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Nurse manager turnover in New South Wales during the 1990s
Nurse manager turnover in New South Wales during the 1990s P Lynne Johnstone, Charles Sturt University
The principal aim of the research reported in this paper was to explore the nature and incidence of various environmental, personal, and work-related factors that are implicated in turnover and retention amongst nurse managers. The study sought to ascertain whether or not turnover patterns during the 1990s were similar for nurse managers working in different specialist areas and settings of health services within New South Wales, and to discover the main reasons why nurse managers change their jobs or stay in their jobs. This paper reports the main findings, and highlights how the factors implicated in nurse manager turnover and retention, whilst not significantly dissimilar across different cohorts of nurse managers, do not parallel those that are implicated in turnover amongst nurses generally. The research has found that the main reason nurse managers change their jobs is for career development, often within the same organisation or, otherwise, the same health sector or geographic area. Second to this is leaving due to dissatisfying aspects of the job and/or work environment. Some differences have been observed in the propensity to change jobs and in the relative importance of particular influences on job changes in certain practice areas and health sectors. Seven per cent of nurse managers would like to quit their present jobs. However, almost 70% are happy to stay either because the job suits their skills and qualifications, the job is personally satisfying/rewarding, they enjoy the company of their coworkers, or their hours of work suit their needs. Key words: Nurse manager, turnover, retention, job satisfaction
P Lynne Johnstone PhD Macq GDipHlthEc NE GDipCom(BusInfSys)W’gong BHSc(Mgt)(Dist)CSturt RN FCHSE CHE School of Public Health, Charles Sturt University. E-mail: [email protected]
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Background The topic of turnover has been comprehensively studied in general terms (eg Mathieu & Baratta 1989, Tyagi & Wotruba 1993, Manlove & Guzell 1997) and in relation to specific groups of employees, including managers (eg Taylor & Zimmerer 1992, Cohen & Hudecek 1993). Turnover amongst clinical nurses has also received substantial attention in the literature (eg Battersby et al 1989, Parasuraman 1989, Persson et al 1993, Irvine & Evans 1995, Pierce et al 1996, Taunton et al 1997). Over the past few decades, research into nurse shortages, surpluses, and turnover has concluded that the causes are complex and often not well understood. Research has concentrated on factors that are inherent in the job of nursing for clinical nurses, as distinct from the job of being a nurse manager. Topics have ranged from wage structures to working conditions, and from style of management to the lack of child care facilities. No attention seems to have been paid to the different work demands placed on nurses working in different specialist areas of practice or to the potential impact on turnover of their specific levels/grades of appointment. Research into turnover has attracted strong interest during periods of nurse shortages and, consequently, most published research in recent decades was conducted during the 1980s. During this time, a number of American and Australian researchers reported some of the wider social and economic issues which influence nursing turnover (eg Price & Mueller 1981, Fox 1987, Cavanagh 1989). Some studies reported that wastage from nursing increases with higher qualifications (Price & Mueller 1981, Fox 1987). Other studies revealed that turnover is lower amongst part-time nurses than other groups of nurses (Phillips & Carter 1988), and that part-time nurses are a more satisfied group (Price & Mueller 1981, Pilkington & Wood 1986). However, by working part-time, career opportunities are often reduced (Wood 1984) and, hence, it is possible that nurses achieving manager status will have worked on a fulltime basis to achieve such positions. Nurse managers constitute a sizeable subset of nurses, representing approximately 4,000 nurses registered in New South Wales in 1998 (Chaffey 1999). Internationally, scant attention
Nurse manager turnover in New South Wales during the 1990s
has been paid to the incidence and causes of turnover in this group. One notable exception is the work done by the American Organisation for Nurse Executives (AONE) under whose auspices several studies on turnover amongst nurse managers in the USA were conducted in the early 1990s (Anonymous 1994). The AONE study revealed that turnover amongst USA nurse managers was on the rise. The main influences on that turnover were found to be changes in the complexity of the roles and responsibilities of nurse managers, fiscal constraints, insufficient time to do everything, uncompensated work time, and accountability without authority (Anonymous 1994) in an environment beset by downsizing and restructuring (ShindulRothschild et al 1999). Moreover, it was found that over 10% of nurse managers intended to quit their jobs within a period of six months, and that 40% of those with quitting intentions did not intend to seek another position in nursing management (Anonymous 1994). No similar research appears to have been done in Australia. This researcher has argued elsewhere that even amongst similar categories of clinical nurses, the specialist practice area of the nurse will present a different set of work and personal demands (Johnstone 2000, 2001). The present research aimed to find out if this proposition can be sustained for nurse managers working in different practice areas and settings within NSW. Research questions The key questions guiding this research were: 1. Is turnover amongst NSW nurse managers significantly different according to geographical location of work, age or gender of nurse manager, health sector, or specialty practice area? 2. Why do nurse managers change their jobs? 3. Why do nurse managers remain in their jobs?
them were sent a questionnaire. Figure 1 summarises the distribution of potential informants working in each type of health service and Figure 2 summarises them according to the seven practice areas in public and private hospitals. The first series of questions in the questionnaire obtained informant characteristic data. Data fields relating to the practice area and grade of nurse manager appointment correlated with those employed in the NSW Health Workforce database (NSW Health 1999). The remainder of the questionnaire sought information from informants about their jobs as nurse managers throughout the 1990s. The questions were developed primarily from the literature concerning employee turnover and retention in general, and nurse turnover and retention in particular. The questionnaire asked two questions about informants’ reasons for leaving each nurse manager job. The first asked them to select a single statement from the fourteen provided, which best described their reason for leaving a particular nurse manager job. The second question asked them to select and rank, for each nurse manager job change, factors from a different set of 14 that influenced their decision to leave. They were Private hospitals (n=192)10.0%
Private nursing homes or hostels (n=360) 18.8% Public hospitals (n=744) 38.9%
Source: NSW Health Workforce Planning Unit
Research methods The research was conducted during the year 2000. A projectspecific survey questionnaire was used to collect the data. It was first pilot tested in a regional area health service amongst eight nurse managers, who were subsequently interviewed to find out what, if any, difficulties they had in understanding instructions or interpreting questions contained in it. This resulted in some minor modifications. Potential informants were selected from the NSW Health Workforce Planning Unit’s database of all grades of nurses registered to practise in 1998 (NSW Health 1999). This database can distinguish non-nurse managers from nurse managers, and can distinguish nurse managers according to any one of ten incremental grades of nurse manager. It contains 67 identifiable specialist areas of nursing practice. One thousand nine hundred and thirteen nurse managers working during 1998 in nine nursing practice areas - seven within public and private hospitals, plus aged care and community health services – were selected from the database as potential study informants. All of
Public nursing homes or hostels (n=345) 18.0%
Community health settings (n=272) 14.2%
Figure 1: Workplaces of potential informants
Midwifery/obstetrics (n=160) 17.1%
General medicine (n=153) 16.0%
General mental health (n=116) 12.4%
Operating theatre services (n=227) 24.3%
Intensive care departments (n=79) 8.4% Emergency departments (n=105) 11.2%
General surgical (n=96) 10.3%
Source: NSW Health Workforce Planning Unit
Figure 2: Practice areas of potential informants in public and private hospitals Collegian Vol 10 No1 2003 9
asked to rank any number of influences, but only those that were actually influential for a particular job change. The 14th optional response in each of the two questions was ‘other reason/factor’ which, if selected, required the informant to specify the reason/influence. The questionnaire also asked informants who were working as nurse managers at the time of the study to select and rank one or more of 10 statements about their intentions to stay in their current jobs. Eight of nine factors influencing their decisions to stay related to personal preferences and/or organisational characteristics, whilst the ninth option, ‘other reasons’, gave informants the opportunity to provide a reason not covered by the other eight. The 10th statement in this list was: ‘I would like to quit this job, but I don’t have another job to go to’. Mailing of the questionnaires was facilitated via a collaborative effort between the NSW Nurses’ Registration Board, the NSW Health Workforce Planning Unit, and the researcher. By late 2000, 803 completed survey questionnaires had been returned, representing a response rate of about 42%. Data entry into a Microsoft Access database was completed by a research assistant and analysis was undertaken by the researcher. Ethical considerations Approval to conduct the research was given by the Charles Sturt University Human Ethics Committee. To ensure confidentiality, questionnaires were completed anonymously. The return of a completed questionnaire was deemed to be participant consent. Results Profile of respondents
Table 1 summarises the distribution of the respondents across practice areas and the health sectors and geographic areas of their employment in 2000. The representation of nurses in all practice areas compared favourably with the study population, although there was relatively more respondents in ‘no one area
of practice’ in regional/rural NSW public sector than in the other five categories. The geographic spread of the study population is not known, but the study respondents were well represented in each of the three areas - Sydney region (n=250), other metropolitan areas (n=178) and regional NSW (n=351). Moreover, one in three respondents worked in the private sector (calculated from Table 1). This compares favourably with the population distribution of 28.8% (for private hospitals and nursing homes/hostels) represented in Figure 1.
