Original Manuscript
Professional values, job satisfaction, career development, and intent to stay
Nursing Ethics 1–11 ª The Author(s) 2016 Reprints and permission: sagepub.co.uk/journalsPermissions.nav 10.1177/0969733015623098 nej.sagepub.com
Susan Yarbrough, Pam Martin and Danita Alfred The University of Texas at Tyler, USA
Charleen McNeill The University of Arkansas, USA
Abstract Background: Hospitals are experiencing an estimated 16.5% turnover rate of registered nurses costing from $44,380 - $63,400 per nurse—an estimated $4.21 to $6.02 million financial loss annually for hospitals in the United States of America. Attrition of all nurses is costly. Most past research has focused on the new graduate nurse with little focus on the mid-career nurse. Attrition of mid-career nurses is a loss for the profession now and into the future. Research objective: The purpose of the study was to explore relationships of professional values orientation, career development, job satisfaction, and intent to stay in recently hired mid-career and early-career nurses in a large hospital system. Research design: A descriptive correlational study of personal and professional factors on job satisfaction and retention was conducted. Participants and research context: A convenience sample of nurses from a mid-sized hospital in a metropolitan area in the Southwestern United States was recruited via in-house email. Sixty-seven nurses met the eligibility criteria and completed survey documents. Ethical considerations: Institutional Review Board approval was obtained from both the university and hospital system. Findings: Findings indicated a strong correlation between professional values and career development and that both job satisfaction and career development correlated positively with retention. Discussion: Newly hired mid-career nurses scored higher on job satisfaction and planned to remain in their jobs. This is important because their expertise and leadership are necessary to sustain the profession into the future. Conclusion: Nurse managers should be aware that when nurses perceive value conflicts, retention might be adversely affected. The practice environment stimulates nurses to consider whether to remain on the job or look for other opportunities. Keywords Professional values, retention, career development, job satisfaction, early-career nurses, mid-career nurses
Corresponding author: Susan Yarbrough, School of Nursing, The University of Texas at Tyler, 3900 University Blvd, Tyler, TX 75799, USA. Email: [email protected]
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Introduction Hospitals are experiencing an estimated 16.5% turnover rate of registered nurses (RNs), increased from 14.7% in 2012. Estimates of RN turnover costs range from US$44,380 to US$63,400 per nurse—an estimated US$4.21 to US$6.02 million financial loss per year for hospitals. The increase reported for 2014 is the first time the turnover rate exceeded 2009 levels.1 This upward trend in turnover signals the end of the forewarned ‘‘bubble’’ in nursing labor supply as a result of a troubled economy2 and is expected to continue as the economy improves.1 In a discussion with nurse administrators of a large multi-site healthcare system in the southwest, it was determined that retention of mid-career newly hired nurses was problematic. Employment statistics of this group indicated a higher rate of voluntary termination after costly orientation sessions and acculturation efforts of hospital managers and coworkers. Nurses with more than 10 years at their current job reported less satisfaction than those with less than 2 years at their current job. This phenomenon is contrary to most reports that higher turnover rates occur in the new RN population.3 Kovner et al.4 estimated the 1-year turnover rate of newly licensed RNs at 17.5%. The exact cause of the premature departure from the system was unclear, and the cost of replacing a staff nurse was estimated to be between US$82,000 and US$88,000,5,6 making it imperative to ensure that recruitment and orientation efforts result in a longterm employee. In addition to the significant replacement costs, valuable wisdom and experience are lost when more experienced nurses leave the system.7 The mid-career nurse plays an important role in stabilizing staff and in facilitating the transition of the new nurse by providing essential expertise, support, and assistance. Recent reports indicate that the RN shortage will be staggering. According to the Bureau of Labor Statistics, even though the RN workforce will grow to nearly 3.24 million by 2022, this will still not be enough nurses.8 With the impending retirement of nearly 1 million nurses in the next 10–15 years, the need to retain new RNs and those in mid-career is clearly a major issue affecting hospitals today. Due to the importance of this matter, this study focused on the influence of traditional predictors of retention. Traditional factors included job satisfaction, career development, and intent to stay in early-career new graduates and recently hired mid-career RNs. Professional values were added to the mix of traditional predictors of retention after a review of the literature revealed that conflicts between the nurses’ values and organizational’ values often lead to voluntary nurse employee separation.
Background Nurse professional values Stacey et al.9 analyzed how a group of mental health nurses responded to conflicts between their professional practice and their values and how their values influence their experience of being a professional nurse. Utilizing qualitative methodologies, 12 nurses with between 6 months and 3 years’ experience were interviewed. The nurses sampled recognized dissonance between their values and their practice and tended to respond to this dissonance in three primary ways: acceptance, rejection, or innovation. The authors found that nurses’ values were embedded early during the education process and remained intact during professional practice. Participants cited organizational constraints impacting their practice, resulting in the inability to express those values in practice. In trying to cope with this dissonance between values and practice, nurses had to determine whether they would accept this dissonance and remain, challenge the system and find ways to initiate change within the system, or to reject the dissonance and leave to find another position. This study serves to highlight the importance of values and values dissonance within the arena of retention and/or nurse turnover.
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Intergenerational professional nursing values were surveyed by LeDuc and Kotzer10 in response to the increasing generational diversity within nursing to determine how those differences challenge the nursing profession. The authors state that there were more similarities among the generations than there were differences and that experience is not necessary for the development of professional values. Additionally, the authors state that work environments must foster the strengths of each generation as well as accommodate all individuals within it to achieve a healthy balance in which nurses can practice. LeDuc and Kotzer further assert that environments where retention priorities include nurses of all ages and experience levels are paramount to ensure the viability of the profession and the prosperity of the organization. A third study of nursing values sought to determine the extent to which values in nursing are associated with age groups, job stages, job satisfaction, productivity, and organizational commitment.11 Intergenerational differences were significant in only a few areas, including individual work values, economic returns, prestige, and variety. There was a negative relationship between economic value and job satisfaction with Generation X nurses placing higher value on variety and economic returns, though there were significant differences between all generations for variety. Among the nurses in this sample, those within the top third for job satisfaction, organizational commitment, and productivity also had higher scores for other values including creativity, esthetics, and management. Conversely, those in the bottom third demonstrated higher scores solely in economic returns. The authors state that the scores for this group were consistently lower to the extent that they wondered ‘‘which came first: a tendency to place less emphasis on values or lower job satisfaction, productivity, and organizational commitment’’ (p. 268).
Job satisfaction Job satisfaction has been the focus of several studies including work-related values that were linked to job satisfaction and intent to stay.12 Five themes identified by the participants centered on harmony, commitment, unity, altruism, and spiritual values. In another study, themes were also identified related to job satisfaction that reflected how nurses weigh the costs and benefits of remaining in a position.13 Variables identified that impacted a nurse’s decision about remaining in a position were drive time to work, age and flexible scheduling, availability of a career ladder, and years of experience related to the working conditions and wages. Van der Heijden et al.14 investigated how social environmental factors, such as social support from one’s direct supervisor and from one’s colleagues, can impact nurses’ intentions to stay or leave their profession aside from job satisfaction and nurse’s age. Analysis of the data supported the notion that social support from the supervisor negatively correlated with the intention to leave. The respondents did not perceive that their supervisors had much interest in their capabilities and lacked an understanding of how to stimulate or support the nurses. In another study of Taiwanese nurses,15 findings supported that perceptions of the work environment and the quality of care on their units impacted whether they would stay or leave current positions. In a systematic review of the literature,16 common themes were identified from over 100 published articles on job satisfaction and intent to stay. As previously discussed, and in the literature review, common themes are organizational environment, job stresses, organizational and professional commitment, role perception, and role content. Even though most studies identify the commonality of why nurses may intend to leave positions due to lack of job satisfaction, there is still not a clear picture of how the different variables can predict job satisfaction.
