for tracking responses, a second postcard was sent to all graduates 4 weeks later, thanking those who had returned their surveys and reminding those who had not. Time to complete the survey was approximately 15 minutes.
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Instruments
Table 1. Demographics (N = 390)
After a review of the literature, a survey of demographics and practice patterns was designed by the authors, who, combined, have more than 50 years of experience teaching baccalaureate nursing students. The first page of the survey solicited information on age, years in nursing, basic education, type of practice setting, and nursing role. The second page of the survey included questions about intentions and practice patterns with regard to hospital nursing. Specifically, participants who indicated they currently worked in hospital nursing were asked how long they worked in the hospital, if they intended to leave within the next 3–5 years, and reasons for their intentions to leave. Participants were also asked their reasons for pursuing graduate education in either nursing or another discipline and to rate on a 4-point Likert scale the degree to which they were satisfied in their current jobs, with 1 indicating very satisfied and 4 indicating very dissatisfied. Participants who indicated that they had left hospital nursing were asked how long they worked in hospital nursing and why they left. Finally, respondents who worked in hospital nursing at the time of the survey were asked to complete the Practice Environment Scale of the Nursing Work Index (PES-NWI; Lake, 2002). The PES-NWI is a 31-item, fivesubscale instrument derived from the Nursing Work Index. It assesses the extent to which a practice environment possesses characteristics most strongly associated with magnet hospitals, which are known for their ability to attract and retain nurses. Lake reported satisfactory construct validity and subscale reliability coefficients ranging from alpha value of .71 to .84 for individual respondents. Reliability coefficients for this study ranged from alpha value of .80 to .87 and were almost identical to those reported by Lake for all subscales, except Collegial Nurse–Physician Relations, which was higher (α = .80) in this study.
Age, M (SD) Years in nursing, M (SD) Basic educational preparation, n (%) BSN Diploma AD LPN Missing Hospital nursing * (n = 380), n (%) Currently practice hospital nursing Left hospital nursing Never practiced hospital nursing
Data Analysis All data were analyzed using SPSS statistical software. For the entire sample, frequencies were calculated for nominal data, and descriptive statistics were calculated for interval and ratio level data. Comparisons between respondents who worked in hospital nursing and those who had left, as well as between those who intended to stay and those who intended to leave hospital nursing, were carried out using chi-square analysis and independent samples t tests.
Results Seven hundred twenty surveys were mailed, and 390 graduates responded for a response rate of 54%. The average age of respondents was 33.65 years, and the average number of years in nursing was 10.59. Ninety percent of respondents reported a baccalaureate degree as their basic education; the remainder, although now baccalaureate-prepared, reported an RN diploma or an LPN certificate as their basic educational preparation
33.65 10.59
7.30 6.59
351 27 4 7 1
90 6.9 1.0 1.8 0.003
214 157 9
56.3 41.3 2.3
* Usable surveys.
(Table 1). The questions on practice patterns with regard to hospital nursing proved to be problematic. The questions, in a yes/no format, were meant to be mutually exclusive, but several respondents gave contradictory answers. For example, a respondent who was not practicing hospital nursing at the time of the survey would not have been expected to agree that he or she was planning to leave hospital nursing in the next 3–5 years. Another area of confusion was that many respondents simultaneously worked in and outside of hospital nursing. Those respondents were coded as currently practicing hospital nursing. Hence, after carefully reviewing responses to the questions on hospital nursing, 380 respondents had usable data. Of those, 2.3% had never practiced hospital nursing, 41.3% had practiced hospital nursing and left, and 56.3% identified themselves as still practicing hospital nursing, although some of these nurses were not practicing in direct care roles. Those still practicing hospital nursing were significantly younger (M = 31.44) than those who had left (M = 36.66, t = 7.26, df = 376, P b .001) and had fewer years in nursing (M = 8.6) than those who had left (M = 13.24, t = 7.15, df = 377, P b .001). Those who were prepared as LPNs or diploma RNs before earning a baccalaureate degree were more likely to have left than those who were initially educated at the baccalaureate level (χ2 = 3.92, df = 1, P = .05). Two respondents had missing age data, and one did not report years in nursing. Of the 214 respondents who were currently practicing hospital nursing, 81.8% were practicing in direct care roles, and 26.9% of these nurses intended to leave hospital nursing within the next 3–5 years. There were no statistically significant differences in terms of age (P = .37) and number of years in nursing (P = .48) between those direct care nurses who intended to stay in hospital nursing and those who intended to leave. There were, however, statistically significant differences on subscales of the PES-NWI between direct care nurses who intended to stay in hospital nursing and those who intended to leave in 3–5 years, although six of those intending to stay had incomplete or missing data for the PES-NWI. Compared with nurses intending to stay in hospital nursing, those intending to leave were
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Table 2. Results: The Practice Environment Scale (n = 169) *
Intend to leave hospital nursing Subscale Collegial RN–physician relations Nurse participation
M
SD
2.72 2.91 2.44 2.63 2.76 2.91 2.47 2.65 2.34 2.55
0.58 0.56 0.51 0.58 0.42 0.47 0.65 0.64 0.58 0.61
t
P
Yes = 47 No = 122
Yes No Yes No Nursing foundations for Yes quality of care No RN manager ability, Yes leadership, support No Staffing and resources Yes No
−2.00 .048 .048 −1.94 −1.90 .059 −1.63 .099 −2.06 .041
* Six cases missing or incomplete data.