The data reveal a high level of public or private sector loyalty amongst nurse managers, with 86% of nurse managers working in only one health sector during the 1990s. The number of respondents working in each type of health facility approximated their relative numbers in the study population: hospitals (54.4%), nursing homes or aged care hostels (24.2%), and community health services (14.4%). Most of the remaining 7% had either retired or were working in various other (non-)health organisations. The majority of respondents (65%) worked in facilities of between 50 and 250 beds (or residents), while 10.5% worked in facilities with more than 500 beds. Each practice area was well represented across the full range of sizes of health service facilities. The age distribution of respondents was negatively skewed with 83% being at least 40 years of age and 45-49 years being the mean age range. These data indicate that nurse managers are, on average, at least ten years older than all registered nurses (cf Hegney et al 2002). About 11% of respondents were male, which is slightly higher than the gender distribution of all nurses both within NSW and Australia, which is 8% male (NSW Health 1999, Harris 2002). This provides some support for anecdotal evidence that relatively more male than female nurses
Table 1: Current practice areas, geographic location, and health sector of work of respondents Capital city
General medicine Operating theatre services General surgical Emergency department Intensive care units General mental health Midwifery/obstetrics No one area of practice Aged care, gerontology Community, unspecified Nurs/general administration Paediatric, child & family None of the above Practice area not specified Total 10
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Public sector
Private sector
Public sector
Other metropolitan Private sector
Regional/Rural NSW Public sector
Private sector
Geog. area not specified
Total informants
11 34 0 7 7 13 22 4 11 7 11 12 12 1 153
6 17 5 2 3 2 5 1 33 1 4 1 14 3 97
8 13 4 8 12 15 8 3 13 9 5 2 3 2 105
2 10 2 0 2 1 4 0 40 2 5 0 5 0 73
35 24 15 19 9 21 28 30 17 22 16 5 15 2 258
8 9 9 1 2 2 5 3 41 1 5 0 7 0 93
0 2 1 1 0 2 1 0 3 2 1 0 1 10 24
70 109 36 38 35 56 74 41 158 44 47 20 57 18 803
Nurse manager turnover in New South Wales during the 1990s
work in management positions. About one in three of all respondents had not changed their jobs during the ten years, during which time almost 9% of respondents (n=60) changed their nurse manager jobs three or more times. About 66% of respondents were not nurse managers in 1990, but were appointed to their first nurse manager positions at some time during the intervening ten years. Of those who held nurse manager positions in both 1990 and 2000 (n=213), only 62% (n=131) had worked continuously in positions which were categorically nurse manager positions during that time, and only 18 of these individuals were still in the same jobs that they occupied in 1990. Furthermore, some of those who were nurse managers in 1990 were among the 19% of respondents (n=153) who were no longer in positions that were categorically nurse manager despite having been, according to the NSW Nursing Workforce database (NSW Health 1999), a nurse manager in 1998. At least 45 of them had either returned to clinical nursing positions or moved into senior clinical positions such as clinical nurse specialist, clinical nurse consultant, clinical team leader, clinical educator, or clinical researcher. At least another 21 had moved into managerial positions such as program manager, business manager, quality assessor/coordinator, general manager, or hostel or health service manager. Job changes and health sector
The data reveal a high level of public or private sector loyalty amongst nurse managers, with 86% of nurse managers working in only one health sector during the 1990s. Of those currently working in the public sector (n=531), 91% had worked only in that sector during the 1990s, and about half of them had changed jobs at least once within that sector. In the private sector, 77% of those currently working there (n=265) had worked only in the private sector, 45% of whom had changed jobs at least once within that sector. Job changes and geographic area
Respondents reported the geographic area of each job according to the following three categories: capital city, other metropolitan, and regional/rural. Analysis of the frequency of nurse manager job changes within and between geographic areas reveals that 44.2% (n=344) had changed jobs at least once within a category of geographic area, whilst 10.6% (n=83) had worked in more
Table 2: Frequency of job changes within each geographic area No 1 2 3 4 change change changes changes changes Worked only in Sydney region 97 Worked only in other metro area 88 Worked only in regional NSW 167 Total 352 Proportions 50.6%
62 40 90 192 27.6%
34 20 36 90 12.9%
18 5 18 41 5.9%
7 8 6 21 3.0%
than one geographic area as nurse managers during the 1990s. These data must not be construed as meaning that only 10.6% of respondents had relocated when they had changed jobs. What they do reveal, however, is that among the 54.8% of respondents who changed nurse manager jobs at least once during the 1990s, about four in five had worked only within either greater Sydney, in minor metropolitan areas such as Wollongong and Newcastle, or within regional NSW. Table 2 summarises the data on the frequencies of changes within each geographic area. Table 3 then introduces two concepts that provide complementary means of comparing turnover between groups. These are propensity to change, which represents ‘total changes’ as a proportion of ‘all currently in a given class’ (in this case, in a geographic area), and relative stability, which is the ratio of ‘no changes’ to ‘changes’ within a given class. The higher the propensity to change value, the more likely nurse managers in that class are likely to change their jobs. The higher the relative stability ratio, the more stable the nurse manager workforce in that class is deemed to be. Propensity to change jobs was five percentage points higher in Sydney (48%) than in regional NSW (43%) and seven percentage points higher than in other metropolitan areas (41%). Moreover, turnover within nurse manager positions, based on the relative stability ratio, was greatest within Sydney (RSR=0.80) and least within other metropolitan areas (RSR=1.21). No explanation can be found in the study data for these trends, but it is possible that nurses working in greater Sydney simply had more opportunities to change jobs due to the significantly larger number of health service facilities in proximity. Job changes and practice area There appears to be a fairly high degree of practice area loyalty amongst nurse managers, a finding that should not be surprising in a profession in which specialisation is more the rule than the exception. Indeed, altogether about 85% of respondents had either not changed jobs (n=376) or moved only within practice areas (n=290) in their nurse manager jobs during the 1990s. Table 4 presents the results for each practice area in order from the highest to lowest propensity to change jobs. It reveals that those working in general surgical, medicine and mental health were the least likely to have changed jobs. On the other hand, those working in no specific area of practice and nursing/general administration were most likely to have changed
Table 3: Relative stability and propensity to change jobs within each geographic area No change Number Propensity Relative of changes to change stability Worked only in Sydney region Worked only in other metro area Worked only in regional NSW Total
97 88 167 352
121 73 150 344
48% 41% 43%
0.80 1.21 1.11
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jobs. Although nurse managers in ‘no specific area of practice’ stand out as changing jobs relatively more often than others, they represent too diverse a range of practice areas for analysis in the present paper.