Generational differences and nurse values Nursing is currently experiencing unique generational diversity composed of four cohorts: the Traditionalists, also referred to as the Veterans (born before 1945), the Baby Boomers (born 1945–1964), Generation
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X (Gen X) (born 1964–1980), and Generation Y, also known as the Millennials (born 1980–2000).17,18 Differences in generational values and attributes contribute to the complexity of the work environment and present challenges to nurse leaders and administrators to maintain a stable workforce. In a literature review of 19 articles published between 1980 and 2009, Wolff et al.19 gleaned insight about how generational differences affect nurses’ work-related attitudes and behavior. Diversity in the nurses’ ages contributed to negative behaviors toward others in the work group and a lack of collegiality in relationships. Individuals who perceived themselves to have different values than others in their work group were more likely to leave their current position or suffer from burnout. Leiter et al.20 also studied work values by comparing Baby Boomer and Gen X nurses and found that Gen X nurses had a greater value mismatch between the individual and the organization than Baby Boomer nurses. Due to the greater mismatch, there was also an increased susceptibility to burnout and greater likelihood for an intention to quit in the Gen X nurses. Being aware that generational differences and nurse turnover are significant concerns to nurse managers, Wieck et al.21 conducted a generational assessment of job satisfaction, work environment, and desired characteristics of managers that can improve nurse retention. The data revealed that all generations preferred working for a supportive manager with good people skills and nurse/physician relationships were satisfactory among all generations. However, the Millennial’s were least satisfied with the control over their practice and organizational support and the Gen X nurses were least satisfied with their autonomy and control over practice. Nurses over the age of 40 demonstrated overall satisfaction in almost all areas, and the Baby Boomers were significantly more satisfied than the Gen X nurses. In contrast, Sparks,22 in a study of psychological empowerment and job satisfaction, found no differences in total job satisfaction between the Baby Boomers and Gen X cohorts. In the Nurse Incentives Project conducted in a 22-hospital system located in four southern and western states, Wieck et al.23 explored (a) generational differences in how nurses value benefits as incentives; (b) the relationships between perceived stress, satisfaction with incentives, floating, intent to stay, and satisfaction; and (c) the most important benefits to nurses. Responses were received from 1559 RNs. The data demonstrated that the most important benefit was a cohesive working environment. Nurses with higher stress scores were significantly less satisfied with their jobs. A correlation between the intent to stay and job satisfaction indicated that nurses who planned to stay longer in their current positions were consistently more satisfied and less stressed. The youngest nurses were the most stressed and more likely to leave. The most important incentives for Millennial’s and Gen Xers were overtime and premium pay while pension and retirement benefits were more important to Baby Boomers and older nurses. Similarly, Val Palumbo et al.24 explored perceptions among 583 RNs of the organizational and unit-level culture regarding older nurses in the workplace as well as human resource issues and practices. Respondents aged 55 years or older indicated that the recruitment of nurses over 50 years of age, compensation, and retirement options were important.
Stage of career and tenure Murff and DeFer25 noted that turnover rates at a large Southwest healthcare system were higher between 1 and 3 years of employment. They determined that almost 30% of RN turnover occurred within the first year; however, an additional 45% of RN turnover occurred within the first 3 years. In an effort to decrease controllable turnover, the healthcare system implemented a six-step strategy incorporating previously identified quality improvement measures. Upon implementing this strategy, the authors noted that the first-year retention rates improved each month, and increased awareness of at-risk RNs by managers facilitated increased focus to prevent RN turnover. The second group, those from 1 to 3 years, did not improve as rapidly as the new RNs.
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VALUES
WORK ENVIRONMENT
WORK SATISFACTION
OUTCOME INTENT TO STAY
CAREER DEVELOPMENT
Figure 1. Conceptual framework.
Coshow et al.26 found a similar pattern in job satisfaction among 56,253 RNs from 43 states related to their tenure or the length of time employed with one particular hospital. The most tenured nurses reported less job satisfaction across all dimensions of the survey and overall satisfaction scores. LeVasseur et al.27 looked at nurse turnover by generation and noted The Gen XMs (the combined category of Generation X and Millennials) were employed in their second, third, and fourth positions for less time as compared to the Veterans and the Baby Boomers.
Objectives The purpose of the study was to explore relationships of professional values orientation, career development, job satisfaction, and intent to stay in recently hired mid-career and early-career nurses with the overall goal of developing strategies to increase retention and to identify areas of values dissonance that may impact employment longevity.
Theoretical model The theoretical model that guided the study is an adaptation of Fishbein and Ajzen’s28 Expectancy–Value Theory. For the purpose of this study, Fishbein and Ajzen’s idea of beliefs will be measured as ‘‘professional values orientation’’ and evaluation will be assessed through ‘‘work environment’’ aspects, specifically work satisfaction and career development. It is proposed that intent to stay is indicative of a positive view of Fishbein and Ajzen’s perception of gratifications obtained, that is, nurses are more inclined to stay employed in their present work setting if they perceive that they are getting what they want (Figure 1).
Methods Approvals were obtained from the university and hospital system institutional review boards (IRBs). The researchers prepared an online survey to gather demographic, professional values, career development, job satisfaction, and retention data for this descriptive correlational study. The influence of personal and professional factors on job satisfaction and retention was explored and described. Perspectives of midcareer nurses were obtained through in-depth interviews with those who agreed to speak with us.
Sample A convenience sample of nurses from a mid-sized hospital in a metropolitan area in the Southwestern United States were recruited via in-house email. To be eligible for participation, the RN worked at least 24 h/week, was without licensure restrictions or recent gaps in active practice, and held no position higher than mid-management. A minimum sample of 60 nurses was calculated a priori. Estimates were based on
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Table 1. Sample characteristics. New hires
N ¼ 67 Mean age Mean years at hospital Mean years of RN experience Mean years RN intends to stay Mean job satisfaction Mean career development Mean professional values Sole support of self/others
>1 year
Early-career
Mid-career
All others
14 26.36 0.87 1.07 6.27 12.55 41.00 101.81 10 (71%)
9 45.56 0.89 15.56 12.20 15.20 44.60 105.20 4 (44%)
44 46.84 7.33 17.55 9.48 13.24 38.36 99.21 22 (50%)
RN: registered nurse.
bivariate correlation, with a moderate effect size of 0.35, power of 0.80, and a ¼ 0.05.29 Of 119 participants who entered the online survey system, 67 nurses felt they were adequately informed about the purpose of the study and met the eligibility criteria. The sample was not different from most found in the geographic area of the study, composed of predominantly female (60; 90%), Caucasian, non-Hispanic (56; 84%), and held a bachelor’s degree (39; 58%) or associate degree (21; 31%) in nursing. See Table 1 for more detailed description of demographic characteristics.