more likely to disagree that RNs played a participatory role in hospital affairs (P = .048), that there were adequate staffing and resources (P = .041), and that RN– physician relationships were collegial (P = .048). Nursing foundations for quality of care (P = .059) and manager ability and leadership (P = .099) did not differ significantly between the two groups (Table 2). Finally, for direct care nurses who answered the question on job satisfaction, those who intended to leave rated themselves significantly less satisfied (M = 2.5) in their jobs than those who intended to stay (M = 3.1, t = −4.71, df = 164, P b .0001). Respondents who had already left hospital nursing at the time of the survey had practiced in this setting for an average of 6.4 years, a median of 5 years, and a range of 0.5 to 26 years (SD = 4.15 years). Table 3 summarizes respondents' reasons for having left or intending to leave hospital nursing. Respondents' reasons for pursuing graduate education in nursing included a desire for a new role/new opportunities (62%), a desire for better working conditions/pay (34%), to advance education/ knowledge (31%), and a desire for autonomy/respect (14%). Those interested in a nonnursing graduate degree overwhelmingly cited a desire for a career change (62%), followed by feelings of underappreciation and lack of respect with too many responsibilities and a fear of liability. Table 3. Reasons for Leaving or Intending to Leave Hospital Nursing *
Reasons Education/Job opportunities Inadequate staffing Family demands Burnout/Stress Long hours Lack of administrative support/respect Poor pay/Benefits Other
Intend to Left Hospital Leave Hospital Nursing, n (%) Nursing, n (%) 62 49 35 34 23 23
(39) (31) (22) (22) (15) (15)
20 (43) 1 (2) 5 (11) 10 (21) 10 (21) 10 (21)
20 (13) 2 (2)
8 (17) 2 (4)
* Participants gave multiple responses.
Discussion This study assessed the practice patterns of baccalaureate nurses from one program. At the time of the survey, more than 50% of all graduates responded. Of these, more than half worked in hospital nursing, but more than a quarter of these nurses intended to leave hospital nursing within the next 3–5 years. Those who worked in hospital nursing were younger and had fewer years in nursing than those who had left. The latter group worked in hospital nursing for fewer than 6 years. Those who intended to leave were less satisfied than those who intended to stay and were less likely to agree that their practice environments offered participation in hospital affairs, adequate staffing, and collegial nurse–physician relationships as measured by the PES-NWI. Furthermore, open-ended comments supported PES-NWI findings and revealed that job stress, inadequate staffing, and lack of administrative support/respect were reasons for leaving. Other reasons for leaving included family responsibilities and, perhaps, most notably, educational and job opportunities. The latter finding, coupled with the result that nurses initially prepared at less than a baccalaureate degree were more likely to have left hospital nursing, suggests that the baccalaureate degree does, indeed, afford career mobility away from hospital nursing. Because the baccalaureate program has only been in existence since 1985, the respondents in this study were younger and had fewer years of experience than the national average, which may explain why, unlike in other studies (Ingersoll et al., 2002, Larrabee et al., 2003; Strachota et al., 2003), there were no statistically significant differences in age or years in nursing between those intending to leave hospital nursing and those intending to stay. In this study, all of the respondents were relatively young (mean age = 34), with an average of 11 years of nursing experience. Hence, the finding that 41% of respondents had already left hospital nursing and 27% intended to leave in the next 3 to 5 years is particularly troubling because, if representative of a larger trend, it portends a hospital environment managed primarily by inexperienced nurses. According to Benner (1984), expertise may take 6 or more years to develop. If baccalaureate nurses leave hospital nursing in fewer than 6 years, benefits to patients resulting from education and experience will not be realized. Viewing the registered nurse as essential to decision making is critical from an administrative perspective. Nurses expect to participate in hospital affairs, to have control over their practice, and to positively impact patient outcomes. If there is a perceived loss of control over basic issues such as safe patient care, hospitals will continue to be perceived as bad places to work. In a study comparing the opinions of Australian RN executives with RNs on factors important to retention, O'Brien-Pallais et al. (2006) found that professional issues were most important to nurses who had left nursing. On the other hand, hospital executives rated professional issues third in importance after external values/beliefs and legal and employer issues, thus demonstrating a disparity in
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perceptions between nurses and executives on factors that affect retention. A study by Buerhaus et al. (2007) also found a statistically significant difference between nurses' and CEO's perceptions of the impact of the nursing shortage on care delivery processes with the latter group underestimating the impact. In contrast, organizations characterized by shared governance between administration and nursing provide higher levels of job satisfaction and empowerment among nurses, which is most notable in magnet hospitals. Common key organizational characteristics of magnet hospitals can be directly tied to intent to stay and include the following: nurse executives as formal members of the highest decision-making bodies in the organization; organizing nursing services in a “flat” structure, thereby minimizing levels between clinical nurses and nurse executives; decentralized decision making; and administrative structures that support nurses' decisions about patient care (Kramer, 1990; Buchan, 1999; Dwyer-Schull, 1984). Similarly Kramer and Schmalenberg (2002) described control of nursing practice as it is viewed by nurses working in magnet hospitals as involving nurses in policy decision, internal governance, and professional autonomy. In this study, nurses who intended to leave hospital nursing perceived inadequate staffing and resources at their organizations. The relationship among nurse staffing, dissatisfaction, and intent to leave has been well documented (Aiken et al., 2001; Aiken, Clarke, Sochalski & Silber, 2002; Aiken et al., 2010; American Hospital Association, 2007) and is likely explained by such variables as burnout (Aiken et al., 2002) and stress (McGillis, Doran, & Pink, 2008) related to perceptions of poor care quality (Letvak & Buck, 2008). Indeed, respondents in this study cited stress and burnout as reasons for leaving. Compared with those who had already left hospital nursing, those who intended to leave identified stress and burnout more frequently than inadequate staffing, suggesting that the phenomena are not completely linked. A sample of graduating associate degree nurses (AMN Healthcare, 2007b) ranked “nurse-to-patient ratios” higher than pay as factors in their decision of where to accept a first job, thus further demonstrating the importance of the staffing dimension of the practice environment to nurses. In this study, pay was not even among the top three reasons given by nurses who had already left and was third among those who intended to leave. In this study, those nurses intending to leave disagreed that nurse–physician relationships were collegial. In a landmark study of 42 intensive care units (ICUs) evaluating the factors associated with positive patient and unit outcomes, Shortell et al. (1994) found that lower nurse turnover was associated with good RN–physician interaction, whereas the nurse staffing ratio had no effect on turnover. The lack of an effect of staffing ratio on turnover may have been explained by uniform staffing ratios between units.
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A survey (Manojlovich & DeCicco, 2007) of 866 nurses working in 25 ICUs evaluated the relationship between nurse–physician communication on selected clinical variables. All three of the variables, medication errors, ventilator-associated pneumonia, and catheter-associated sepsis, had a significant inverse relationship to RN– physician communication. A limitation of this study is its reliance on RN's recall of clinical events resulting in either over- or underreporting. Rosenstein (2002) emphasized the need to address the quality of nurse–physician relationships as organizations seek to improve nurse recruitment, retention, overall satisfaction, and morale.