… there is a strong propensity for nurse managers to change jobs for career development, often associated with a promotion, within the same organisation or the same health sector. Two practice areas, then, stand out as both having a higher propensity to change than others - operating theatre services (PTC=46.8%) and nursing/general administration (PTC=53.2%). Positions in these practice areas also appear to be the most unstable, with relative stability ratios of 0.96 and 0.84 respectively - issues that are touched on later in the following section. General medicine (RSR=6.67) and general surgical (RSR=3.83) appear to be the most stable of those studied in the present research. Reasons for changing/leaving jobs
The single statement that best described respondents’ reasons for leaving a nurse manager job (given by 23.7% of respondents) was ‘I did not leave. I was successful in my application for another management position within the organisation’. However, it has been found that the probability of changing jobs within an organisation declines with each job change. Evidently, there comes a point in a nurse manager’s career that the desired promotion can only be achieved by moving outside the organisation within which (s)he has had one or more promotions. The second ranked reason was not similarly positive, with 13.8% selecting the response, ‘I left of my own free will due to dissatisfying aspects of the job that I didn’t want in my life’. Patterns were similar for each nurse manager job change,
although changing jobs because of work-related stress appears to increase in relative terms with each nurse manager job change and, therefore, generally with more senior positions. Analysis of the primary reasons given by respondents for leaving up to three nurse manager jobs was undertaken by grouping statements with common elements. The results are depicted in Figure 3. Two are statistically significant (χ2 = 27.12, df=1, p<0.0001): (a) a significantly higher proportion of public sector nurse managers changing management jobs because of restructuring or for promotion/career development within the same organisation, and (b) a significantly higher proportion of private sector nurse managers than public sector nurse managers leaving because of dissatisfying aspects of their jobs. Analysis of the influences on private sector nurse managers reveals two that are significant (χ2=13.3, df=3, p<0.005): ‘too often having to take work home to finish’ and ‘insufficient time to satisfy the demands of the job’. It appears that nurse managers in the private sector are feeling significantly more time pressured in their work than their public sector peers. Qualitative analysis of the ‘other reasons’ for changing jobs revealed that secondment to acting/relieving positions was the most common, while retirement, partner relocation, personal/family reasons, and facility closure were not uncommon. It appears that the practice of seconding individuals to acting/relief positions, often for uncertain and protracted periods, is a characteristic of the public sector. Some respondents regarded it positively in terms of experience in higher positions that might enhance their likelihood of a subsequent promotion. Others saw it as unsettling, particularly when they accepted a seconded position because they felt that they had no other option, and would rather have remained in their substantive position. Overall, about 70% of nurse managers changed jobs for largely positive, personal or professional reasons, including promotion and/or career development. The remaining 30%, comprising rel-
Table 4: Patterns of nurse manager job changes within each practice area Practice area
Miscellaneous No one area of practice Nursing/general administration Operating theatre services Child/family/paediatric Gerontology/aged care Midwifery/obstetrics Community health Emergency departments Intensive care units General mental health General surgical General medicine Total 12
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Currently working in practice area
No change of any kind
Total changed only within practice area
Propensity to change
Relative stability ratio
57 41 47 109 20 158 74 44 38 35 56 36 70 785
12 13 21 49 9 76 41 22 21 18 31 23 40 376
43 28 25 51 7 55 25 14 10 8 12 6 6 290
75.4% 68.3% 53.2% 46.8% 35.0% 34.8% 33.8% 31.8% 26.3% 22.9% 21.4% 16.7% 8.6%
0.28 0.46 0.84 0.96 1.29 1.38 1.64 1.57 2.10 2.25 2.58 3.83 6.67
NOTES: (1) No change of any kind refers to respondents who have changed jobs neither within nor between practice areas. (2) Propensity to change refers to ‘total changes’ as a proportion of all ‘currently working in a practice area’. (3) Relative stability is the ratio of ‘no changes’ to ‘changes’ within a practice area. (4) Propensity to change will be slightly underestimated and relative stability will be slightly overestimated due to the absence of data on a small number of respondents who have had more than four nurse manager positions during the ten years, but are not included in this table.
Nurse manager turnover in New South Wales during the 1990s
40 35
Public sector Private sector
Relative frequencies (%)
30 25 20 15 10 5
Ot he rr ea so ns
Le ft
of ow or n fre pr e of wi es ll sio for na pe l r rs ea on so al Le ns dis ft sa of tis ow fy n ing fre as e w pe ill cts du Le ft of e to be job ca u wi se th of ou st t a res job s w to ith go or to Or pr gan es is su at re ion on al m po e t liti o cs lea – ve Em plo ym en t by term em in plo ate ye d r re du T nd oo an k v cy ol Ch pa unt an ck ary ge ag d to e job an o in th sa er m m e o an rg age an m Ch isa en an tio t ge n to n in on sa -m m an eo a rg ger an ial isa jo tio b n
0
Figure 3: Reasons for leaving all nurse manager jobs - public and private sectors
atively more private sector nurse managers, changed jobs because of aspects of the jobs that they found dissatisfying, distressing, and/or intolerable due to political pressures on them. Table 5 summarises the frequencies of the top five ranked influences on respondents’ first, second, third, and fourth nurse manager job changes during the 1990s. It reveals the relative importance of numerous underlying factors that are influential in nurse managers’ decisions to change/leave their jobs, promotion/career advancement was the most important (13.5%), the
Evidently, there comes a point in a nurse manager’s career that the desired promotion can only be achieved by moving outside the organisation within which (s)he has had one or more promotions. five highest ranked influences after that relate to negative organisational factors - factors that combined to account for 44.3% of the top five. Second, and equal ranked in overall importance, are ‘dissatisfaction with the work environment’ (10.2%) and ‘not feeling valued by the organisation’ (10.2%). Close behind these two influences are ‘insufficient time to satisfy the demands of the job’ (8.2%), ‘too much accountability without the power to act’ (8.1%), and ‘too often having to take work home to finish’ (7.6%). Overall, despite the relative importance of these dissatisfying influences, the propensity to change jobs because of them did not alter significantly with each job change. It is notable that several factors were conspicuous by their low ratings. They relate to working hours and opportunities for staff development - factors that are typically regarded by organi-
sations as enhancing retention if they are present in someone’s job, or, if absent, contributing to increased turnover. However, these factors (1 and 7) were the least influential of all on nurse manager turnover. In most cases, the reasons for changing jobs and the influences on the decisions to do so were not significantly different for each practice area. However, there were two exceptions, and they concern the two practice areas of nurse managers that were identified previously as having a greater propensity to turnover. First, operating theatre service nurse managers had an atypically high frequency of turnover for either personal or professional reasons (28% compared to 19% overall). Secondly, those in nursing/general administration cited ‘too often having to take work home to finish’ and ‘dissatisfaction with the work environment’ at atypically high rates of 13% and 16% respectively (compared to 7.6% and 10.2% respectively overall). Further research is needed if this higher turnover phenomenon amongst both groups is to be explained. Reasons for staying in current job
Table 6 lists 10 reasons for nurse managers staying in their current jobs, and presents the frequencies with which respondents ranked them from the most important (#1) to the fifth most important reason. Six hundred and twenty-nine respondents reported at least one reason for staying in their current nurse manager jobs whilst 358 provided at least five prioritised reasons. By far the most important reason for staying, ranked as #1 by 44% (n=276) of respondents, was that the job was satisfying/rewarding. Next in importance was the suitability of the work for the respondents’ skills and qualifications - the case for almost 23% of the nurse managers. These were followed by Collegian Vol 10 No1 2003 13
the suitability of hours of work (11.6%) and the enjoyment of the company of co-workers (5.9%). Despite the large proportion of respondents who seemed quite satisfied with their jobs and were not in a hurry to move on, 7% of respondents (n=44) reported that they would have like to quit, but did not have another job to go to. This is less than the 10% quitting intentions of nurse managers in the USA reported in the AONE study (Anonymous 1994). When the #1 to #5 ranked reasons for staying are analysed together, it is possible to gain a picture of the factors that are the most important influences on nurse managers remaining in their jobs. The resultant top four reasons relate to characteristics of the job and the working environment. They are (from Table 6): 1. The work suits my skills and qualifications (19.2%); 2. I find the job satisfying and/or rewarding (17.9%); 3. I enjoy the company of the people I work with (16.9%); 4. The hours suit my needs (14.7%). Being happy with what they are paid to do in their jobs was next in overall importance (9.7%), but evidently not nearly as important a reason for staying in a nurse manager job as the
above four positive characteristics of their jobs and/or working environments. The relative importance of these reasons for staying was similar for nurse managers across the various practice areas, geographic locations, and health sectors. However, based on the turnover patterns reported herein, many who were happy enough with their jobs would change them when opportunities arose for promotion/career development within or outside their respective organisations. Limitations of the study The technique used to select participants in this research could not capture all nurses who had worked at any time during the 1990s as nurse managers in the practice areas selected for study. The only way to have overcome this limitation would have been to have surveyed all currently and previously registered nurses in NSW. This would have been a very costly exercise. It is proposed that the present research was of sufficient scale and scope to provide a reliable and comprehensive picture of the phenomena of turnover and retention amongst nurse managers during the 1990s.