Data collection An online survey was constructed that included four instruments and a demographic profile. The Nurses Professional Values Scale–Revised (NPVS-R#) was developed and tested by Weis and Schank.30 It is composed of 26 Likert-type items representing the five domains (Caring, Activism, Trust, Professionalism, and Justice) of the 2008 Code of Ethics for Nurses. Subjects rate their agreement with the 26 items of the NPVS-R using a scale of 5 (most important) to 1 (not important). The total scale yielded an alpha coefficient of 0.92 when tested on 782 subjects. Four judges with expertise in the Code of Ethics for Nurses reviewed the instrument for content validity. The experts’ review resulted in 100% agreement regarding the relevance and sufficiency of the items to the Code of Ethics for Nurses. Cronbach’s internal consistency reliability for this use of the NPVS-R was 0.94 Participants responded to the single item Intent to Stay# with the number of years that they planned to stay with the current employer. Wieck et al.23 effectively used the instrument to determine intent to stay in a study of nurse retention. Nurse Job Satisfaction Index# is composed of four Likert-type items that when summed provide a measure of overall job satisfaction. Wieck et al.23 tested the instrument in the nurse retention project. The reliability a ¼ 0.85 and factor analysis supported measurement of the single component. Cronbach’s alpha for this study was 0.76. Perceived Development Climate31 was used to assess participants’ opportunities and support for professional development. In a study of resistance to organizational change, Van Dam et al.32 found the 11-item tool to be a reliable measure, yielding a Cronbach’s alpha of 0.87. The study of nursing retention yielded a Cronbach’s alpha of 0.91. Institutional Review Board approval was obtained from both the university and hospital system. The university researchers emailed survey information to the hospital research liaison, a nurse educator in a
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Table 2. Correlations between key variables and select demographics.
1. Age 2. Years at hospital 3. Years intends to stay 4. Job satisfaction 5. Career development 6. Professional values
1
2
3
4
5
6
1.00 0.55** 0.06 0.18 0.05 0.02
1.00 0.08 0.04 0.21 0.02
1.00 0.40** 0.29* 0.21
1.00 0.59** 0.25
1.00 0.47**
1.00
*Correlation is significant at 0.05 level (two-tailed). **Correlation is significant at 0.01 level (two-tailed).
non-supervisory position, who distributed the survey along with a cover letter and consent information to potential participants via the hospital’s email system. The survey was conducted using Qualtrics, an online survey software program. Interested participants clicked on a link which took them to the survey. No identifying information was asked for or collected except for those mid-career nurses who volunteered for an interview. Since the survey was disseminated online, potential participants determined whether they met the inclusion criteria and felt they were informed of the study purpose, risks, and benefits. Several potential participants accessed the survey but did not feel they had enough information to participate or were not eligible and were subsequently not included in the final sample. Finally, interested mid-career nurses were interviewed regarding factors influencing their decision to remain or leave the facility.
Findings Influences on retention Neither professional values orientation nor its component subscales correlated significantly with retention. However, there was a strong correlation between professional values and career development (r ¼ 0.39, p < 0.001). Both job satisfaction (r ¼ 0.39, p ¼ 0.003) and career development (r ¼ 0.29, p ¼ 0.037) correlated positively with retention. Even after correcting for multiple comparisons and use of nonparametric statistics, job satisfaction was strongly correlated with retention. To further explore retention, the relationship between longevity of employment and increasing age was tested and neither was significantly correlated with retention. Details of the correlations including selected demographics and the NPVS-R and its subscales are depicted in Table 2.
Career stage and retention A subset of 23 participants from the sample was used to examine differences in key employment characteristics. The newly hired mid-career nurses (5 or more years) scored significantly higher on retention (U ¼ 14.5, p ¼ 0.041) and job satisfaction (U ¼ 18.5, p ¼ 0.005) than early-career nurses (less than 5 years).
Individual characteristics and retention The participants were queried on a variety of demographic and career-related characteristics. One characteristic stood out that may be of particular interest. Instead of asking about household income, participants were asked if they were the sole support of self and/or others versus they had assistance with support of self and/or others. Those who reported they had assistance with support scored significantly higher on retention
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(U ¼ 214.5, p ¼ 0.006) and job satisfaction (U ¼ 339.5, p ¼ 0.006) than nurses who reported that they were the sole support of themselves and/or others.
Mid-career nurses’ perspectives on retention Mid-career nurse participants were asked to speak with researchers to help increase the understanding of the issues and concerns of that cohort. Five agreed to participate, but only two actually provided in-depth information through telephone interviews. Informed consent was obtained prior to conducting the interviews. No identifiers were used in recording, transcribing, or analysis of these interviews. These interviews were informative but not transferrable beyond these participants’ own experiences. When asked to describe the barriers and facilitators to a satisfactory work experience in a new hospital, the participants described the work environment as positive and a primary reason they chose to stay. The work ethic was much better than previous places of employment; there was a sense of camaraderie and teamwork with administrative support. The nursing staff was expected to be patient advocates, to put the patients first. Other positive factors identified included an optimal orientation and opportunities for continuing education provided by the facility. The hospital provides ways for career development and offers reimbursement for certification. The primary barriers identified or reasons staff chose not to stay included being short staffed and the turnover of both new and senior staff. The highest turnover seemed to be in the ‘‘less seasoned nurse.’’ Differences identified between the new graduate nurse and the seasoned nurse included being ‘‘too entitled’’ and expecting the perfect schedule and not working holidays. ‘‘They have a different work ethic and choose to do the barest minimum to get by.’’ To the new graduate, it is just a job, not a passion, money is more important. They do not see themselves as part of the team to help each other and do not work extra when the unit is ‘‘drowning,’’ instead they may go out partying: they are young, less mature. The new grad does not realize the depth of the profession; therefore, no commitment. New graduates are always looking for the ‘‘greener grass’’ and it does not exist. One participant stated she would like a new nurse who has found their ‘‘dream job’’ and will remain. A second participant stated there is a difference in values—‘‘I am here to make a difference’’ and she did not see this in new grads who have less loyalty to the profession. Another barrier identified was the amount of added paperwork taking away from actual nursing care and ‘‘feeling that hands are tied.’’ Some leave thinking they will find a less stressful job. The participants believed that it was important to keep both new graduates and more senior nurses at the bedside. They suggested that the organization change their perspective to keep early-career nurses. They like bonuses and more flexibility in scheduling. They also suggested that the organization come up with ways to keep senior nurses at the bedside and offer incentives for the seasoned nurse who is dedicated to bedside nursing. When asked how the professional values of nurses compared with those of the institution, all were in agreement and felt they were aligned. Professional values are seen in the whole culture and start with the orientation process which was detailed; an ‘‘incredible’’ orientation, the positive culture that meets work ethic, teaches respect of peers. One participant stated, ‘‘but must remember the budget and bottom line, it is a business; this is where I see the values are not meeting.’’ The participants said they were satisfied with their work. One remarked, ‘‘I am very, very satisfied, love to go to work.’’
Discussion Saber33 indicated that all generations are essential to the continuum of the nursing workforce. The midcareer and seasoned nurses bring experience and stability to quality healthcare, while early-career nurses bring new ideas and increased ease with technology. As the age of RNs decreases, it brings a new opportunity for positive change. Nursing retention is vital and turnover is costly to the facility.