Recommendations The findings of this pilot study on baccalaureate nurses reflect those in the literature on registered nurses in general with regard to intent to stay in hospital nursing. More importantly, it suggests that hospital nursing is not a long-term career choice for many baccalaureate nurses and that they leave before developing expertise. The study should be replicated on a larger scale, but it further suggests that “nurse education programs are not properly preparing students regarding what to expect on the job; organizations are hiring nurses into an inflexible model that doesn't accommodate what young nurses want to put into and get out of nursing” (PricewaterhouseCoopers, 2007, p. 21). The professional–bureaucratic role conflict underlying “reality shock” (Kramer, 1974) among nurses explains, at least in part, why nurses leave jobs in hospitals (Takasi, Phillip & Manias, 2006). Many hospitals are still structured according to mechanistic models for the manufacture of goods with the assumption that the workforce is uneducated and requires a great deal of direction (Kerfoot & Wantz, 2003). In Kramer's studies, baccalaureate nurses were particularly likely to experience role conflict, but Genrich (1990) did not find any difference in nurses' intentions to leave according to educational preparation. More recently, however, McGillis et al. (2008) reported that baccalaureate nurses experienced significantly more job stress than other hospital nurses, which might be explained by their “added knowledge and understanding” (p. 44). To retain baccalaureate nurses in hospital nursing, the professional–bureaucratic conflict must be overcome, but specific recommendations by national nursing and health care organizations for collaboration between nursing education and the nursing workplace have yet to be enacted on a wide scale. Recommendations include individualized mentoring, internships, and residencies, and work transition initiatives (Hofler, 2008). In addition, testing and refining educational approaches that foster professional resilience may help nurses to cope and “sustain their practices instead of giving up” (Hodges, Keeley, & Grier, 2005, p. 549) in the face of workplace challenges. Educators prepare baccalaureate nurses primarily to work in hospitals but then entice them away from the bedside either implicitly or explicitly by commending the
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merits of advanced practice. In addition, hospital administrators reward competent nurses with managerial positions, thus removing them from the bedside where their skills are most needed. Educators must work with administrators to make patient care attractive because if they are already very goal oriented and have been convinced that nursing is a career, it would be unreasonable to expect baccalaureate nurses not to consider opportunities for professional advancement. Clinical ladder programs are one solution that has been posited to reward expert nurses and retain them as direct care providers. After initiation of a clinical ladder program, one health care system found, among participating RNs, a 5.1% turnover rate compared to a 14.1% rate among nonparticipating RNs. Even with a 6% pay increase for those who were promoted, the system realized a cost savings. However, of the 268 RNs who received clinical promotions, 27 assumed advanced practice roles, potentially removing them from direct patient care (Drenkard & Swartwout, 2005). Another study (Bjork, Hansen, Samdal, Torstad, & Hamilton, 2007) found that the primary reasons RNs chose to participate in a clinical ladder program were for personal improvement and a desire to provide better patient care, and that as RNs moved up the clinical ladder, their intent to stay for more than 1 year increased. Although neither study reported intent to stay by educational preparation, it may be surmised that baccalaureate nurses, who elect the most rigorous nursing preparation, would be especially interested in advancing their professional development. Pursuing magnet recognition is, perhaps, another way for hospitals to retain baccalaureate nurses. Upenieks (2003) presented a prevention model for retention and recruitment of nursing grounded in a magnet hospital model. Her prevention model includes recognizing the versatility of nursing as a career, encouraging professional nursing autonomy, recognizing professional practice environments, developing career enhancement incentives, recruiting more qualified students, and implementing strategies to promote the retention of registered nurses. Finally, if nursing moved to require baccalaureate preparation as minimum entry into practice, then there would be greater standardization in nurse preparation. In turn, nursing could then focus on hospital practice environments, knowing that those providing care possessed the diagnostic and monitoring skills as well as the critical thinking and problem-solving skills that are increasingly essential to direct patient care in these settings.
Conclusion As the nation's hospitals face a severe nursing shortage, baccalaureate nurses, in particular, are in demand. Because of the superior critical thinking and problemsolving skills of baccalaureate nurses, research has shown that hospitals employing large numbers of them have better outcomes. Yet, as the results of this study indicate,
many baccalaureate nurses view hospital nursing as only a way station to another career in nursing, whereas others decide to leave the profession altogether. The reasons for this view are varied but revolve primarily around hospital practice environment issues. If administrators and educators are to stem the hemorrhage of the most qualified nurses from the bedside, then they must learn from what is known about their reasons for leaving. By adopting clinical ladders and a magnet model, administrators can empower hospital nurses to assume control of their own practice, a measure that has been shown to improve satisfaction and aid retention. Educators must teach students the skills to become more adaptable to today's health care environment and instill in them the confidence to promote the work of hospital nursing. Although not discouraging advanced education, they can help students see that a graduate degree and bedside nursing are not mutually exclusive. Finally, cooperation between educators and administrators is critical to ensure that nursing students are prepared for the realities of today's hospital practice environments.
Acknowledgments The authors wish to thank Amy Crouthamel, Melissa Kalinowski, and Rachel Galati for their assistance with data entry.
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Tourangeau, A. E., Doran, D. M., Hall, L. M., Pallas, L. O., Pringle, D., Tu, J. V., et al. (2006). Impact of hospital care on 30day mortality for acute medical patients. Journal of Advanced Nursing, 57, 32–44. Ulrich, C., O'Donnell, P., Taylor, C. & Farrar, A. (2007). Ethical climate, ethics stress, and the job satisfaction of nurses and social workers in the United States. Social Science and Medicine, 65, 1708. Upenieks, V. (2003). Recruitment and retention strategies: A magnet hospital prevention model. Nursing Economics, 21, 7–13, 23. U.S. Department of Health and Human Services [USDHHS]. (2006). What is behind HRSA's projected supply, demand, and shortage of registered nurses? Retrieved August 24, 2008 from http://bhpr.hrsa.gov/healthworkforce/reports/behindrnproject ions/5.htm. Zangaro, G. A. & Soeken, K. L. (2007). A meta-analysis of studies of nurses' job satisfaction. Research in Nursing & Health, 30, 445.
