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A report of a national survey of Directors
of Nursing of District Health Boards on current practices and policies
related to turnover of nurses in New Zealand’s public hospitals
Dr Nicola North, Prof. Frances Hughes, Dr Mary Finlayson, Erling
Rasmussen,
Dr Toni Ashton, Taima Campbell, Sharon Tomkins
School of Nursing, The University of Auckland
Introduction
Nursing turnover is a significant problem for New Zealand (NZ), impacting
on outcomes for patients, nursing workforces and the health system. NZ
research indicates that 30-40% of nurses consistently intend to leave
their job within 12 months (Cobden-Grainge & Walker, 2002; Gower &
Finlayson, 2002). An inability to retain even new graduates perpetuates
a common perception of nursing in NZ as a poorly paid, overworked profession
with little opportunity for advancement (Carryer, 2001; Dearnaley, 2003).
Poor working conditions and opportunities have been identified as contributing
to over 50% of NZ nurses ceasing active employment as a Registered Nurse
(RN) within 11 years of initial registration (Nursing Council of New Zealand,
2000). High rates of nursing turnover and tight budgets have resulted
in nursing shortages and a reliance on the casual nursing workforce leading
to instances of inadequate experience and inappropriate skill mix in patient
care (Health and Disability Commissioner, 1998; O’Conner, 1996).
[ADD HWAC COMMENTS] Lower nurse-patient ratios, in turn, are associated
in studies overseas with higher rates of nurse burnout, workplace injuries,
patient morbidity and mortality (Aiken et. al., 2002; Needleman et. al.,
2002).
The study and methods
The New Zealand Cost of Turnover study, associated with an international
study assessing the cost of nursing turnover and its impacts, set out
to answer the question: What are the levels of nursing turnover and associated
costs (direct and indirect), and the impacts on patient, nursing workforce
and health systems outcomes?
The specific objectives of the study are:
1. To describe the direct and indirect costs of turnover.
2. To explain the relationship between staffing practices, the costs of
turnover and the opportunity costs of turnover
3. To identify the relationship between the cost of turnover and patient
outcomes.
4. To identify the relationship between the cost of turnover and Registered
Nurse workforce outcomes.
5. To describe the relationship between the cost of nursing turnover and
broad health systems quality outcomes.
To contextualise the longitudinal study of the direct and indirect costs
of nursing turnover in New Zealand’s public hospitals, as a first
stage staffing practices and policies and information on turnover rates
were collected nationally. The Directors of Nursing (DONs) in all twenty-one
District Health Boards (DHBs) throughout New Zealand were contacted and
asked to participate in the first stage. Twenty DHBs and DONs agreed to
be involved by either returning completed questionnaires or participating
in a telephone interview. DONs were requested to provide the following
data: information related to nursing turnover currently collected; data,
policy and initiatives on retention and recruitment; and relevant studies
and reports conducted internally. The results of the survey of DONs of
New Zealand’s public hospitals and health services are reported
below, providing a descriptive but not statistical account of such practices
in the NZ public health system.
Results
Profile of participants
The titles of the highest nursing position included: Director of Nursing
(DON) [12]; Director of Nursing & Midwifery [4]; Executive Director
of Nursing [2]. Nursing turnover was reflected in these highest positions:
the DONs and equivalent had been with their current employer, not necessarily
in the current role, for 1-20 years, most frequently for less than 5 years,
and 2 of the participants were in an acting capacity.
Reported turnover
Thirteen DONs reported that nursing turnover was a problem, or it was
becoming an increasing priority. This was turnover that normally ranged
between 12% and 25%. Five DHBs, primarily in the main cities of New Zealand,
reported turnover rates that were at or over 20%. DHBs in regional areas,
were more likely to report that there was low turnover, or they had not
felt major turnover issues for some time, reporting turnover rates of
5% to10%. Negative impacts due to nurse shortages included bed closures,
restricted elective surgery, reduced inpatient admission and ED service
restrictions.
The survey did not establish how turnover rates were determined. While
the majority of DONs reported receiving regular reports from Human Resources
or Payroll on resignations and new appointments at weekly or monthly intervals,
in 3 no data on nursing turnover was collected, and in others nurses and
midwives are not separated from other staff so true figures cannot be
derived. Turnover is not evenly distributed: DHBs in metropolitan areas
and in areas where there is high competition for nurses report more difficulty,
or turnover was an issue in certain areas only, e.g. Emergency, Mental
Health.
There was little information on reasons for turnover. In almost all DHBs
HR manage exit interviews, but only 3 DONs reported that the information
was routinely collated and reported on. These 3 DHBs show the most common
reasons for leaving are: family/personal reasons; further education; career
development /future career prospects; offer of employment elsewhere; and
overseas travel. The main attractions of a new job included better career
prospects and better wage/salary level.