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The purpose of this research was to examine retention within a large multi-site system. The sample accessed for this study represents only one facility in the system. Responses from participants indicated that mid-career nurses were significantly more likely to continue employment than the early-career nurses. This differs from the concerns expressed by administrators of the system that the retention of mid-career nurses was problematic. However, the voluntary participants in this study, early- and mid-career nurses, may not be representative of the larger system or the nurses who do not intend to stay. Both of the nurses interviewed indicated that there is a difference between the perceptions of early- and mid-career nurses related to dedication to the profession, their peers in the work setting, the employing facility, long-term commitment, and expectations of what it means to be an RN. Val Palumbo et al.24 suggested that there may be intergenerational tensions that should be addressed emphasizing that nurses of all ages are important and needed in the workplace. Generational differences may be even more important today than 5–6 years ago as the nursing population ages and newer RNs are in the age groups of early 20s. Previous recommendations to improve retention efforts included the formation of intergenerational groups of nurses to collaborate and make recommendations to their organization to improve working conditions were made,34 yet there continues to be an area of concern regarding the retention of mid-career nurses.25–27 But findings in this study indicated that newly hired mid-career nurses intended to remain longer than earlycareer new hires and all others employed longer than 1 year. In congruence with Murff and DeFer,25 findings support that increasing managers’ knowledge of which RNs belonged in a particular group facilitated intervention to prevent loss, facilitated information necessary to maintain staff engagement, and increased nursing’s voice in the work environment. Of great concern was that 61% of the RNs planned to leave employment within 10 years regardless of high satisfaction levels.21 Methods discussed to retain older and more experienced nurses focused on work redesign to include the number of shifts worked each week, the number of hours per shift, and physical demands for aging nurses. The findings of the study supported the theoretical model with the exception of values and intent to stay. The initial perception of the researchers was that a difference of professional values and institutional values would affect retention. Neither early-career nurses nor mid-career nurses indicated that professional values influenced their intent to stay. However, the influence of professional values may be adequately captured through assessment of the nurses’ career development. Job satisfaction and career development did influence retention, and an additional finding indicated that when the nurse was not the sole financial support of self or others, the intent to stay employed was higher. This finding may represent a non-modifiable factor for the facilities that has not been given adequate consideration to date. Nei et al.35 may have captured this factor indirectly in a recent meta-analysis of causes of nurse turnover. The meta-analysis revealed secondary factors affecting nurse turnover including role strain that may be more difficult for those who provide the sole financial support for themselves and/or others.
Limitations The findings from this small sample of mid- and early-career nurses do not generalize to other facilities or even to those within a single facility who might not have the same level of satisfaction. Those who were not satisfied with their work may not have responded to the survey at all. However, this does not diminish the importance of learning what does influence satisfaction and retention as found in this study. Although self-selection bias must be considered, there are a myriad of other possible reasons why a busy staff nurse did not respond.
Next steps Facilities need to consider several factors when addressing retention efforts. These could include exploring methods of compensation that are highly valued by younger nurses. Consideration that professional values,
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when supported, may not influence retention but when nurses do perceive value conflicts, retention may be adversely affected. The practice environment stimulates nurses to consider whether to remain on the job or look for other opportunities. The importance of keeping the experienced nurse at the bedside contributes to quality patient care and mentorship of the novice professional. The mid-career nurse is likely to be the senior nurse of tomorrow. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. Funding The author(s) received no financial support for the research, authorship, and/or publication of this article. References 1. Nursing Solutions, Inc. 2014 National Healthcare & RN Retention Report, http://www.nsinursingsolutions.com/ Files/assets/library/retention-institute/NationalHealthcareRNRetentionReport2014.pdf (2014, accessed 22 April 2015). 2. Staiger D, Auerbach D and Buerhaus P. Registered nurse labor supply and the recession—are we in a bubble? N Engl J Med 2012; 366(16): 1463–1465. 3. Salt J, Cummings GG and Profetto-McGrath J. Increasing retention of new graduates: a systematic review of interventions by healthcare organizations. J Nurs Adm 2008; 18(6): 287–296, http://dx.doi.org/10.1097/01.NNA. 0000312788.88093.2e 4. Kovner CT, Brewer CS, Fatehi F, et al. What does nurse turnover rate mean and what is the rate? Policy Polit Nurs Pract 2014; 15: 64–71. 5. Jones CB. Revisiting nurse turnover costs: adjusting for inflation. J Nurs Adm 2008; 38(1): 11–18, http://dx.doi.org/ 10.1097/01.NNA.0000295636.03216.6f 6. Li Y and Jones CB. A literature review of nursing turnover costs. J Nurs Manag 2013; 21(3): 405–418. 7. Sherrod D. Strategies for retaining older nurses. Nurs Manag 2006; 37(10): 12–14, http://journals.lww.com/nursingmanagement/Citation/2006/10000/Strategies_for_retaining_older_nurses.3.aspx 8. Kelly C. Facing the nursing shortage. Columbia Business Times, 25 January 2015, http://columbiabusinesstimes. com/25059/2015/01/25/facing-the-nursing-shortage/ (accessed 22 April 2015). 9. Stacey G, Johnston K, Stickley T, et al. How do nurses cope when values and practice conflict? Nurs Times 2011; 107(5): 20–23, http://www.nursingtimes.net/Journals/2013/01/18/p/r/c/080211How-do-nurses-cope-when-values-and-practice-conflict.pdf 10. LeDuc K and Kotzer A. Bridging the gap: a comparison of the professional nursing values of students, new graduates, and seasoned professionals. Nurs Educ Perspect 2009; 30(5): 279–284, http://www.nln.org/newsroom/newsletters-and-journal/nursing-educationperspectives-journal 11. McNeese-Smith D and Crook M. Nursing values and a changing nurse workforce—values, age, and job stages. J Nurs Adm 2003; 33(5): 260–270, http://dx.doi.org/10.1097/00005110-200305000-00002 12. Ravari A, Bazargan-Hejazi S, Ebadi A, et al. Work values and job satisfaction: a qualitative study of Iranian nurses. Nurs Ethics 2013; 20(4): 448–458. 13. Hodgin R, Chandra A and Weaver C. Correlates to long-term-care nurse turnover: survey results from the state of West Virginia. Hosp Top 2010; 88(4): 91–97. 14. van der Heijden B, Ku¨mmerling A, van Dam K, et al. The impact of social support upon intention to leave among female nurses in Europe: secondary analysis of data from the NEXT survey. Int J Nurs Stud 2010; 47(4): 434–445.