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Hospitals want to hire baccalaureate nurses. Even if there were sufficient numbers of baccalaureate nurses to fill hospital vacancies, however, it is unclear how long these nurses stay at the “bedside.” Until the profession can ascertain how many baccalaureate nurses stay in hospital nursing, simply preparing enough of them will not suffice. Because no published studies were identified that examined either how long baccalaureate nurses stay in hospital nursing or these nurses' reasons for leaving hospital nursing, we undertook a pilot study of our own baccalaureate graduates. Specifically, this comparative descriptive pilot study examined baccalaureate nurses' average number of years in hospital nursing and their reasons for leaving or intending to leave hospital nursing. Three hundred ninety graduates responded. Forty percent had left hospital nursing after an average of 6.4 years, with a median of 5 years. Just over 56% were still practicing hospital nursing, and of these, 81.8% were staff RNs, 26.9% of whom intended to leave hospital nursing in the next 3–5 years. Nurses who intended to leave were less satisfied in their jobs (P b .0001) than those who did not intend to leave. They were also more likely to disagree that RNs played a participatory role in hospital affairs (P = .048), that there were adequate staffing and resources (P = .041), and that RN–physician relationships were collegial (P = .048). The most frequent reasons for intent to leave were the following: to advance education or to take new positions (43%), stress/burnout, long hours, and lack of administrative support/respect (21%, respectively). Only 17% cited poor pay/benefits as a reason for intent to leave. Respondents who had already left hospital nursing cited similar reasons. Dissatisfaction with the practice environment results in baccalaureate nurses leaving hospital nursing at a time when there is a critical shortage of nurses in all practice settings, but especially hospitals. Considering the accumulating evidence of superior patient outcomes in hospitals well staffed by baccalaureate nurses, it is critical to identify and implement solutions to ensure that adequate numbers of experienced, baccalaureate nurses stay at the bedside. (Index words: Baccalaureate nurses; Hospital nurses; Personnel turnover) J Prof Nurs 26:278–286, 2010. © 2010 Elsevier Inc. All rights reserved.
B
ACCALAUREATE NURSES ARE in demand. Many hospitals now prefer to hire them over nonbaccalaureate nurses (AMN Healthcare, 2007a; Burling, 2010), echoing earlier research that documented chief nursing officers' preference for hiring baccalaureate nurses in academic medical centers (Goode et al., 2001). Studies demonstrating superior patient outcomes
⁎The University of Scranton, Scranton, PA. Address correspondence to Dr. DiMattio: The University of Scranton, Department of Nursing, 800 Linden Street, Scranton, PA 18510. E-mails: [email protected], [email protected] 8755-7223/10/$ - see front matter 278 doi:10.1016/j.profnurs.2010.06.005
in hospitals employing large numbers of baccalaureate nurses have likely increased interest in this subgroup of the registered nurse workforce (Aiken, Clarke, Cheung, Sloane & Silber, 2003; Aiken, Clark, Sloane, Lake, & Cheney, 2008; Estabrooks, Midozi, Cummings, Ricker, & Giovannetti, 2005; Tourangeau et al., 2006). The studies validate the position that many have maintained for years: Baccalaureate nurses possess advanced critical thinking and problem-solving skills and hence are better prepared than nonbaccalaureate nurses for the “diagnostic and monitoring” (Benner, 1984) function of the nurse. The American Association of Colleges of Nursing (AACN) reports that enrollments in baccalaureate
Journal of Professional Nursing, Vol 26, No. 5 (September–October), 2010: pp 278–286 © 2010 Elsevier Inc. All rights reserved.
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nursing programs are up despite persistent shortages of qualified faculty (AACN, 2009). The hospital sector, which remains the largest employer of nurses and stands to be hardest hit by the projected shortage of registered nurses, would welcome an influx of baccalaureate nurses. However, even if there were sufficient numbers of baccalaureate nurses, it remains unclear how long these nurses will continue to practice “bedside” or hospital nursing because there is evidence that baccalaureate nurses' careers are characterized by several position and job changes early on (Rambur, McIntosh, Palumbo, & Reineir, 2005). Certainly, recruitment of baccalaureate nurses is important, but retention of these same nurses as they become more experienced is also essential. The loss of experienced nurses from the hospital setting impacts not only patient care but also mentoring of new, less experienced nurses. Therefore, it is critical to understand intent to stay in hospital nursing as perceived by baccalaureate nurses and factors that contribute to intent to leave. The practice environment is, perhaps, one of the greatest challenges faced by hospitals in recruiting and retaining registered nurses in general. Hospitals are simply not considered good places to work (PricewatererhouseCoopers Health Research Institute, 2007, p. 32). Furthermore, opportunities for advanced practice are attractive to new nurses. Norman, Buerhaus, Donelan, McCloskey, and Dittus (2005) reported that inasmuch as 61% of their sample of baccalaureate and associate degree nursing students planned to work in hospitals after graduation, almost a quarter had their sights set on immediate graduate studies for advanced practice. If hospital nursing is increasingly viewed as a temporary place for registered nurses to work, particularly baccalaureate nurses, then benefits to hospitalized patients will be lost. The purpose of this pilot study was to begin to address the gaps in understanding the practice patterns of baccalaureate nurses with respect to hospital nursing. Data were collected and analyzed from graduates of one baccalaureate nursing program in northeastern Pennsylvania. The aims of the study were to determine (a) the number of baccalaureate graduates currently practicing hospital nursing; (b) the numbers who left and who intend to leave hospital nursing; (c) the average time graduates practice hospital nursing before leaving; and (d) factors that contribute to leaving or planning to leave hospital nursing. Hospital nursing was defined as nursing that is practiced in a hospital, involving direct care of individuals experiencing acute illnesses, life transitions (such as childbirth), or exacerbations of chronic health conditions, and that does not include nursing in an advanced practice role or in administration.
Review of Literature A search of the CINAHL database was undertaken for studies published between 2002 and 2008 on baccalaureate nurses, hospital nursing, and nurse practice patterns using the following search terms: baccalaureate
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nurse, hospital nurses, and personnel turnover. Additional studies were identified from reference lists. Finally, national reports and white papers were reviewed for findings on the major study concepts.