Strategies used to improve retention and reduce turnover
Generally, retention is seen as a major priority in reducing turnover,
the more so as the pool of available nurses decreases. The most frequent
strategies involved professional development, beginning with new graduates
and including advanced education support, strengthening nursing leadership
and addressing work environment concerns, and strategies connected to
Magnet hospital status and models of care.
New graduate programmes, that almost every DHB was involved in, when
well-supported by continuing education, were used as a retention strategy,
with several DHBs reporting their preference for “growing their
own nurses”. A DON reported a retention rate the previous year of
91% during the programme and 83% immediately after. Another said that
on completion of the programme employment, not necessarily in a particular
unit or ward, was guaranteed.
Six DHBs have been investing in post-graduate education for nurses as
a strategy for reducing turnover, and in the case of 5 DHBs this was in
partnership with a University nursing programme. Included were CTA funded
programmes, e.g. post-graduate certificates in specific clinical areas,
programmes in leadership, clinical supervision and clinical teaching,
and to support nurses enrolled in Masters programmes, e.g. through CNE
funding and scholarships. Commonly DHBs encouraged and supported employees
who want to further their education/training and development, offering
assistance in the form of leave with or without pay and/or financial assistance.
Four DHBs reported strengthening nursing leadership in order to improve
retention. For example, a DHB had introduced charge nurses and nurse leaders
where there were none previously, as part of an organisational restructure.
There are measures to improve the working environment for nurses; a family
focus, flexible rosters, better parking and café facilities and
addressing issues identified through exit interviews. Almost half DHBs
reported on progress toward establishing nurse practitioner positions.
These strategies are reflected in Magnet hospital strategies, with 4 DHBs
indicating their interest in achieving Magnet status.
Nurse participation in ‘Models of Care’ was discussed by
5 DONs in order to offer more opportunities. Included were deployment
of enrolled nurses and the employment of health care assistants or other
such roles as strategies of managing shortages of registered nurses. The
majority of DHBs employed enrolled nurses, and about two thirds employed
unregulated workers, mainly in non-nursing work or restricted duties.
Employee exchange and workplace surveys were other strategies reported
to retain nurses.
Recruitment policies and initiatives
A New Grad programme and overseas recruitment initiatives were by far
the most frequent recruitment measures. Career expos and polytechnic promotions
were used to attract New Grads. Fourteen DHBs had participated in overseas
recruitment drives recently or periodically, especially for specialist
roles such as emergency or mental health nursing. The most common location
for sourcing nurses was the UK followed by Australia, Canada and the United
States. Five DHBs were not recruiting overseas either because they did
not have a turnover/recruitment problems or preferred using other strategies
instead i.e. marketing. A policy position of some DHBs is that vacant
positions are required to be advertised internally in the first instance.
Use of advertising, using the web and traditional print advertising,
were the main methods or recruiting, but several had no direct or specific
recruitment strategies. Only 4 DHBs reported using recruitment agencies.
In contrast, 3 reported initiatives such as the position of a nurse recruiter
(2 cases), recruitment consultant (1 case) and a special recruitment unit
(in 1 case). The rationale of these initiatives was to improve efficiency
and process of recruitment. Other strategies included: a ‘talent
pool’ of nurses so that when a vacancy arises the talent pool can
be accessed to find a nurse with the required experience. Networking was
described by a few, through staff contacts. Others spoke of maintaining
contact with former staff who were overseas, to attract them back, and
of holding positions open for former staff planning to return. Return
to nursing programmes is also being promoted. In addition were Careers
Open Days promoting nursing as a career.
Managing nursing vacancies and temporary cover
The use of internal pools (variously termed bureaus, float, allocation
and resource teams) of staff was reported by 15 DHBs, with nurses guaranteed
a regular amount of work per week in some cases, or work was on an as-required
basis. Other approaches used were overtime, increasing the hours of part-time
staff, and acting up. External agencies are being used occasionally or
as a last resort; nevertheless, 7 DHBs reported using agencies. For longer
periods of time casual or temporary contracts are being used, specified
by 11 DHBs. Participants stated that frequently this was to cover parental
leave and other fixed time extended vacancies, and there were clear employment
guidelines regarding their use. In addition to temporary cover, other
responses to nurse shortages were closing beds and wards and postponing
surgery.