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15. Ma J, Lee P, Yang Y, et al. Predicting factors related to nurses’ intention to leave, job satisfaction, and perception of quality of care in acute care hospitals. Nurs Econ 2009; 27(3): 178, http://www.nursingeconomics.net/cgi-bin/ WebObjects/NECJournal.woa 16. Lu H, Barriball K, Zhang X, et al. Job satisfaction among hospital nurses revisited: a systematic review. Int J Nurs Stud 2012; 49(8): 1017–1038. 17. Krischke MM. Generational differences in nursing: has the work ethic changed? NurseZone, 7 May 2014, http:// www.nursezone.com/Nursing-News-Events/more-news/Generational-Differences-in-Nursing-Has-the-WorkEthic-Changed_42173.aspx (accessed 22 April 2015). 18. Hendricks JM and Cope VC. Generational diversity: what nurse managers need to know. J Adv Nurs 2013; 69(3): 717–725. 19. Wolff A, Ratner P, Robinson S, et al. Beyond generational differences: a literature review of the impact of relational diversity on nurses’ attitudes and work. J Nurs Manag 2010; 18(8): 948–969. 20. Leiter M, Jackson N and Shaughnessy K. Contrasting burnout, turnover intention, control, value congruence and knowledge sharing between Baby Boomers and Generation X. J Nurs Manag 2009; 17(1): 100–109. 21. Wieck KL, Dols JJ and Landrum PP. Retention priorities for the intergenerational nurse workforce. Nurs Forum 2010; 45(1): 7–17. 22. Sparks AM. Psychological empowerment and job satisfaction between Baby Boomers and Generation X nurses. J Nurs Manag 2012; 20(4): 451–460. 23. Wieck K, Dols J and Northam S. What nurses want: the nurse incentives project. Nurs Econ 2009; 27(3): 169–201, http://www.medscape.com/viewarticle/708170 24. Val Palumbo M, McIntosh B, Rambur B, et al. Retaining an aging nurse workforce: perceptions of human resource practices. Nurs Econ 2009; 27(4): 221–232, http://www.medscape.com/viewarticle/709768 25. Murff M and DeFer T. Improving controllable nursing retention. Nurse Lead 2010; 8(3): 53–57. 26. Coshow S, Davis P and Wolosin R. The ‘‘big dip’’: decrements in RN satisfaction at mid-career. Nurs Econ 2009; 27(1): 15–18, http://www.medscape.com/viewarticle/706046 27. LeVasseur SA, Chen-Yen W, Mathews B, et al. Generational differences in registered nurse turnover. Policy Polit Nurs Pract 2009; 10(3): 212. 28. Fishbein M and Ajzen I. Attitudes towards objects as predictors of single and multiple behavioural criteria. Psychol Rev 1974; 81(1): 29–74. 29. Faul F, Erdfelder E, Buchner A, et al. Statistical power analyses using G*Power 3.1: tests for correlation and regression analyses. Behav Res Methods 2009; 41(4): 1149–1160, http://www.gpower.hhu.de/fileadmin/redaktion/Fakultaeten/Mathematisch-Naturwissenschaftliche_Fakultaet/Psychologie/AAP/gpower/GPower31-BRMPaper.pdf 30. Weis D and Schank MJ. Development and psychometric evaluation of the Nurses Professional Values Scale—revised, J Nurs Meas 2010; 18(1): 70–72, http://dx.doi.org/10.1891/1061-3749.17.3.221 31. Bezuijen XM. Leadership and employee development. Dissertation, Tilburg University, The Netherlands, 2005, https://pure.uvt.nl/portal/files/690910/171718.pdf 32. Van Dam K, Oreg S and Schyns B. Daily work contexts and resistance to organizational change: the role of leader-member exchange, development climate, and change process characteristics. Appl Psychol: Int Rev 2008; 57(2): 313–334. 33. Saber DA.Generational differences of frontline nursing workforce in relation to job satisfaction. What does the literature reveal? Healthcare Manag 2013; 32(4): 329–335. 34. Yarbrough S, Alfred D and Martin P. Recruitment & retention report. Research study: professional values and retention. Nurs Manag 2008; 39(4): 10–18, http://www.nursingcenter.com/lnc/pdfjournal?AID¼7844 55&an¼00006247-200804000-00003&Journal_ID¼&Issue_ID¼. 35. Nei D, Snyder L and Litwiller B. Promoting retention of nurses: a meta-analytic examination of causes of nurse turnover. Health Care Manag Rev 2015; 40(3): 237–253.
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Professional values, job satisfaction, career development, and intent to stay
Nursing Ethics 1–11 ª The Author(s) 2016 Reprints and permission: sagepub.co.uk/journalsPermissions.nav 10.1177/0969733015623098 nej.sagepub.com
Susan Yarbrough, Pam Martin and Danita Alfred The University of Texas at Tyler, USA
Charleen McNeill The University of Arkansas, USA
Abstract Background: Hospitals are experiencing an estimated 16.5% turnover rate of registered nurses costing from $44,380 - $63,400 per nurse—an estimated $4.21 to $6.02 million financial loss annually for hospitals in the United States of America. Attrition of all nurses is costly. Most past research has focused on the new graduate nurse with little focus on the mid-career nurse. Attrition of mid-career nurses is a loss for the profession now and into the future. Research objective: The purpose of the study was to explore relationships of professional values orientation, career development, job satisfaction, and intent to stay in recently hired mid-career and early-career nurses in a large hospital system. Research design: A descriptive correlational study of personal and professional factors on job satisfaction and retention was conducted. Participants and research context: A convenience sample of nurses from a mid-sized hospital in a metropolitan area in the Southwestern United States was recruited via in-house email. Sixty-seven nurses met the eligibility criteria and completed survey documents. Ethical considerations: Institutional Review Board approval was obtained from both the university and hospital system. Findings: Findings indicated a strong correlation between professional values and career development and that both job satisfaction and career development correlated positively with retention. Discussion: Newly hired mid-career nurses scored higher on job satisfaction and planned to remain in their jobs. This is important because their expertise and leadership are necessary to sustain the profession into the future. Conclusion: Nurse managers should be aware that when nurses perceive value conflicts, retention might be adversely affected. The practice environment stimulates nurses to consider whether to remain on the job or look for other opportunities. Keywords Professional values, retention, career development, job satisfaction, early-career nurses, mid-career nurses
Corresponding author: Susan Yarbrough, School of Nursing, The University of Texas at Tyler, 3900 University Blvd, Tyler, TX 75799, USA. Email: [email protected]
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Introduction Hospitals are experiencing an estimated 16.5% turnover rate of registered nurses (RNs), increased from 14.7% in 2012. Estimates of RN turnover costs range from US$44,380 to US$63,400 per nurse—an estimated US$4.21 to US$6.02 million financial loss per year for hospitals. The increase reported for 2014 is the first time the turnover rate exceeded 2009 levels.1 This upward trend in turnover signals the end of the forewarned ‘‘bubble’’ in nursing labor supply as a result of a troubled economy2 and is expected to continue as the economy improves.1 In a discussion with nurse administrators of a large multi-site healthcare system in the southwest, it was determined that retention of mid-career newly hired nurses was problematic. Employment statistics of this group indicated a higher rate of voluntary termination after costly orientation sessions and acculturation efforts of hospital managers and coworkers. Nurses with more than 10 years at their current job reported less satisfaction than those with less than 2 years at their current job. This phenomenon is contrary to most reports that higher turnover rates occur in the new RN population.3 Kovner et al.4 estimated the 1-year turnover rate of newly licensed RNs at 17.5%. The exact cause of the premature departure from the system was unclear, and the cost of replacing a staff nurse was estimated to be between US$82,000 and US$88,000,5,6 making it imperative to ensure that recruitment and orientation efforts result in a longterm employee. In addition to the significant replacement costs, valuable wisdom and experience are lost when more experienced nurses leave the system.7 The mid-career nurse plays an important role in stabilizing staff and in facilitating the transition of the new nurse by providing essential expertise, support, and assistance. Recent reports indicate that the RN shortage will be staggering. According to the Bureau of Labor Statistics, even though the RN workforce will grow to nearly 3.24 million by 2022, this will still not be enough nurses.8 With the impending retirement of nearly 1 million nurses in the next 10–15 years, the need to retain new RNs and those in mid-career is clearly a major issue affecting hospitals today. Due to the importance of this matter, this study focused on the influence of traditional predictors of retention. Traditional factors included job satisfaction, career development, and intent to stay in early-career new graduates and recently hired mid-career RNs. Professional values were added to the mix of traditional predictors of retention after a review of the literature revealed that conflicts between the nurses’ values and organizational’ values often lead to voluntary nurse employee separation.
Background Nurse professional values Stacey et al.9 analyzed how a group of mental health nurses responded to conflicts between their professional practice and their values and how their values influence their experience of being a professional nurse. Utilizing qualitative methodologies, 12 nurses with between 6 months and 3 years’ experience were interviewed. The nurses sampled recognized dissonance between their values and their practice and tended to respond to this dissonance in three primary ways: acceptance, rejection, or innovation. The authors found that nurses’ values were embedded early during the education process and remained intact during professional practice. Participants cited organizational constraints impacting their practice, resulting in the inability to express those values in practice. In trying to cope with this dissonance between values and practice, nurses had to determine whether they would accept this dissonance and remain, challenge the system and find ways to initiate change within the system, or to reject the dissonance and leave to find another position. This study serves to highlight the importance of values and values dissonance within the arena of retention and/or nurse turnover.