Education and Intent to Stay In a study of 1,853 New York State RN's, Ingersoll, Olsen, Drew-Cates, Devinney, and Davies (2002) found that baccalaureate nurses were more likely than nurses prepared at other levels to intend to change positions in 5 years. The researchers did not report the settings in which the baccalaureate nurses were employed, however. In two studies of hospital nurses, researchers found no difference in nurses' intent on leaving their positions according to educational level (Larrabee et al., 2003; Stone et al., 2006). Larrabee et al.'s study had a small sample of 90 nurses; Stone et al. had a large sample but only studied intensive care nurses. Studies have found that half of all new nurses leave or feel ready to leave their first jobs within 2 years (Kovner et al., 2007; PricewaterhouseCoopers, 2007). In other studies, nurses who were most likely to leave or who have the intent to leave their jobs were younger (Ingersoll et al., 2002), had fewer years in the job (Larrabee et al., 2003), or had fewer years in nursing (Bowles & Candela, 2005; Larrabee et al., 2003; Strachota, Nomandin, O'Brian, Clary, & Krukow, 2003) than those who did not intend to leave. None of the studies reviewed assessed intention to leave hospital nursing altogether.
Satisfaction and Intent to Stay Not surprisingly, satisfaction was a recurring concept in studies reviewed, and it appears that baccalaureate nurses are less satisfied in their jobs than master's and doctorally prepared nurses (Buerhaus et al., 2005; Ingersoll et al., 2002). Satisfaction is an important concept because it is linked with intent to stay. In a sample of 123 recent baccalaureate graduates, nurses intending to stay in their current positions for a year were significantly more satisfied on seven of the eight dimensions of a satisfaction survey than those who did not (Roberts, Jones, & Lynn, 2004). The study included nurses working in both hospitals and outpatient settings and did not define the term recent. Rambur, Palumbo, McIntosh, and Mongeon (2003) found that job dissatisfaction was the most frequent reason given by all registered nurses who planned to leave their jobs in the next 12 months, regardless of educational level, but more baccalaureate nurses were dissatisfied. Fifty-four percent of baccalaureate nurses compared to 41% of master's-prepared nurses cited job dissatisfaction over situational reasons or career advancement as their reason for intending to leave. These studies did not report practice settings but found that nurses working in hospitals and nursing homes were the least satisfied of nurses employed in all areas, consistent with trends identified in national samples of nurses working in hospitals and nursing homes (U.S. Department of Health and Human Services [USDHHS], 2006) and in
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direct care positions (Buerhaus et al., 2005). In keeping with all of these findings, Two studies (Larrabee et al., 2003; Lynn & Redman, 2005) reported that high job satisfaction was a negative predictor of hospital nurses' intent to leave. Zangaro & Soeken (2007) conducted a meta-analysis of studies addressing staff nurses' job satisfaction. Job satisfaction was most strongly and negatively correlated with job stress, followed by physician–nurse collaboration and autonomy. It is unclear if all of the studies included in the analysis were of hospital nurses. Ulrich, O'Donnell, Taylor, and Farrar (2007) studied the impact of the ethical climate in the workplace and its relationship to job satisfaction and intent to leave hospital nursing. Feelings of powerlessness, frustration, and fatigue when ethical issues cannot be resolved were related to job dissatisfaction and intent to leave.
Practice Environment and Intent to Stay Satisfaction and, subsequently, intent to stay are linked to issues in the practice environment, which is defined as the “organizational characteristics of a work setting that facilitate or constrain professional nursing practice” (Lake, 2002, p. 178). Hospital nurses have reported being unable to “imagine” to continue working in inpatient settings unless work conditions improved (Kimball & O'Neil, 2003, p. 44). Other hospital nurses reported that scheduling, pay, poor staffing, unsupportive management, unhappy coworkers, and high patient acuity were among their reasons for terminating their employment or changing to per diem status (Strachota et al., 2003). Conversely, transformational leadership, nurse–physician collaboration, and group cohesiveness were predictors of psychological empowerment, which negatively predicted job dissatisfaction among hospital nurses (Larrabee et al., 2003). Dimensions of the practice environment also figured prominently in nurses' reasons for leaving their first jobs and included high acuity, inadequate staffing, unsafe patient care, lack of support and guidance from management, and too much responsibility (Bowles & Candela, 2005). Of the 352 nurses in the study, 93% worked in hospitals. Nurse practice patterns have been positively influenced by the practice environment in magnet hospitals. There is evidence to suggest that nurses employed in hospitals with magnet recognition experience greater satisfaction with the work environment, which links positively with retention (Cimiotti et al., 2005; Upenieks, 2003; Brady-Schwartz, 2005). Practically speaking it should be a goal to not only prepare baccalaureate nurses but also retain them at the bedside. Constant turnover has implications for jeopardizing patient care because the experience that is necessary to provide expert care is lost (Benner, 1984; Hatcher et al., 2006). No studies were identified on the length of time baccalaureate nurses remain in hospital nursing. Data from the Health Resources and Services Administration show that beginning in their early 30s, baccalaureate nurses have lower workforce participation rates than
diploma/associate nurses, and this trend continues through their early 50s when their rates of workforce participation begin to match those of diploma/associate nurses with all showing a sharp decline. Workforce participation is defined as providing nursing services or seeking employment in nursing (USDHHS, 2006). Whereas these findings are not broken down by setting, they do not bode well for hospitals seeking to employ baccalaureate nurses. In contrast, a study of Vermont nurses found that baccalaureate nurses were employed longer and had held more jobs than associate degree nurses. Statistically, more associate degree nurses worked in hospitals and direct patient care (Rambur et al., 2005). Hence, the latter study lends support to the idea that the baccalaureate degree provides for career mobility away from the direct care of patients in hospitals. In summary, the literature shows that nurses do not stay long in their first jobs; nurses in direct care roles and who have less than a master's degree are less satisfied in their jobs than those with more education, and nurses who are dissatisfied intend to leave their jobs. Factors contributing to dissatisfaction and intent to leave are related to the practice environment and include job stress related to patient acuity, inadequate staffing, inadequate support from management, and lack of collaboration with physicians. It is unclear, however, if all of these findings hold true for the subset of baccalaureate nurses and how long baccalaureate nurses stay in hospital nursing.