Table 5: Factors influencing respondents’ decisions to change jobs Factors
Frequency in public sector
Frequency in private sector
Total frequency
Relative total frequency
Overall ranking
152 105 100 75 77 72 89 82 68 40 54 42 34 29
57 53 58 52 49 46 27 32 34 35 18 26 28 20
209 158 158 127 126 118 116 114 102 75 72 68 62 49
13.5% 10.2% 10.2% 8.2% 8.1% 7.6% 7.5% 7.3% 6.6% 4.8% 4.6% 4.2% 4.0% 3.2%
1 2 3 4 5 6 7 8 9 10 11 12 13 14
11. Promotion/career advancement 4. I was dissatisfied with the work environment 5. I didn’t feel valued by the organisation 6. Insufficient time to satisfy demands of the job 8. Too much accountability without power to act 3. Too often having to take work home to finish 14. Other work-related factors (specify) 12. Organisational restructuring 10. I no longer enjoyed doing the job 2. I didn’t feel I was paid enough for the job I did 13. Personal/family reasons already covered 9. Budgetary/financial constraints 7. Inadequate staff development opportunities 1. The hours didn’t suit me or my family
Table 6: Respondents’ reasons for staying in current jobs Reasons
Work suits skills & qualifications Job is satisfying/rewarding Enjoy company of other workers Suitable hours of work Happy with pay Professionalism of others Organisation values its employees Want to leave but have no job to go to Necessary equipment available Other reasons for staying in job Total 14
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Ranked #1
Ranked #2
Ranked #3
Ranked #4
Ranked #5
Grand Total
Total relative freq
Overall ranking
143 276 37 73 26 6 11 44 1 12 629
154 71 123 89 41 31 22 19 21 8 579
82 54 123 89 71 42 40 15 16 4 536
69 31 93 70 71 49 30 14 29 4 460
44 26 57 56 40 59 28 12 33 3 358
492 458 433 377 249 187 131 104 100 31 2562
19.2% 17.9% 16.9% 14.7% 9.7% 7.3% 5.1% 4.1% 3.9% 1.2%
1 2 3 4 5 6 7 8 9 10
Nurse manager turnover in New South Wales during the 1990s
Summary and recommendations There have been no previous Australian studies that have examined factors influencing the retention of nurse managers, or the incidence of and reasons for turnover amongst nurse managers. Consequently, the major contribution of the present research is that it provides an empirical basis upon which future studies may be conducted. It is comprehensively reported in a monograph by Johnstone (2002). The present paper has revealed that there is a strong propensity for nurse managers to change jobs for career development, often associated with a promotion, within the same organisation or the same health sector. It has also highlighted that specialisation in a particular practice area virtually dictates that a nurse manager will change jobs within the same practice area unless (s)he moves into a more senior health services manager or nursing director position, at which time (s)he is more likely to move between health sectors or to another geographic area. Overall, the findings reported herein do not present a picture of turnover amongst nurse managers that is consistent with the findings of previous studies that have explored turnover amongst registered nurses generally. For example, studies by Short et al (1988), Phillips and Carter (1988), Battersby et al (1989), Battersby et al (1990), Persson et al (1993), Hegney et al (2002) identified a number of important influences on turnover, including: job dissatisfaction and low morale as a consequence of nursing shortages; shift work; the style of management of nursing administration and/or communication problems between clinical nurses and nurse managers; inflexible workplace practices relating particularly to managing family responsibilities such as child care; and inequitable leave arrangements. These factors have not emerged as having any significance for the nurse manager respondents in the present research. It can be argued, therefore, that registered nurses are not a homogeneous group where issues such as turnover and retention are concerned. This research serves to highlight the importance of differentiating between nurses according to their specific roles, such as nurse manager, and practice areas. Such differentiation is necessary to better inform practice and strategies aimed at minimising avoidable turnover amongst specific categories of nurses. Due to the absence of nurse manager specific data against which the results reported herein can be compared, it is inappropriate to advance a conclusion that turnover is either normal or excessive. Nevertheless, the evidence of nurse managers in the private sector changing or leaving jobs because they feel intolerably time pressured and are taking too much work home to complete, cannot be ignored. Future research is necessary, possibly in the form of a more detailed comparative study of organisational environments and human resource practices within public and private health care facilities, before any recommendations for practice can be made in this regard.
Acknowledgements The author acknowledges, with appreciation, the funding grants received from both the Faculty of Health Studies and the Centre for Cultural Risk Research at Charles Sturt University, and the generous practical assistance by the NSW Health Workforce Planning Unit and the NSW Nurses’ Registration Board. References Anonymous 1994 Nurse manager recruitment and retention. Nursing Management 25(1):28-29 Battersby D, Kermode S, van der Wal J, Boylan C, Kerr R, King B 1989 Calculating nurse turnover in NSW. Australian Journal of Advanced Nursing 6(2):4-7 Battersby D, Hemmings L, Cox J, Sutherland S, Adcock L 1990 A study of the retention, job satisfaction and morale of nurses in the Western Sydney Area Health Service. Nursing Research Unit, Charles Sturt University, Wagga Wagga Cavanagh S J 1989 Nursing turnover: literature review and methodological critique. Journal of Advanced Nursing 14:587-596 Campion M A 1991 Meaning and measurement of turnover: comparison of alternative measures and recommendations for research. Journal of Applied Psychology 76(2):199-212 Chaffey K 1999 Workforce Planner, NSW Health Workforce Planning Unit, Personal communication. 12th March 1999 Cohen A, Hudecek N 1993 Organisational commitment-turnover relationship across occupational groups: a meta-analysis. Group and Organisation Management 18(2):188-213 Fox S 1987 The origins of wastage from nursing. Australian Journal of Advanced Nursing 5(1):11-17 Harris M 2002 Planning and policy implications of projected medical and health professional shortages. ACHSE Health Autumn 16-19 Hegney D, McCarthy A, Rogers-Clark C, Gorman D 2002 Why nurses are resigning from rural and remote Queensland health facilities. Collegian 9(2):33-39 Irvine D M, Evans M G 1995 Job satisfaction and turnover among nurses: integrating research findings across studies. Nursing Research 44(4):246-253 Johnstone P L 2000 1990s surgical technologies implicated in role conflictinducing stress amongst operating theatre scrub and circulating nurses. ACORN Journal 13(1):19-27 Johnstone P L 2001 The process and organisational consequences of new artefact adoption in surgery. Unpublished PhD thesis, Macquarie University, Sydney Johnstone P L 2002 Nurse manager turnover and retention in New South Wales during the 1990s. School of Public Health Monograph No.1, 2002. Charles Sturt University, Bathurst, NSW Manlove E E, Guzell J R 1997 Intention to leave, anticipated reasons for leaving, and 12-month turnover of child care centre staff. Early Childhood Research Quarterly 12(2):145-167 Mathieu J E, Baratta J E 1989 Turnover type as a moderator of the performanceturnover relationship. Human Performance 2(1):61-71 New South Wales Health 1999 Nursing Workforce Annual Survey, NSW, 1998. Workforce Planning Branch, NSW Health, North Sydney Parasuraman S 1989 Nursing turnover: an integrated model. Research in Nursing and Health 12(4):267-277 Persson L, Hallberg I R, Athlin E 1993 Nurse turnover with special reference to factors relating to nursing itself. Scandinavian Journal of Caring Sciences 7(1):29-36 Phillips C, Carter M 1988 Quantifying discontent in the nursing profession: a study of staff mobility in Victorian nursing homes. Australian Health Review 11(4):256-276 Pierce L L, Hazel C M, Mion L C 1996 Effect of a professional practice model on autonomy, job satisfaction and turnover. Nursing Management 27(2):48M-48T Pilkington W, Wood J 1986 Job satisfaction, role conflict and role ambiguity - a study of hospital nurses. Australian Journal of Advanced Nursing 3(3):3-14 Price J L, Mueller C 1981 Professional turnover: the case for nurses. SP Medical and Scientific Books, New York Shindul-Rothschild J, Berry D, Long-Middleton E 1999 The cost of caring: lessons from nurses in the USA. The Lamp 56(8):21-25 Short S, Short J, Sharman E 1988 The effects of shiftwork on nurses: implications for Australian hospitals. Australian Health Review 11(4):277-283 Taunton R L, Boyle D K, Woods C Q, Hansen H E, Bott M J 1997 Manager leadership and retention of hospital staff nurses. Western Journal of Nursing Research 19(2):205-226 Taylor G S, Zimmerer T W 1992 Voluntary turnover among middle-level managers: an analysis of perceived causes. Journal of Managerial Issues 4(3):424-437 Tyagi P K, Wotruba T R 1993 An exploratory study of reverse causality relationships among sales force turnover variables. Journal of the Academy of Marketing Science 21(2):143-153 Wood J 1984 Part-time employment: making the future work in education. Work and People 10(1):6-14 Collegian Vol 10 No1 2003 15
The principal aim of the research reported in this paper was to explore the nature and incidence of various environmental, personal, and work-related factors that are implicated in turnover and retention amongst nurse managers. The study sought to ascertain whether or not turnover patterns during the 1990s were similar for nurse managers working in different specialist areas and settings of health services within New South Wales, and to discover the main reasons why nurse managers change their jobs or stay in their jobs. This paper reports the main findings, and highlights how the factors implicated in nurse manager turnover and retention, whilst not significantly dissimilar across different cohorts of nurse managers, do not parallel those that are implicated in turnover amongst nurses generally. The research has found that the main reason nurse managers change their jobs is for career development, often within the same organisation or, otherwise, the same health sector or geographic area. Second to this is leaving due to dissatisfying aspects of the job and/or work environment. Some differences have been observed in the propensity to change jobs and in the relative importance of particular influences on job changes in certain practice areas and health sectors. Seven per cent of nurse managers would like to quit their present jobs. However, almost 70% are happy to stay either because the job suits their skills and qualifications, the job is personally satisfying/rewarding, they enjoy the company of their coworkers, or their hours of work suit their needs. Key words: Nurse manager, turnover, retention, job satisfaction