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Intergenerational professional nursing values were surveyed by LeDuc and Kotzer10 in response to the increasing generational diversity within nursing to determine how those differences challenge the nursing profession. The authors state that there were more similarities among the generations than there were differences and that experience is not necessary for the development of professional values. Additionally, the authors state that work environments must foster the strengths of each generation as well as accommodate all individuals within it to achieve a healthy balance in which nurses can practice. LeDuc and Kotzer further assert that environments where retention priorities include nurses of all ages and experience levels are paramount to ensure the viability of the profession and the prosperity of the organization. A third study of nursing values sought to determine the extent to which values in nursing are associated with age groups, job stages, job satisfaction, productivity, and organizational commitment.11 Intergenerational differences were significant in only a few areas, including individual work values, economic returns, prestige, and variety. There was a negative relationship between economic value and job satisfaction with Generation X nurses placing higher value on variety and economic returns, though there were significant differences between all generations for variety. Among the nurses in this sample, those within the top third for job satisfaction, organizational commitment, and productivity also had higher scores for other values including creativity, esthetics, and management. Conversely, those in the bottom third demonstrated higher scores solely in economic returns. The authors state that the scores for this group were consistently lower to the extent that they wondered ‘‘which came first: a tendency to place less emphasis on values or lower job satisfaction, productivity, and organizational commitment’’ (p. 268).
Job satisfaction Job satisfaction has been the focus of several studies including work-related values that were linked to job satisfaction and intent to stay.12 Five themes identified by the participants centered on harmony, commitment, unity, altruism, and spiritual values. In another study, themes were also identified related to job satisfaction that reflected how nurses weigh the costs and benefits of remaining in a position.13 Variables identified that impacted a nurse’s decision about remaining in a position were drive time to work, age and flexible scheduling, availability of a career ladder, and years of experience related to the working conditions and wages. Van der Heijden et al.14 investigated how social environmental factors, such as social support from one’s direct supervisor and from one’s colleagues, can impact nurses’ intentions to stay or leave their profession aside from job satisfaction and nurse’s age. Analysis of the data supported the notion that social support from the supervisor negatively correlated with the intention to leave. The respondents did not perceive that their supervisors had much interest in their capabilities and lacked an understanding of how to stimulate or support the nurses. In another study of Taiwanese nurses,15 findings supported that perceptions of the work environment and the quality of care on their units impacted whether they would stay or leave current positions. In a systematic review of the literature,16 common themes were identified from over 100 published articles on job satisfaction and intent to stay. As previously discussed, and in the literature review, common themes are organizational environment, job stresses, organizational and professional commitment, role perception, and role content. Even though most studies identify the commonality of why nurses may intend to leave positions due to lack of job satisfaction, there is still not a clear picture of how the different variables can predict job satisfaction.
Generational differences and nurse values Nursing is currently experiencing unique generational diversity composed of four cohorts: the Traditionalists, also referred to as the Veterans (born before 1945), the Baby Boomers (born 1945–1964), Generation
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X (Gen X) (born 1964–1980), and Generation Y, also known as the Millennials (born 1980–2000).17,18 Differences in generational values and attributes contribute to the complexity of the work environment and present challenges to nurse leaders and administrators to maintain a stable workforce. In a literature review of 19 articles published between 1980 and 2009, Wolff et al.19 gleaned insight about how generational differences affect nurses’ work-related attitudes and behavior. Diversity in the nurses’ ages contributed to negative behaviors toward others in the work group and a lack of collegiality in relationships. Individuals who perceived themselves to have different values than others in their work group were more likely to leave their current position or suffer from burnout. Leiter et al.20 also studied work values by comparing Baby Boomer and Gen X nurses and found that Gen X nurses had a greater value mismatch between the individual and the organization than Baby Boomer nurses. Due to the greater mismatch, there was also an increased susceptibility to burnout and greater likelihood for an intention to quit in the Gen X nurses. Being aware that generational differences and nurse turnover are significant concerns to nurse managers, Wieck et al.21 conducted a generational assessment of job satisfaction, work environment, and desired characteristics of managers that can improve nurse retention. The data revealed that all generations preferred working for a supportive manager with good people skills and nurse/physician relationships were satisfactory among all generations. However, the Millennial’s were least satisfied with the control over their practice and organizational support and the Gen X nurses were least satisfied with their autonomy and control over practice. Nurses over the age of 40 demonstrated overall satisfaction in almost all areas, and the Baby Boomers were significantly more satisfied than the Gen X nurses. In contrast, Sparks,22 in a study of psychological empowerment and job satisfaction, found no differences in total job satisfaction between the Baby Boomers and Gen X cohorts. In the Nurse Incentives Project conducted in a 22-hospital system located in four southern and western states, Wieck et al.23 explored (a) generational differences in how nurses value benefits as incentives; (b) the relationships between perceived stress, satisfaction with incentives, floating, intent to stay, and satisfaction; and (c) the most important benefits to nurses. Responses were received from 1559 RNs. The data demonstrated that the most important benefit was a cohesive working environment. Nurses with higher stress scores were significantly less satisfied with their jobs. A correlation between the intent to stay and job satisfaction indicated that nurses who planned to stay longer in their current positions were consistently more satisfied and less stressed. The youngest nurses were the most stressed and more likely to leave. The most important incentives for Millennial’s and Gen Xers were overtime and premium pay while pension and retirement benefits were more important to Baby Boomers and older nurses. Similarly, Val Palumbo et al.24 explored perceptions among 583 RNs of the organizational and unit-level culture regarding older nurses in the workplace as well as human resource issues and practices. Respondents aged 55 years or older indicated that the recruitment of nurses over 50 years of age, compensation, and retirement options were important.
Stage of career and tenure Murff and DeFer25 noted that turnover rates at a large Southwest healthcare system were higher between 1 and 3 years of employment. They determined that almost 30% of RN turnover occurred within the first year; however, an additional 45% of RN turnover occurred within the first 3 years. In an effort to decrease controllable turnover, the healthcare system implemented a six-step strategy incorporating previously identified quality improvement measures. Upon implementing this strategy, the authors noted that the first-year retention rates improved each month, and increased awareness of at-risk RNs by managers facilitated increased focus to prevent RN turnover. The second group, those from 1 to 3 years, did not improve as rapidly as the new RNs.
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VALUES
WORK ENVIRONMENT
WORK SATISFACTION
OUTCOME INTENT TO STAY
CAREER DEVELOPMENT
Figure 1. Conceptual framework.
Coshow et al.26 found a similar pattern in job satisfaction among 56,253 RNs from 43 states related to their tenure or the length of time employed with one particular hospital. The most tenured nurses reported less job satisfaction across all dimensions of the survey and overall satisfaction scores. LeVasseur et al.27 looked at nurse turnover by generation and noted The Gen XMs (the combined category of Generation X and Millennials) were employed in their second, third, and fourth positions for less time as compared to the Veterans and the Baby Boomers.
Objectives The purpose of the study was to explore relationships of professional values orientation, career development, job satisfaction, and intent to stay in recently hired mid-career and early-career nurses with the overall goal of developing strategies to increase retention and to identify areas of values dissonance that may impact employment longevity.