Methodology Design and Sample This cross-sectional, comparative descriptive pilot study surveyed baccalaureate nurses who graduated from a university in northeastern Pennsylvania. The program, which prepares traditional students in addition to offering RN and LPN to baccalaureate completion tracks, primarily draws students from Pennsylvania, New York, New Jersey, and Connecticut and has graduated more than 700 baccalaureate nurses in 26 years. There is also a graduate nursing program with several tracks at the university; however, graduates from this program were not included in the study.
Procedure Prior to data collection, approval for the pilot study was obtained from the appropriate institutional review board. With the assistance of the alumni office, a postcard was mailed to all baccalaureate graduates (n = 720) describing the study and alerting them to the arrival of a survey packet within 4 weeks receipt of the postcard. The packet contained a cover letter describing the study, assuring human subjects' protections, and requesting participation. Participants were asked to refrain from placing identifying information on the surveys and to return them in a postage-paid envelope. Because there was no system for tracking responses, a second postcard was sent to all graduates 4 weeks later, thanking those who had returned their surveys and reminding those who had not. Time to complete the survey was approximately 15 minutes.
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Instruments
Table 1. Demographics (N = 390)
After a review of the literature, a survey of demographics and practice patterns was designed by the authors, who, combined, have more than 50 years of experience teaching baccalaureate nursing students. The first page of the survey solicited information on age, years in nursing, basic education, type of practice setting, and nursing role. The second page of the survey included questions about intentions and practice patterns with regard to hospital nursing. Specifically, participants who indicated they currently worked in hospital nursing were asked how long they worked in the hospital, if they intended to leave within the next 3–5 years, and reasons for their intentions to leave. Participants were also asked their reasons for pursuing graduate education in either nursing or another discipline and to rate on a 4-point Likert scale the degree to which they were satisfied in their current jobs, with 1 indicating very satisfied and 4 indicating very dissatisfied. Participants who indicated that they had left hospital nursing were asked how long they worked in hospital nursing and why they left. Finally, respondents who worked in hospital nursing at the time of the survey were asked to complete the Practice Environment Scale of the Nursing Work Index (PES-NWI; Lake, 2002). The PES-NWI is a 31-item, fivesubscale instrument derived from the Nursing Work Index. It assesses the extent to which a practice environment possesses characteristics most strongly associated with magnet hospitals, which are known for their ability to attract and retain nurses. Lake reported satisfactory construct validity and subscale reliability coefficients ranging from alpha value of .71 to .84 for individual respondents. Reliability coefficients for this study ranged from alpha value of .80 to .87 and were almost identical to those reported by Lake for all subscales, except Collegial Nurse–Physician Relations, which was higher (α = .80) in this study.
Age, M (SD) Years in nursing, M (SD) Basic educational preparation, n (%) BSN Diploma AD LPN Missing Hospital nursing * (n = 380), n (%) Currently practice hospital nursing Left hospital nursing Never practiced hospital nursing
Data Analysis All data were analyzed using SPSS statistical software. For the entire sample, frequencies were calculated for nominal data, and descriptive statistics were calculated for interval and ratio level data. Comparisons between respondents who worked in hospital nursing and those who had left, as well as between those who intended to stay and those who intended to leave hospital nursing, were carried out using chi-square analysis and independent samples t tests.
Results Seven hundred twenty surveys were mailed, and 390 graduates responded for a response rate of 54%. The average age of respondents was 33.65 years, and the average number of years in nursing was 10.59. Ninety percent of respondents reported a baccalaureate degree as their basic education; the remainder, although now baccalaureate-prepared, reported an RN diploma or an LPN certificate as their basic educational preparation
33.65 10.59
7.30 6.59
351 27 4 7 1
90 6.9 1.0 1.8 0.003
214 157 9
56.3 41.3 2.3
* Usable surveys.
(Table 1). The questions on practice patterns with regard to hospital nursing proved to be problematic. The questions, in a yes/no format, were meant to be mutually exclusive, but several respondents gave contradictory answers. For example, a respondent who was not practicing hospital nursing at the time of the survey would not have been expected to agree that he or she was planning to leave hospital nursing in the next 3–5 years. Another area of confusion was that many respondents simultaneously worked in and outside of hospital nursing. Those respondents were coded as currently practicing hospital nursing. Hence, after carefully reviewing responses to the questions on hospital nursing, 380 respondents had usable data. Of those, 2.3% had never practiced hospital nursing, 41.3% had practiced hospital nursing and left, and 56.3% identified themselves as still practicing hospital nursing, although some of these nurses were not practicing in direct care roles. Those still practicing hospital nursing were significantly younger (M = 31.44) than those who had left (M = 36.66, t = 7.26, df = 376, P b .001) and had fewer years in nursing (M = 8.6) than those who had left (M = 13.24, t = 7.15, df = 377, P b .001). Those who were prepared as LPNs or diploma RNs before earning a baccalaureate degree were more likely to have left than those who were initially educated at the baccalaureate level (χ2 = 3.92, df = 1, P = .05). Two respondents had missing age data, and one did not report years in nursing. Of the 214 respondents who were currently practicing hospital nursing, 81.8% were practicing in direct care roles, and 26.9% of these nurses intended to leave hospital nursing within the next 3–5 years. There were no statistically significant differences in terms of age (P = .37) and number of years in nursing (P = .48) between those direct care nurses who intended to stay in hospital nursing and those who intended to leave. There were, however, statistically significant differences on subscales of the PES-NWI between direct care nurses who intended to stay in hospital nursing and those who intended to leave in 3–5 years, although six of those intending to stay had incomplete or missing data for the PES-NWI. Compared with nurses intending to stay in hospital nursing, those intending to leave were
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Table 2. Results: The Practice Environment Scale (n = 169) *
Intend to leave hospital nursing Subscale Collegial RN–physician relations Nurse participation
M
SD
2.72 2.91 2.44 2.63 2.76 2.91 2.47 2.65 2.34 2.55
0.58 0.56 0.51 0.58 0.42 0.47 0.65 0.64 0.58 0.61
t
P
Yes = 47 No = 122
Yes No Yes No Nursing foundations for Yes quality of care No RN manager ability, Yes leadership, support No Staffing and resources Yes No
−2.00 .048 .048 −1.94 −1.90 .059 −1.63 .099 −2.06 .041
* Six cases missing or incomplete data.