P Lynne Johnstone PhD Macq GDipHlthEc NE GDipCom(BusInfSys)W’gong BHSc(Mgt)(Dist)CSturt RN FCHSE CHE School of Public Health, Charles Sturt University. E-mail: [email protected]
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Background The topic of turnover has been comprehensively studied in general terms (eg Mathieu & Baratta 1989, Tyagi & Wotruba 1993, Manlove & Guzell 1997) and in relation to specific groups of employees, including managers (eg Taylor & Zimmerer 1992, Cohen & Hudecek 1993). Turnover amongst clinical nurses has also received substantial attention in the literature (eg Battersby et al 1989, Parasuraman 1989, Persson et al 1993, Irvine & Evans 1995, Pierce et al 1996, Taunton et al 1997). Over the past few decades, research into nurse shortages, surpluses, and turnover has concluded that the causes are complex and often not well understood. Research has concentrated on factors that are inherent in the job of nursing for clinical nurses, as distinct from the job of being a nurse manager. Topics have ranged from wage structures to working conditions, and from style of management to the lack of child care facilities. No attention seems to have been paid to the different work demands placed on nurses working in different specialist areas of practice or to the potential impact on turnover of their specific levels/grades of appointment. Research into turnover has attracted strong interest during periods of nurse shortages and, consequently, most published research in recent decades was conducted during the 1980s. During this time, a number of American and Australian researchers reported some of the wider social and economic issues which influence nursing turnover (eg Price & Mueller 1981, Fox 1987, Cavanagh 1989). Some studies reported that wastage from nursing increases with higher qualifications (Price & Mueller 1981, Fox 1987). Other studies revealed that turnover is lower amongst part-time nurses than other groups of nurses (Phillips & Carter 1988), and that part-time nurses are a more satisfied group (Price & Mueller 1981, Pilkington & Wood 1986). However, by working part-time, career opportunities are often reduced (Wood 1984) and, hence, it is possible that nurses achieving manager status will have worked on a fulltime basis to achieve such positions. Nurse managers constitute a sizeable subset of nurses, representing approximately 4,000 nurses registered in New South Wales in 1998 (Chaffey 1999). Internationally, scant attention
Nurse manager turnover in New South Wales during the 1990s
has been paid to the incidence and causes of turnover in this group. One notable exception is the work done by the American Organisation for Nurse Executives (AONE) under whose auspices several studies on turnover amongst nurse managers in the USA were conducted in the early 1990s (Anonymous 1994). The AONE study revealed that turnover amongst USA nurse managers was on the rise. The main influences on that turnover were found to be changes in the complexity of the roles and responsibilities of nurse managers, fiscal constraints, insufficient time to do everything, uncompensated work time, and accountability without authority (Anonymous 1994) in an environment beset by downsizing and restructuring (ShindulRothschild et al 1999). Moreover, it was found that over 10% of nurse managers intended to quit their jobs within a period of six months, and that 40% of those with quitting intentions did not intend to seek another position in nursing management (Anonymous 1994). No similar research appears to have been done in Australia. This researcher has argued elsewhere that even amongst similar categories of clinical nurses, the specialist practice area of the nurse will present a different set of work and personal demands (Johnstone 2000, 2001). The present research aimed to find out if this proposition can be sustained for nurse managers working in different practice areas and settings within NSW. Research questions The key questions guiding this research were: 1. Is turnover amongst NSW nurse managers significantly different according to geographical location of work, age or gender of nurse manager, health sector, or specialty practice area? 2. Why do nurse managers change their jobs? 3. Why do nurse managers remain in their jobs?
them were sent a questionnaire. Figure 1 summarises the distribution of potential informants working in each type of health service and Figure 2 summarises them according to the seven practice areas in public and private hospitals. The first series of questions in the questionnaire obtained informant characteristic data. Data fields relating to the practice area and grade of nurse manager appointment correlated with those employed in the NSW Health Workforce database (NSW Health 1999). The remainder of the questionnaire sought information from informants about their jobs as nurse managers throughout the 1990s. The questions were developed primarily from the literature concerning employee turnover and retention in general, and nurse turnover and retention in particular. The questionnaire asked two questions about informants’ reasons for leaving each nurse manager job. The first asked them to select a single statement from the fourteen provided, which best described their reason for leaving a particular nurse manager job. The second question asked them to select and rank, for each nurse manager job change, factors from a different set of 14 that influenced their decision to leave. They were Private hospitals (n=192)10.0%
Private nursing homes or hostels (n=360) 18.8% Public hospitals (n=744) 38.9%
Source: NSW Health Workforce Planning Unit
Research methods The research was conducted during the year 2000. A projectspecific survey questionnaire was used to collect the data. It was first pilot tested in a regional area health service amongst eight nurse managers, who were subsequently interviewed to find out what, if any, difficulties they had in understanding instructions or interpreting questions contained in it. This resulted in some minor modifications. Potential informants were selected from the NSW Health Workforce Planning Unit’s database of all grades of nurses registered to practise in 1998 (NSW Health 1999). This database can distinguish non-nurse managers from nurse managers, and can distinguish nurse managers according to any one of ten incremental grades of nurse manager. It contains 67 identifiable specialist areas of nursing practice. One thousand nine hundred and thirteen nurse managers working during 1998 in nine nursing practice areas - seven within public and private hospitals, plus aged care and community health services – were selected from the database as potential study informants. All of
Public nursing homes or hostels (n=345) 18.0%
Community health settings (n=272) 14.2%
Figure 1: Workplaces of potential informants
Midwifery/obstetrics (n=160) 17.1%
General medicine (n=153) 16.0%
General mental health (n=116) 12.4%
Operating theatre services (n=227) 24.3%
Intensive care departments (n=79) 8.4% Emergency departments (n=105) 11.2%
General surgical (n=96) 10.3%
Source: NSW Health Workforce Planning Unit
Figure 2: Practice areas of potential informants in public and private hospitals Collegian Vol 10 No1 2003 9
asked to rank any number of influences, but only those that were actually influential for a particular job change. The 14th optional response in each of the two questions was ‘other reason/factor’ which, if selected, required the informant to specify the reason/influence. The questionnaire also asked informants who were working as nurse managers at the time of the study to select and rank one or more of 10 statements about their intentions to stay in their current jobs. Eight of nine factors influencing their decisions to stay related to personal preferences and/or organisational characteristics, whilst the ninth option, ‘other reasons’, gave informants the opportunity to provide a reason not covered by the other eight. The 10th statement in this list was: ‘I would like to quit this job, but I don’t have another job to go to’. Mailing of the questionnaires was facilitated via a collaborative effort between the NSW Nurses’ Registration Board, the NSW Health Workforce Planning Unit, and the researcher. By late 2000, 803 completed survey questionnaires had been returned, representing a response rate of about 42%. Data entry into a Microsoft Access database was completed by a research assistant and analysis was undertaken by the researcher. Ethical considerations Approval to conduct the research was given by the Charles Sturt University Human Ethics Committee. To ensure confidentiality, questionnaires were completed anonymously. The return of a completed questionnaire was deemed to be participant consent. Results Profile of respondents
Table 1 summarises the distribution of the respondents across practice areas and the health sectors and geographic areas of their employment in 2000. The representation of nurses in all practice areas compared favourably with the study population, although there was relatively more respondents in ‘no one area
of practice’ in regional/rural NSW public sector than in the other five categories. The geographic spread of the study population is not known, but the study respondents were well represented in each of the three areas - Sydney region (n=250), other metropolitan areas (n=178) and regional NSW (n=351). Moreover, one in three respondents worked in the private sector (calculated from Table 1). This compares favourably with the population distribution of 28.8% (for private hospitals and nursing homes/hostels) represented in Figure 1.