Theoretical model The theoretical model that guided the study is an adaptation of Fishbein and Ajzen’s28 Expectancy–Value Theory. For the purpose of this study, Fishbein and Ajzen’s idea of beliefs will be measured as ‘‘professional values orientation’’ and evaluation will be assessed through ‘‘work environment’’ aspects, specifically work satisfaction and career development. It is proposed that intent to stay is indicative of a positive view of Fishbein and Ajzen’s perception of gratifications obtained, that is, nurses are more inclined to stay employed in their present work setting if they perceive that they are getting what they want (Figure 1).
Methods Approvals were obtained from the university and hospital system institutional review boards (IRBs). The researchers prepared an online survey to gather demographic, professional values, career development, job satisfaction, and retention data for this descriptive correlational study. The influence of personal and professional factors on job satisfaction and retention was explored and described. Perspectives of midcareer nurses were obtained through in-depth interviews with those who agreed to speak with us.
Sample A convenience sample of nurses from a mid-sized hospital in a metropolitan area in the Southwestern United States were recruited via in-house email. To be eligible for participation, the RN worked at least 24 h/week, was without licensure restrictions or recent gaps in active practice, and held no position higher than mid-management. A minimum sample of 60 nurses was calculated a priori. Estimates were based on
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Table 1. Sample characteristics. New hires
N ¼ 67 Mean age Mean years at hospital Mean years of RN experience Mean years RN intends to stay Mean job satisfaction Mean career development Mean professional values Sole support of self/others
>1 year
Early-career
Mid-career
All others
14 26.36 0.87 1.07 6.27 12.55 41.00 101.81 10 (71%)
9 45.56 0.89 15.56 12.20 15.20 44.60 105.20 4 (44%)
44 46.84 7.33 17.55 9.48 13.24 38.36 99.21 22 (50%)
RN: registered nurse.
bivariate correlation, with a moderate effect size of 0.35, power of 0.80, and a ¼ 0.05.29 Of 119 participants who entered the online survey system, 67 nurses felt they were adequately informed about the purpose of the study and met the eligibility criteria. The sample was not different from most found in the geographic area of the study, composed of predominantly female (60; 90%), Caucasian, non-Hispanic (56; 84%), and held a bachelor’s degree (39; 58%) or associate degree (21; 31%) in nursing. See Table 1 for more detailed description of demographic characteristics.
Data collection An online survey was constructed that included four instruments and a demographic profile. The Nurses Professional Values Scale–Revised (NPVS-R#) was developed and tested by Weis and Schank.30 It is composed of 26 Likert-type items representing the five domains (Caring, Activism, Trust, Professionalism, and Justice) of the 2008 Code of Ethics for Nurses. Subjects rate their agreement with the 26 items of the NPVS-R using a scale of 5 (most important) to 1 (not important). The total scale yielded an alpha coefficient of 0.92 when tested on 782 subjects. Four judges with expertise in the Code of Ethics for Nurses reviewed the instrument for content validity. The experts’ review resulted in 100% agreement regarding the relevance and sufficiency of the items to the Code of Ethics for Nurses. Cronbach’s internal consistency reliability for this use of the NPVS-R was 0.94 Participants responded to the single item Intent to Stay# with the number of years that they planned to stay with the current employer. Wieck et al.23 effectively used the instrument to determine intent to stay in a study of nurse retention. Nurse Job Satisfaction Index# is composed of four Likert-type items that when summed provide a measure of overall job satisfaction. Wieck et al.23 tested the instrument in the nurse retention project. The reliability a ¼ 0.85 and factor analysis supported measurement of the single component. Cronbach’s alpha for this study was 0.76. Perceived Development Climate31 was used to assess participants’ opportunities and support for professional development. In a study of resistance to organizational change, Van Dam et al.32 found the 11-item tool to be a reliable measure, yielding a Cronbach’s alpha of 0.87. The study of nursing retention yielded a Cronbach’s alpha of 0.91. Institutional Review Board approval was obtained from both the university and hospital system. The university researchers emailed survey information to the hospital research liaison, a nurse educator in a
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Table 2. Correlations between key variables and select demographics.
1. Age 2. Years at hospital 3. Years intends to stay 4. Job satisfaction 5. Career development 6. Professional values
1
2
3
4
5
6
1.00 0.55** 0.06 0.18 0.05 0.02
1.00 0.08 0.04 0.21 0.02
1.00 0.40** 0.29* 0.21
1.00 0.59** 0.25
1.00 0.47**
1.00
*Correlation is significant at 0.05 level (two-tailed). **Correlation is significant at 0.01 level (two-tailed).
non-supervisory position, who distributed the survey along with a cover letter and consent information to potential participants via the hospital’s email system. The survey was conducted using Qualtrics, an online survey software program. Interested participants clicked on a link which took them to the survey. No identifying information was asked for or collected except for those mid-career nurses who volunteered for an interview. Since the survey was disseminated online, potential participants determined whether they met the inclusion criteria and felt they were informed of the study purpose, risks, and benefits. Several potential participants accessed the survey but did not feel they had enough information to participate or were not eligible and were subsequently not included in the final sample. Finally, interested mid-career nurses were interviewed regarding factors influencing their decision to remain or leave the facility.
Findings Influences on retention Neither professional values orientation nor its component subscales correlated significantly with retention. However, there was a strong correlation between professional values and career development (r ¼ 0.39, p < 0.001). Both job satisfaction (r ¼ 0.39, p ¼ 0.003) and career development (r ¼ 0.29, p ¼ 0.037) correlated positively with retention. Even after correcting for multiple comparisons and use of nonparametric statistics, job satisfaction was strongly correlated with retention. To further explore retention, the relationship between longevity of employment and increasing age was tested and neither was significantly correlated with retention. Details of the correlations including selected demographics and the NPVS-R and its subscales are depicted in Table 2.
Career stage and retention A subset of 23 participants from the sample was used to examine differences in key employment characteristics. The newly hired mid-career nurses (5 or more years) scored significantly higher on retention (U ¼ 14.5, p ¼ 0.041) and job satisfaction (U ¼ 18.5, p ¼ 0.005) than early-career nurses (less than 5 years).
Individual characteristics and retention The participants were queried on a variety of demographic and career-related characteristics. One characteristic stood out that may be of particular interest. Instead of asking about household income, participants were asked if they were the sole support of self and/or others versus they had assistance with support of self and/or others. Those who reported they had assistance with support scored significantly higher on retention
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(U ¼ 214.5, p ¼ 0.006) and job satisfaction (U ¼ 339.5, p ¼ 0.006) than nurses who reported that they were the sole support of themselves and/or others.