more likely to disagree that RNs played a participatory role in hospital affairs (P = .048), that there were adequate staffing and resources (P = .041), and that RN– physician relationships were collegial (P = .048). Nursing foundations for quality of care (P = .059) and manager ability and leadership (P = .099) did not differ significantly between the two groups (Table 2). Finally, for direct care nurses who answered the question on job satisfaction, those who intended to leave rated themselves significantly less satisfied (M = 2.5) in their jobs than those who intended to stay (M = 3.1, t = −4.71, df = 164, P b .0001). Respondents who had already left hospital nursing at the time of the survey had practiced in this setting for an average of 6.4 years, a median of 5 years, and a range of 0.5 to 26 years (SD = 4.15 years). Table 3 summarizes respondents' reasons for having left or intending to leave hospital nursing. Respondents' reasons for pursuing graduate education in nursing included a desire for a new role/new opportunities (62%), a desire for better working conditions/pay (34%), to advance education/ knowledge (31%), and a desire for autonomy/respect (14%). Those interested in a nonnursing graduate degree overwhelmingly cited a desire for a career change (62%), followed by feelings of underappreciation and lack of respect with too many responsibilities and a fear of liability. Table 3. Reasons for Leaving or Intending to Leave Hospital Nursing *
Reasons Education/Job opportunities Inadequate staffing Family demands Burnout/Stress Long hours Lack of administrative support/respect Poor pay/Benefits Other
Intend to Left Hospital Leave Hospital Nursing, n (%) Nursing, n (%) 62 49 35 34 23 23
(39) (31) (22) (22) (15) (15)
20 (43) 1 (2) 5 (11) 10 (21) 10 (21) 10 (21)
20 (13) 2 (2)
8 (17) 2 (4)
* Participants gave multiple responses.
Discussion This study assessed the practice patterns of baccalaureate nurses from one program. At the time of the survey, more than 50% of all graduates responded. Of these, more than half worked in hospital nursing, but more than a quarter of these nurses intended to leave hospital nursing within the next 3–5 years. Those who worked in hospital nursing were younger and had fewer years in nursing than those who had left. The latter group worked in hospital nursing for fewer than 6 years. Those who intended to leave were less satisfied than those who intended to stay and were less likely to agree that their practice environments offered participation in hospital affairs, adequate staffing, and collegial nurse–physician relationships as measured by the PES-NWI. Furthermore, open-ended comments supported PES-NWI findings and revealed that job stress, inadequate staffing, and lack of administrative support/respect were reasons for leaving. Other reasons for leaving included family responsibilities and, perhaps, most notably, educational and job opportunities. The latter finding, coupled with the result that nurses initially prepared at less than a baccalaureate degree were more likely to have left hospital nursing, suggests that the baccalaureate degree does, indeed, afford career mobility away from hospital nursing. Because the baccalaureate program has only been in existence since 1985, the respondents in this study were younger and had fewer years of experience than the national average, which may explain why, unlike in other studies (Ingersoll et al., 2002, Larrabee et al., 2003; Strachota et al., 2003), there were no statistically significant differences in age or years in nursing between those intending to leave hospital nursing and those intending to stay. In this study, all of the respondents were relatively young (mean age = 34), with an average of 11 years of nursing experience. Hence, the finding that 41% of respondents had already left hospital nursing and 27% intended to leave in the next 3 to 5 years is particularly troubling because, if representative of a larger trend, it portends a hospital environment managed primarily by inexperienced nurses. According to Benner (1984), expertise may take 6 or more years to develop. If baccalaureate nurses leave hospital nursing in fewer than 6 years, benefits to patients resulting from education and experience will not be realized. Viewing the registered nurse as essential to decision making is critical from an administrative perspective. Nurses expect to participate in hospital affairs, to have control over their practice, and to positively impact patient outcomes. If there is a perceived loss of control over basic issues such as safe patient care, hospitals will continue to be perceived as bad places to work. In a study comparing the opinions of Australian RN executives with RNs on factors important to retention, O'Brien-Pallais et al. (2006) found that professional issues were most important to nurses who had left nursing. On the other hand, hospital executives rated professional issues third in importance after external values/beliefs and legal and employer issues, thus demonstrating a disparity in
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perceptions between nurses and executives on factors that affect retention. A study by Buerhaus et al. (2007) also found a statistically significant difference between nurses' and CEO's perceptions of the impact of the nursing shortage on care delivery processes with the latter group underestimating the impact. In contrast, organizations characterized by shared governance between administration and nursing provide higher levels of job satisfaction and empowerment among nurses, which is most notable in magnet hospitals. Common key organizational characteristics of magnet hospitals can be directly tied to intent to stay and include the following: nurse executives as formal members of the highest decision-making bodies in the organization; organizing nursing services in a “flat” structure, thereby minimizing levels between clinical nurses and nurse executives; decentralized decision making; and administrative structures that support nurses' decisions about patient care (Kramer, 1990; Buchan, 1999; Dwyer-Schull, 1984). Similarly Kramer and Schmalenberg (2002) described control of nursing practice as it is viewed by nurses working in magnet hospitals as involving nurses in policy decision, internal governance, and professional autonomy. In this study, nurses who intended to leave hospital nursing perceived inadequate staffing and resources at their organizations. The relationship among nurse staffing, dissatisfaction, and intent to leave has been well documented (Aiken et al., 2001; Aiken, Clarke, Sochalski & Silber, 2002; Aiken et al., 2010; American Hospital Association, 2007) and is likely explained by such variables as burnout (Aiken et al., 2002) and stress (McGillis, Doran, & Pink, 2008) related to perceptions of poor care quality (Letvak & Buck, 2008). Indeed, respondents in this study cited stress and burnout as reasons for leaving. Compared with those who had already left hospital nursing, those who intended to leave identified stress and burnout more frequently than inadequate staffing, suggesting that the phenomena are not completely linked. A sample of graduating associate degree nurses (AMN Healthcare, 2007b) ranked “nurse-to-patient ratios” higher than pay as factors in their decision of where to accept a first job, thus further demonstrating the importance of the staffing dimension of the practice environment to nurses. In this study, pay was not even among the top three reasons given by nurses who had already left and was third among those who intended to leave. In this study, those nurses intending to leave disagreed that nurse–physician relationships were collegial. In a landmark study of 42 intensive care units (ICUs) evaluating the factors associated with positive patient and unit outcomes, Shortell et al. (1994) found that lower nurse turnover was associated with good RN–physician interaction, whereas the nurse staffing ratio had no effect on turnover. The lack of an effect of staffing ratio on turnover may have been explained by uniform staffing ratios between units.