The data reveal a high level of public or private sector loyalty amongst nurse managers, with 86% of nurse managers working in only one health sector during the 1990s. The number of respondents working in each type of health facility approximated their relative numbers in the study population: hospitals (54.4%), nursing homes or aged care hostels (24.2%), and community health services (14.4%). Most of the remaining 7% had either retired or were working in various other (non-)health organisations. The majority of respondents (65%) worked in facilities of between 50 and 250 beds (or residents), while 10.5% worked in facilities with more than 500 beds. Each practice area was well represented across the full range of sizes of health service facilities. The age distribution of respondents was negatively skewed with 83% being at least 40 years of age and 45-49 years being the mean age range. These data indicate that nurse managers are, on average, at least ten years older than all registered nurses (cf Hegney et al 2002). About 11% of respondents were male, which is slightly higher than the gender distribution of all nurses both within NSW and Australia, which is 8% male (NSW Health 1999, Harris 2002). This provides some support for anecdotal evidence that relatively more male than female nurses
Table 1: Current practice areas, geographic location, and health sector of work of respondents Capital city
General medicine Operating theatre services General surgical Emergency department Intensive care units General mental health Midwifery/obstetrics No one area of practice Aged care, gerontology Community, unspecified Nurs/general administration Paediatric, child & family None of the above Practice area not specified Total 10
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Public sector
Private sector
Public sector
Other metropolitan Private sector
Regional/Rural NSW Public sector
Private sector
Geog. area not specified
Total informants
11 34 0 7 7 13 22 4 11 7 11 12 12 1 153
6 17 5 2 3 2 5 1 33 1 4 1 14 3 97
8 13 4 8 12 15 8 3 13 9 5 2 3 2 105
2 10 2 0 2 1 4 0 40 2 5 0 5 0 73
35 24 15 19 9 21 28 30 17 22 16 5 15 2 258
8 9 9 1 2 2 5 3 41 1 5 0 7 0 93
0 2 1 1 0 2 1 0 3 2 1 0 1 10 24
70 109 36 38 35 56 74 41 158 44 47 20 57 18 803
Nurse manager turnover in New South Wales during the 1990s
work in management positions. About one in three of all respondents had not changed their jobs during the ten years, during which time almost 9% of respondents (n=60) changed their nurse manager jobs three or more times. About 66% of respondents were not nurse managers in 1990, but were appointed to their first nurse manager positions at some time during the intervening ten years. Of those who held nurse manager positions in both 1990 and 2000 (n=213), only 62% (n=131) had worked continuously in positions which were categorically nurse manager positions during that time, and only 18 of these individuals were still in the same jobs that they occupied in 1990. Furthermore, some of those who were nurse managers in 1990 were among the 19% of respondents (n=153) who were no longer in positions that were categorically nurse manager despite having been, according to the NSW Nursing Workforce database (NSW Health 1999), a nurse manager in 1998. At least 45 of them had either returned to clinical nursing positions or moved into senior clinical positions such as clinical nurse specialist, clinical nurse consultant, clinical team leader, clinical educator, or clinical researcher. At least another 21 had moved into managerial positions such as program manager, business manager, quality assessor/coordinator, general manager, or hostel or health service manager. Job changes and health sector
The data reveal a high level of public or private sector loyalty amongst nurse managers, with 86% of nurse managers working in only one health sector during the 1990s. Of those currently working in the public sector (n=531), 91% had worked only in that sector during the 1990s, and about half of them had changed jobs at least once within that sector. In the private sector, 77% of those currently working there (n=265) had worked only in the private sector, 45% of whom had changed jobs at least once within that sector. Job changes and geographic area
Respondents reported the geographic area of each job according to the following three categories: capital city, other metropolitan, and regional/rural. Analysis of the frequency of nurse manager job changes within and between geographic areas reveals that 44.2% (n=344) had changed jobs at least once within a category of geographic area, whilst 10.6% (n=83) had worked in more
Table 2: Frequency of job changes within each geographic area No 1 2 3 4 change change changes changes changes Worked only in Sydney region 97 Worked only in other metro area 88 Worked only in regional NSW 167 Total 352 Proportions 50.6%
62 40 90 192 27.6%
34 20 36 90 12.9%
18 5 18 41 5.9%
7 8 6 21 3.0%
than one geographic area as nurse managers during the 1990s. These data must not be construed as meaning that only 10.6% of respondents had relocated when they had changed jobs. What they do reveal, however, is that among the 54.8% of respondents who changed nurse manager jobs at least once during the 1990s, about four in five had worked only within either greater Sydney, in minor metropolitan areas such as Wollongong and Newcastle, or within regional NSW. Table 2 summarises the data on the frequencies of changes within each geographic area. Table 3 then introduces two concepts that provide complementary means of comparing turnover between groups. These are propensity to change, which represents ‘total changes’ as a proportion of ‘all currently in a given class’ (in this case, in a geographic area), and relative stability, which is the ratio of ‘no changes’ to ‘changes’ within a given class. The higher the propensity to change value, the more likely nurse managers in that class are likely to change their jobs. The higher the relative stability ratio, the more stable the nurse manager workforce in that class is deemed to be. Propensity to change jobs was five percentage points higher in Sydney (48%) than in regional NSW (43%) and seven percentage points higher than in other metropolitan areas (41%). Moreover, turnover within nurse manager positions, based on the relative stability ratio, was greatest within Sydney (RSR=0.80) and least within other metropolitan areas (RSR=1.21). No explanation can be found in the study data for these trends, but it is possible that nurses working in greater Sydney simply had more opportunities to change jobs due to the significantly larger number of health service facilities in proximity. Job changes and practice area There appears to be a fairly high degree of practice area loyalty amongst nurse managers, a finding that should not be surprising in a profession in which specialisation is more the rule than the exception. Indeed, altogether about 85% of respondents had either not changed jobs (n=376) or moved only within practice areas (n=290) in their nurse manager jobs during the 1990s. Table 4 presents the results for each practice area in order from the highest to lowest propensity to change jobs. It reveals that those working in general surgical, medicine and mental health were the least likely to have changed jobs. On the other hand, those working in no specific area of practice and nursing/general administration were most likely to have changed
Table 3: Relative stability and propensity to change jobs within each geographic area No change Number Propensity Relative of changes to change stability Worked only in Sydney region Worked only in other metro area Worked only in regional NSW Total
97 88 167 352
121 73 150 344
48% 41% 43%
0.80 1.21 1.11
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jobs. Although nurse managers in ‘no specific area of practice’ stand out as changing jobs relatively more often than others, they represent too diverse a range of practice areas for analysis in the present paper.