Nursing workforce diversity: recruitment, retention and priority employment
Maori: The majority indicated that Maori nurses were
employed, and a smaller number that there were policies regarding employment
of Maori nurses. These included targeted recruitment (e.g. through a priority
programme for Maori nurses), support, scholarships for Maori nurses and
Maori nursing workforce development strategies including Te Reo courses
and working with Wananga. In some DHBs, recruitment of Maori nurses was
not a priority. DONs commented on the need for DHBs to proactively encourage
Maori to enter and remain in the nursing workforce, and on the Treaty
of Waitangi as the foundational document.
Pacific Island nurses: About half reported that Pacific
nurses were employed, but few that their recruitment was a priority. In
South Auckland where over 19% of the population of the Counties Manukau
sub-region currently identified as Pacific peoples (projected to be 63%
by 2021) the DHB recognises that it must proactively encourage Pacific
people to enter and remain in its workforce, and support and develop those
individuals while they are employed.
Overseas trained nurses: As previously reported overseas
trained nurses helped address shortages. Only one reported a competency
programme, and a few commented that such former programmes were no longer
offered.
Nursing involvement in managing the nursing workforce
Nursing leadership has been shown in overseas studies to be related to
nursing turnover. The nursing workforce was under the direction of the
DON or equivalent in the majority of DHBs. Specifically, nursing was responsible
for its own workforce operationally and strategically, in relation to
such matters as skill mix, scope of practice, clinical practice and professional
development and policy. Several indicated they controlled the nursing
budget, though a few specified they did not. Many of the DONs participated
in decision-making at senior levels of the DHBs, e.g. by reporting directly
to the CEO, as a member of the Executive or senior management team, in
strategy development, had input into annual and strategic plans, and in
operations management, and reported to the Board on nursing issues. While
some stated they had line management positions, others reported an advisory
role. A few pointed out that in their DHB (former) nurses held the most
senior positions, including CEOs, hospital managers, general managers.
Staffing/Organisational processes affecting turnover
The organisational climate affects employee satisfaction and turnover.
In almost every DHB there are tight controls over recruitment of new staff.
Vacancies are reported as going through a review process before they are
recruited for due to financial constraints. Several DHBs have a freeze
on recruiting RNs except for ‘specialist’ nurse roles. Only
5 DHBs stated that there were no freezes, review, restructures or rationalising
taking place. Five of the 20 DHBs reported they are currently or soon
to have a review of Senior Nursing roles. One DHB has just gone through
a full restructure. Also reported were redeployment and freezes on salary
reviews.
Conclusions
The survey of DONs provided a description of practices and policies affecting
nurses in DHBs. The resulting national overview of nursing turnover gives
a context in which to understand turnover and the cost of nursing turnover,
the purpose of the next stages of the study.
The DONs agreed that nursing turnover was an issue in most DHBs in New
Zealand.
Turnover is not evenly distributed, with DHBs in metropolitan areas and
areas where there is high competition for nurses, and in certain clinical
areas such as mental health and emergency services, reporting higher turnover.
Even where turnover is currently low and recruitment not a problem, with
a nursing workforce approaching retirement it is likely to be so in the
near future. Policies promoted nationally that affect turnover and nursing
workforce development were seen to be influencing developments at DHB
level, albeit unevenly and in some respects at early stages: these included
seeking Magnet hospital status or comparable strategies, clinical career
structures for nurses to nurse practitioner level, and Maori nursing workforce
development.
Recommendations for further research and policy development
The data contributed by DONs in the first stage of the New Zealand Cost
of Nursing Turnover study has highlighted a number of specific recommendations
for further research, analysis of information already collected or readily
available, and the development of policy.
- That the consequences of nursing turnover and shortages are documented
and costs determined (the focus of the Cost of Nursing Turnover study).
- That nursing turnover is a key performance indicator in New Zealand
health services, and that it is calculated and reported consistently.
- That to support retention and recruitment practices profiling of the
nursing workforce by employers be maintained, including gender, age,
ethnicity, hours worked and tenure.
- Evaluation including impact on retention and cost-benefit analyses
of: New Graduate programmes; continuing nursing education and employer
support for professional development; strategies for the temporary cover
of nursing vacancies and regularly updated; overseas recruitment.
- That the relationship between nursing leadership and the work environment,
including Magnet hospital principles, on retention be analysed, and
evaluation of the effectiveness of workplace changes undertaken.
- That employee reasons for casualisation of work are determined and
flexible models of staffing evaluated.
- The subject of diversity of the nursing workforce in general in relation
to recruitment and retention should be researched in the light of increasing
diversity of the New Zealand population, and globalisation of skilled
workforces, and in view of the continuing reliance of New Zealand on
overseas trained nurses. In particular there is a need for investigation
of strategies for recruiting and retaining Maori nurses, and in areas
with high populations of Pacific peoples, also of Pacifica nurses.
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