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A survey (Manojlovich & DeCicco, 2007) of 866 nurses working in 25 ICUs evaluated the relationship between nurse–physician communication on selected clinical variables. All three of the variables, medication errors, ventilator-associated pneumonia, and catheter-associated sepsis, had a significant inverse relationship to RN– physician communication. A limitation of this study is its reliance on RN's recall of clinical events resulting in either over- or underreporting. Rosenstein (2002) emphasized the need to address the quality of nurse–physician relationships as organizations seek to improve nurse recruitment, retention, overall satisfaction, and morale.
Recommendations The findings of this pilot study on baccalaureate nurses reflect those in the literature on registered nurses in general with regard to intent to stay in hospital nursing. More importantly, it suggests that hospital nursing is not a long-term career choice for many baccalaureate nurses and that they leave before developing expertise. The study should be replicated on a larger scale, but it further suggests that “nurse education programs are not properly preparing students regarding what to expect on the job; organizations are hiring nurses into an inflexible model that doesn't accommodate what young nurses want to put into and get out of nursing” (PricewaterhouseCoopers, 2007, p. 21). The professional–bureaucratic role conflict underlying “reality shock” (Kramer, 1974) among nurses explains, at least in part, why nurses leave jobs in hospitals (Takasi, Phillip & Manias, 2006). Many hospitals are still structured according to mechanistic models for the manufacture of goods with the assumption that the workforce is uneducated and requires a great deal of direction (Kerfoot & Wantz, 2003). In Kramer's studies, baccalaureate nurses were particularly likely to experience role conflict, but Genrich (1990) did not find any difference in nurses' intentions to leave according to educational preparation. More recently, however, McGillis et al. (2008) reported that baccalaureate nurses experienced significantly more job stress than other hospital nurses, which might be explained by their “added knowledge and understanding” (p. 44). To retain baccalaureate nurses in hospital nursing, the professional–bureaucratic conflict must be overcome, but specific recommendations by national nursing and health care organizations for collaboration between nursing education and the nursing workplace have yet to be enacted on a wide scale. Recommendations include individualized mentoring, internships, and residencies, and work transition initiatives (Hofler, 2008). In addition, testing and refining educational approaches that foster professional resilience may help nurses to cope and “sustain their practices instead of giving up” (Hodges, Keeley, & Grier, 2005, p. 549) in the face of workplace challenges. Educators prepare baccalaureate nurses primarily to work in hospitals but then entice them away from the bedside either implicitly or explicitly by commending the
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merits of advanced practice. In addition, hospital administrators reward competent nurses with managerial positions, thus removing them from the bedside where their skills are most needed. Educators must work with administrators to make patient care attractive because if they are already very goal oriented and have been convinced that nursing is a career, it would be unreasonable to expect baccalaureate nurses not to consider opportunities for professional advancement. Clinical ladder programs are one solution that has been posited to reward expert nurses and retain them as direct care providers. After initiation of a clinical ladder program, one health care system found, among participating RNs, a 5.1% turnover rate compared to a 14.1% rate among nonparticipating RNs. Even with a 6% pay increase for those who were promoted, the system realized a cost savings. However, of the 268 RNs who received clinical promotions, 27 assumed advanced practice roles, potentially removing them from direct patient care (Drenkard & Swartwout, 2005). Another study (Bjork, Hansen, Samdal, Torstad, & Hamilton, 2007) found that the primary reasons RNs chose to participate in a clinical ladder program were for personal improvement and a desire to provide better patient care, and that as RNs moved up the clinical ladder, their intent to stay for more than 1 year increased. Although neither study reported intent to stay by educational preparation, it may be surmised that baccalaureate nurses, who elect the most rigorous nursing preparation, would be especially interested in advancing their professional development. Pursuing magnet recognition is, perhaps, another way for hospitals to retain baccalaureate nurses. Upenieks (2003) presented a prevention model for retention and recruitment of nursing grounded in a magnet hospital model. Her prevention model includes recognizing the versatility of nursing as a career, encouraging professional nursing autonomy, recognizing professional practice environments, developing career enhancement incentives, recruiting more qualified students, and implementing strategies to promote the retention of registered nurses. Finally, if nursing moved to require baccalaureate preparation as minimum entry into practice, then there would be greater standardization in nurse preparation. In turn, nursing could then focus on hospital practice environments, knowing that those providing care possessed the diagnostic and monitoring skills as well as the critical thinking and problem-solving skills that are increasingly essential to direct patient care in these settings.
Conclusion As the nation's hospitals face a severe nursing shortage, baccalaureate nurses, in particular, are in demand. Because of the superior critical thinking and problemsolving skills of baccalaureate nurses, research has shown that hospitals employing large numbers of them have better outcomes. Yet, as the results of this study indicate,
many baccalaureate nurses view hospital nursing as only a way station to another career in nursing, whereas others decide to leave the profession altogether. The reasons for this view are varied but revolve primarily around hospital practice environment issues. If administrators and educators are to stem the hemorrhage of the most qualified nurses from the bedside, then they must learn from what is known about their reasons for leaving. By adopting clinical ladders and a magnet model, administrators can empower hospital nurses to assume control of their own practice, a measure that has been shown to improve satisfaction and aid retention. Educators must teach students the skills to become more adaptable to today's health care environment and instill in them the confidence to promote the work of hospital nursing. Although not discouraging advanced education, they can help students see that a graduate degree and bedside nursing are not mutually exclusive. Finally, cooperation between educators and administrators is critical to ensure that nursing students are prepared for the realities of today's hospital practice environments.
Acknowledgments The authors wish to thank Amy Crouthamel, Melissa Kalinowski, and Rachel Galati for their assistance with data entry.
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