… there is a strong propensity for nurse managers to change jobs for career development, often associated with a promotion, within the same organisation or the same health sector. Two practice areas, then, stand out as both having a higher propensity to change than others - operating theatre services (PTC=46.8%) and nursing/general administration (PTC=53.2%). Positions in these practice areas also appear to be the most unstable, with relative stability ratios of 0.96 and 0.84 respectively - issues that are touched on later in the following section. General medicine (RSR=6.67) and general surgical (RSR=3.83) appear to be the most stable of those studied in the present research. Reasons for changing/leaving jobs
The single statement that best described respondents’ reasons for leaving a nurse manager job (given by 23.7% of respondents) was ‘I did not leave. I was successful in my application for another management position within the organisation’. However, it has been found that the probability of changing jobs within an organisation declines with each job change. Evidently, there comes a point in a nurse manager’s career that the desired promotion can only be achieved by moving outside the organisation within which (s)he has had one or more promotions. The second ranked reason was not similarly positive, with 13.8% selecting the response, ‘I left of my own free will due to dissatisfying aspects of the job that I didn’t want in my life’. Patterns were similar for each nurse manager job change,
although changing jobs because of work-related stress appears to increase in relative terms with each nurse manager job change and, therefore, generally with more senior positions. Analysis of the primary reasons given by respondents for leaving up to three nurse manager jobs was undertaken by grouping statements with common elements. The results are depicted in Figure 3. Two are statistically significant (χ2 = 27.12, df=1, p<0.0001): (a) a significantly higher proportion of public sector nurse managers changing management jobs because of restructuring or for promotion/career development within the same organisation, and (b) a significantly higher proportion of private sector nurse managers than public sector nurse managers leaving because of dissatisfying aspects of their jobs. Analysis of the influences on private sector nurse managers reveals two that are significant (χ2=13.3, df=3, p<0.005): ‘too often having to take work home to finish’ and ‘insufficient time to satisfy the demands of the job’. It appears that nurse managers in the private sector are feeling significantly more time pressured in their work than their public sector peers. Qualitative analysis of the ‘other reasons’ for changing jobs revealed that secondment to acting/relieving positions was the most common, while retirement, partner relocation, personal/family reasons, and facility closure were not uncommon. It appears that the practice of seconding individuals to acting/relief positions, often for uncertain and protracted periods, is a characteristic of the public sector. Some respondents regarded it positively in terms of experience in higher positions that might enhance their likelihood of a subsequent promotion. Others saw it as unsettling, particularly when they accepted a seconded position because they felt that they had no other option, and would rather have remained in their substantive position. Overall, about 70% of nurse managers changed jobs for largely positive, personal or professional reasons, including promotion and/or career development. The remaining 30%, comprising rel-
Table 4: Patterns of nurse manager job changes within each practice area Practice area
Miscellaneous No one area of practice Nursing/general administration Operating theatre services Child/family/paediatric Gerontology/aged care Midwifery/obstetrics Community health Emergency departments Intensive care units General mental health General surgical General medicine Total 12
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Currently working in practice area
No change of any kind
Total changed only within practice area
Propensity to change
Relative stability ratio
57 41 47 109 20 158 74 44 38 35 56 36 70 785
12 13 21 49 9 76 41 22 21 18 31 23 40 376
43 28 25 51 7 55 25 14 10 8 12 6 6 290
75.4% 68.3% 53.2% 46.8% 35.0% 34.8% 33.8% 31.8% 26.3% 22.9% 21.4% 16.7% 8.6%
0.28 0.46 0.84 0.96 1.29 1.38 1.64 1.57 2.10 2.25 2.58 3.83 6.67
NOTES: (1) No change of any kind refers to respondents who have changed jobs neither within nor between practice areas. (2) Propensity to change refers to ‘total changes’ as a proportion of all ‘currently working in a practice area’. (3) Relative stability is the ratio of ‘no changes’ to ‘changes’ within a practice area. (4) Propensity to change will be slightly underestimated and relative stability will be slightly overestimated due to the absence of data on a small number of respondents who have had more than four nurse manager positions during the ten years, but are not included in this table.
Nurse manager turnover in New South Wales during the 1990s
40 35
Public sector Private sector
Relative frequencies (%)
30 25 20 15 10 5
Ot he rr ea so ns
Le ft
of ow or n fre pr e of wi es ll sio for na pe l r rs ea on so al Le ns dis ft sa of tis ow fy n ing fre as e w pe ill cts du Le ft of e to be job ca u wi se th of ou st t a res job s w to ith go or to Or pr gan es is su at re ion on al m po e t liti o cs lea – ve Em plo ym en t by term em in plo ate ye d r re du T nd oo an k v cy ol Ch pa unt an ck ary ge ag d to e job an o in th sa er m m e o an rg age an m Ch isa en an tio t ge n to n in on sa -m m an eo a rg ger an ial isa jo tio b n
0
Figure 3: Reasons for leaving all nurse manager jobs - public and private sectors
atively more private sector nurse managers, changed jobs because of aspects of the jobs that they found dissatisfying, distressing, and/or intolerable due to political pressures on them. Table 5 summarises the frequencies of the top five ranked influences on respondents’ first, second, third, and fourth nurse manager job changes during the 1990s. It reveals the relative importance of numerous underlying factors that are influential in nurse managers’ decisions to change/leave their jobs, promotion/career advancement was the most important (13.5%), the
Evidently, there comes a point in a nurse manager’s career that the desired promotion can only be achieved by moving outside the organisation within which (s)he has had one or more promotions. five highest ranked influences after that relate to negative organisational factors - factors that combined to account for 44.3% of the top five. Second, and equal ranked in overall importance, are ‘dissatisfaction with the work environment’ (10.2%) and ‘not feeling valued by the organisation’ (10.2%). Close behind these two influences are ‘insufficient time to satisfy the demands of the job’ (8.2%), ‘too much accountability without the power to act’ (8.1%), and ‘too often having to take work home to finish’ (7.6%). Overall, despite the relative importance of these dissatisfying influences, the propensity to change jobs because of them did not alter significantly with each job change. It is notable that several factors were conspicuous by their low ratings. They relate to working hours and opportunities for staff development - factors that are typically regarded by organi-
sations as enhancing retention if they are present in someone’s job, or, if absent, contributing to increased turnover. However, these factors (1 and 7) were the least influential of all on nurse manager turnover. In most cases, the reasons for changing jobs and the influences on the decisions to do so were not significantly different for each practice area. However, there were two exceptions, and they concern the two practice areas of nurse managers that were identified previously as having a greater propensity to turnover. First, operating theatre service nurse managers had an atypically high frequency of turnover for either personal or professional reasons (28% compared to 19% overall). Secondly, those in nursing/general administration cited ‘too often having to take work home to finish’ and ‘dissatisfaction with the work environment’ at atypically high rates of 13% and 16% respectively (compared to 7.6% and 10.2% respectively overall). Further research is needed if this higher turnover phenomenon amongst both groups is to be explained. Reasons for staying in current job
Table 6 lists 10 reasons for nurse managers staying in their current jobs, and presents the frequencies with which respondents ranked them from the most important (#1) to the fifth most important reason. Six hundred and twenty-nine respondents reported at least one reason for staying in their current nurse manager jobs whilst 358 provided at least five prioritised reasons. By far the most important reason for staying, ranked as #1 by 44% (n=276) of respondents, was that the job was satisfying/rewarding. Next in importance was the suitability of the work for the respondents’ skills and qualifications - the case for almost 23% of the nurse managers. These were followed by Collegian Vol 10 No1 2003 13
the suitability of hours of work (11.6%) and the enjoyment of the company of co-workers (5.9%). Despite the large proportion of respondents who seemed quite satisfied with their jobs and were not in a hurry to move on, 7% of respondents (n=44) reported that they would have like to quit, but did not have another job to go to. This is less than the 10% quitting intentions of nurse managers in the USA reported in the AONE study (Anonymous 1994). When the #1 to #5 ranked reasons for staying are analysed together, it is possible to gain a picture of the factors that are the most important influences on nurse managers remaining in their jobs. The resultant top four reasons relate to characteristics of the job and the working environment. They are (from Table 6): 1. The work suits my skills and qualifications (19.2%); 2. I find the job satisfying and/or rewarding (17.9%); 3. I enjoy the company of the people I work with (16.9%); 4. The hours suit my needs (14.7%). Being happy with what they are paid to do in their jobs was next in overall importance (9.7%), but evidently not nearly as important a reason for staying in a nurse manager job as the
above four positive characteristics of their jobs and/or working environments. The relative importance of these reasons for staying was similar for nurse managers across the various practice areas, geographic locations, and health sectors. However, based on the turnover patterns reported herein, many who were happy enough with their jobs would change them when opportunities arose for promotion/career development within or outside their respective organisations. Limitations of the study The technique used to select participants in this research could not capture all nurses who had worked at any time during the 1990s as nurse managers in the practice areas selected for study. The only way to have overcome this limitation would have been to have surveyed all currently and previously registered nurses in NSW. This would have been a very costly exercise. It is proposed that the present research was of sufficient scale and scope to provide a reliable and comprehensive picture of the phenomena of turnover and retention amongst nurse managers during the 1990s.
Table 5: Factors influencing respondents’ decisions to change jobs Factors
Frequency in public sector
Frequency in private sector
Total frequency
Relative total frequency
Overall ranking
152 105 100 75 77 72 89 82 68 40 54 42 34 29
57 53 58 52 49 46 27 32 34 35 18 26 28 20
209 158 158 127 126 118 116 114 102 75 72 68 62 49
13.5% 10.2% 10.2% 8.2% 8.1% 7.6% 7.5% 7.3% 6.6% 4.8% 4.6% 4.2% 4.0% 3.2%
1 2 3 4 5 6 7 8 9 10 11 12 13 14
11. Promotion/career advancement 4. I was dissatisfied with the work environment 5. I didn’t feel valued by the organisation 6. Insufficient time to satisfy demands of the job 8. Too much accountability without power to act 3. Too often having to take work home to finish 14. Other work-related factors (specify) 12. Organisational restructuring 10. I no longer enjoyed doing the job 2. I didn’t feel I was paid enough for the job I did 13. Personal/family reasons already covered 9. Budgetary/financial constraints 7. Inadequate staff development opportunities 1. The hours didn’t suit me or my family
Table 6: Respondents’ reasons for staying in current jobs Reasons
Work suits skills & qualifications Job is satisfying/rewarding Enjoy company of other workers Suitable hours of work Happy with pay Professionalism of others Organisation values its employees Want to leave but have no job to go to Necessary equipment available Other reasons for staying in job Total 14
Collegian Vol 10 No1 2003
Ranked #1
Ranked #2
Ranked #3
Ranked #4
Ranked #5
Grand Total
Total relative freq
Overall ranking
143 276 37 73 26 6 11 44 1 12 629
154 71 123 89 41 31 22 19 21 8 579
82 54 123 89 71 42 40 15 16 4 536
69 31 93 70 71 49 30 14 29 4 460
44 26 57 56 40 59 28 12 33 3 358
492 458 433 377 249 187 131 104 100 31 2562
19.2% 17.9% 16.9% 14.7% 9.7% 7.3% 5.1% 4.1% 3.9% 1.2%
1 2 3 4 5 6 7 8 9 10
Nurse manager turnover in New South Wales during the 1990s
Summary and recommendations There have been no previous Australian studies that have examined factors influencing the retention of nurse managers, or the incidence of and reasons for turnover amongst nurse managers. Consequently, the major contribution of the present research is that it provides an empirical basis upon which future studies may be conducted. It is comprehensively reported in a monograph by Johnstone (2002). The present paper has revealed that there is a strong propensity for nurse managers to change jobs for career development, often associated with a promotion, within the same organisation or the same health sector. It has also highlighted that specialisation in a particular practice area virtually dictates that a nurse manager will change jobs within the same practice area unless (s)he moves into a more senior health services manager or nursing director position, at which time (s)he is more likely to move between health sectors or to another geographic area. Overall, the findings reported herein do not present a picture of turnover amongst nurse managers that is consistent with the findings of previous studies that have explored turnover amongst registered nurses generally. For example, studies by Short et al (1988), Phillips and Carter (1988), Battersby et al (1989), Battersby et al (1990), Persson et al (1993), Hegney et al (2002) identified a number of important influences on turnover, including: job dissatisfaction and low morale as a consequence of nursing shortages; shift work; the style of management of nursing administration and/or communication problems between clinical nurses and nurse managers; inflexible workplace practices relating particularly to managing family responsibilities such as child care; and inequitable leave arrangements. These factors have not emerged as having any significance for the nurse manager respondents in the present research. It can be argued, therefore, that registered nurses are not a homogeneous group where issues such as turnover and retention are concerned. This research serves to highlight the importance of differentiating between nurses according to their specific roles, such as nurse manager, and practice areas. Such differentiation is necessary to better inform practice and strategies aimed at minimising avoidable turnover amongst specific categories of nurses. Due to the absence of nurse manager specific data against which the results reported herein can be compared, it is inappropriate to advance a conclusion that turnover is either normal or excessive. Nevertheless, the evidence of nurse managers in the private sector changing or leaving jobs because they feel intolerably time pressured and are taking too much work home to complete, cannot be ignored. Future research is necessary, possibly in the form of a more detailed comparative study of organisational environments and human resource practices within public and private health care facilities, before any recommendations for practice can be made in this regard.
Acknowledgements The author acknowledges, with appreciation, the funding grants received from both the Faculty of Health Studies and the Centre for Cultural Risk Research at Charles Sturt University, and the generous practical assistance by the NSW Health Workforce Planning Unit and the NSW Nurses’ Registration Board. References Anonymous 1994 Nurse manager recruitment and retention. Nursing Management 25(1):28-29 Battersby D, Kermode S, van der Wal J, Boylan C, Kerr R, King B 1989 Calculating nurse turnover in NSW. Australian Journal of Advanced Nursing 6(2):4-7 Battersby D, Hemmings L, Cox J, Sutherland S, Adcock L 1990 A study of the retention, job satisfaction and morale of nurses in the Western Sydney Area Health Service. Nursing Research Unit, Charles Sturt University, Wagga Wagga Cavanagh S J 1989 Nursing turnover: literature review and methodological critique. Journal of Advanced Nursing 14:587-596 Campion M A 1991 Meaning and measurement of turnover: comparison of alternative measures and recommendations for research. Journal of Applied Psychology 76(2):199-212 Chaffey K 1999 Workforce Planner, NSW Health Workforce Planning Unit, Personal communication. 12th March 1999 Cohen A, Hudecek N 1993 Organisational commitment-turnover relationship across occupational groups: a meta-analysis. Group and Organisation Management 18(2):188-213 Fox S 1987 The origins of wastage from nursing. Australian Journal of Advanced Nursing 5(1):11-17 Harris M 2002 Planning and policy implications of projected medical and health professional shortages. ACHSE Health Autumn 16-19 Hegney D, McCarthy A, Rogers-Clark C, Gorman D 2002 Why nurses are resigning from rural and remote Queensland health facilities. Collegian 9(2):33-39 Irvine D M, Evans M G 1995 Job satisfaction and turnover among nurses: integrating research findings across studies. Nursing Research 44(4):246-253 Johnstone P L 2000 1990s surgical technologies implicated in role conflictinducing stress amongst operating theatre scrub and circulating nurses. ACORN Journal 13(1):19-27 Johnstone P L 2001 The process and organisational consequences of new artefact adoption in surgery. Unpublished PhD thesis, Macquarie University, Sydney Johnstone P L 2002 Nurse manager turnover and retention in New South Wales during the 1990s. School of Public Health Monograph No.1, 2002. Charles Sturt University, Bathurst, NSW Manlove E E, Guzell J R 1997 Intention to leave, anticipated reasons for leaving, and 12-month turnover of child care centre staff. Early Childhood Research Quarterly 12(2):145-167 Mathieu J E, Baratta J E 1989 Turnover type as a moderator of the performanceturnover relationship. Human Performance 2(1):61-71 New South Wales Health 1999 Nursing Workforce Annual Survey, NSW, 1998. Workforce Planning Branch, NSW Health, North Sydney Parasuraman S 1989 Nursing turnover: an integrated model. Research in Nursing and Health 12(4):267-277 Persson L, Hallberg I R, Athlin E 1993 Nurse turnover with special reference to factors relating to nursing itself. Scandinavian Journal of Caring Sciences 7(1):29-36 Phillips C, Carter M 1988 Quantifying discontent in the nursing profession: a study of staff mobility in Victorian nursing homes. Australian Health Review 11(4):256-276 Pierce L L, Hazel C M, Mion L C 1996 Effect of a professional practice model on autonomy, job satisfaction and turnover. Nursing Management 27(2):48M-48T Pilkington W, Wood J 1986 Job satisfaction, role conflict and role ambiguity - a study of hospital nurses. Australian Journal of Advanced Nursing 3(3):3-14 Price J L, Mueller C 1981 Professional turnover: the case for nurses. SP Medical and Scientific Books, New York Shindul-Rothschild J, Berry D, Long-Middleton E 1999 The cost of caring: lessons from nurses in the USA. The Lamp 56(8):21-25 Short S, Short J, Sharman E 1988 The effects of shiftwork on nurses: implications for Australian hospitals. Australian Health Review 11(4):277-283 Taunton R L, Boyle D K, Woods C Q, Hansen H E, Bott M J 1997 Manager leadership and retention of hospital staff nurses. Western Journal of Nursing Research 19(2):205-226 Taylor G S, Zimmerer T W 1992 Voluntary turnover among middle-level managers: an analysis of perceived causes. Journal of Managerial Issues 4(3):424-437 Tyagi P K, Wotruba T R 1993 An exploratory study of reverse causality relationships among sales force turnover variables. Journal of the Academy of Marketing Science 21(2):143-153 Wood J 1984 Part-time employment: making the future work in education. Work and People 10(1):6-14 Collegian Vol 10 No1 2003 15