Mid-career nurses’ perspectives on retention Mid-career nurse participants were asked to speak with researchers to help increase the understanding of the issues and concerns of that cohort. Five agreed to participate, but only two actually provided in-depth information through telephone interviews. Informed consent was obtained prior to conducting the interviews. No identifiers were used in recording, transcribing, or analysis of these interviews. These interviews were informative but not transferrable beyond these participants’ own experiences. When asked to describe the barriers and facilitators to a satisfactory work experience in a new hospital, the participants described the work environment as positive and a primary reason they chose to stay. The work ethic was much better than previous places of employment; there was a sense of camaraderie and teamwork with administrative support. The nursing staff was expected to be patient advocates, to put the patients first. Other positive factors identified included an optimal orientation and opportunities for continuing education provided by the facility. The hospital provides ways for career development and offers reimbursement for certification. The primary barriers identified or reasons staff chose not to stay included being short staffed and the turnover of both new and senior staff. The highest turnover seemed to be in the ‘‘less seasoned nurse.’’ Differences identified between the new graduate nurse and the seasoned nurse included being ‘‘too entitled’’ and expecting the perfect schedule and not working holidays. ‘‘They have a different work ethic and choose to do the barest minimum to get by.’’ To the new graduate, it is just a job, not a passion, money is more important. They do not see themselves as part of the team to help each other and do not work extra when the unit is ‘‘drowning,’’ instead they may go out partying: they are young, less mature. The new grad does not realize the depth of the profession; therefore, no commitment. New graduates are always looking for the ‘‘greener grass’’ and it does not exist. One participant stated she would like a new nurse who has found their ‘‘dream job’’ and will remain. A second participant stated there is a difference in values—‘‘I am here to make a difference’’ and she did not see this in new grads who have less loyalty to the profession. Another barrier identified was the amount of added paperwork taking away from actual nursing care and ‘‘feeling that hands are tied.’’ Some leave thinking they will find a less stressful job. The participants believed that it was important to keep both new graduates and more senior nurses at the bedside. They suggested that the organization change their perspective to keep early-career nurses. They like bonuses and more flexibility in scheduling. They also suggested that the organization come up with ways to keep senior nurses at the bedside and offer incentives for the seasoned nurse who is dedicated to bedside nursing. When asked how the professional values of nurses compared with those of the institution, all were in agreement and felt they were aligned. Professional values are seen in the whole culture and start with the orientation process which was detailed; an ‘‘incredible’’ orientation, the positive culture that meets work ethic, teaches respect of peers. One participant stated, ‘‘but must remember the budget and bottom line, it is a business; this is where I see the values are not meeting.’’ The participants said they were satisfied with their work. One remarked, ‘‘I am very, very satisfied, love to go to work.’’
Discussion Saber33 indicated that all generations are essential to the continuum of the nursing workforce. The midcareer and seasoned nurses bring experience and stability to quality healthcare, while early-career nurses bring new ideas and increased ease with technology. As the age of RNs decreases, it brings a new opportunity for positive change. Nursing retention is vital and turnover is costly to the facility.
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The purpose of this research was to examine retention within a large multi-site system. The sample accessed for this study represents only one facility in the system. Responses from participants indicated that mid-career nurses were significantly more likely to continue employment than the early-career nurses. This differs from the concerns expressed by administrators of the system that the retention of mid-career nurses was problematic. However, the voluntary participants in this study, early- and mid-career nurses, may not be representative of the larger system or the nurses who do not intend to stay. Both of the nurses interviewed indicated that there is a difference between the perceptions of early- and mid-career nurses related to dedication to the profession, their peers in the work setting, the employing facility, long-term commitment, and expectations of what it means to be an RN. Val Palumbo et al.24 suggested that there may be intergenerational tensions that should be addressed emphasizing that nurses of all ages are important and needed in the workplace. Generational differences may be even more important today than 5–6 years ago as the nursing population ages and newer RNs are in the age groups of early 20s. Previous recommendations to improve retention efforts included the formation of intergenerational groups of nurses to collaborate and make recommendations to their organization to improve working conditions were made,34 yet there continues to be an area of concern regarding the retention of mid-career nurses.25–27 But findings in this study indicated that newly hired mid-career nurses intended to remain longer than earlycareer new hires and all others employed longer than 1 year. In congruence with Murff and DeFer,25 findings support that increasing managers’ knowledge of which RNs belonged in a particular group facilitated intervention to prevent loss, facilitated information necessary to maintain staff engagement, and increased nursing’s voice in the work environment. Of great concern was that 61% of the RNs planned to leave employment within 10 years regardless of high satisfaction levels.21 Methods discussed to retain older and more experienced nurses focused on work redesign to include the number of shifts worked each week, the number of hours per shift, and physical demands for aging nurses. The findings of the study supported the theoretical model with the exception of values and intent to stay. The initial perception of the researchers was that a difference of professional values and institutional values would affect retention. Neither early-career nurses nor mid-career nurses indicated that professional values influenced their intent to stay. However, the influence of professional values may be adequately captured through assessment of the nurses’ career development. Job satisfaction and career development did influence retention, and an additional finding indicated that when the nurse was not the sole financial support of self or others, the intent to stay employed was higher. This finding may represent a non-modifiable factor for the facilities that has not been given adequate consideration to date. Nei et al.35 may have captured this factor indirectly in a recent meta-analysis of causes of nurse turnover. The meta-analysis revealed secondary factors affecting nurse turnover including role strain that may be more difficult for those who provide the sole financial support for themselves and/or others.
Limitations The findings from this small sample of mid- and early-career nurses do not generalize to other facilities or even to those within a single facility who might not have the same level of satisfaction. Those who were not satisfied with their work may not have responded to the survey at all. However, this does not diminish the importance of learning what does influence satisfaction and retention as found in this study. Although self-selection bias must be considered, there are a myriad of other possible reasons why a busy staff nurse did not respond.
Next steps Facilities need to consider several factors when addressing retention efforts. These could include exploring methods of compensation that are highly valued by younger nurses. Consideration that professional values,
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when supported, may not influence retention but when nurses do perceive value conflicts, retention may be adversely affected. The practice environment stimulates nurses to consider whether to remain on the job or look for other opportunities. The importance of keeping the experienced nurse at the bedside contributes to quality patient care and mentorship of the novice professional. The mid-career nurse is likely to be the senior nurse of tomorrow. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. Funding The author(s) received no financial support for the research, authorship, and/or publication of this article. References 1. Nursing Solutions, Inc. 2014 National Healthcare & RN Retention Report, http://www.nsinursingsolutions.com/ Files/assets/library/retention-institute/NationalHealthcareRNRetentionReport2014.pdf (2014, accessed 22 April 2015). 2. Staiger D, Auerbach D and Buerhaus P. Registered nurse labor supply and the recession—are we in a bubble? N Engl J Med 2012; 366(16): 1463–1465. 3. Salt J, Cummings GG and Profetto-McGrath J. Increasing retention of new graduates: a systematic review of interventions by healthcare organizations. J Nurs Adm 2008; 18(6): 287–296, http://dx.doi.org/10.1097/01.NNA. 0000312788.88093.2e 4. Kovner CT, Brewer CS, Fatehi F, et al. What does nurse turnover rate mean and what is the rate? Policy Polit Nurs Pract 2014; 15: 64–71. 5. Jones CB. Revisiting nurse turnover costs: adjusting for inflation. J Nurs Adm 2008; 38(1): 11–18, http://dx.doi.org/ 10.1097/01.NNA.0000295636.03216.6f 6. Li Y and Jones CB. A literature review of nursing turnover costs. J Nurs Manag 2013; 21(3): 405–418. 7. Sherrod D. Strategies for retaining older nurses. Nurs Manag 2006; 37(10): 12–14, http://journals.lww.com/nursingmanagement/Citation/2006/10000/Strategies_for_retaining_older_nurses.3.aspx 8. Kelly C. Facing the nursing shortage. Columbia Business Times, 25 January 2015, http://columbiabusinesstimes. com/25059/2015/01/25/facing-the-nursing-shortage/ (accessed 22 April 2015). 9. Stacey G, Johnston K, Stickley T, et al. How do nurses cope when values and practice conflict? Nurs Times 2011; 107(5): 20–23, http://www.nursingtimes.net/Journals/2013/01/18/p/r/c/080211How-do-nurses-cope-when-values-and-practice-conflict.pdf 10. LeDuc K and Kotzer A. Bridging the gap: a comparison of the professional nursing values of students, new graduates, and seasoned professionals. Nurs Educ Perspect 2009; 30(5): 279–284, http://www.nln.org/newsroom/newsletters-and-journal/nursing-educationperspectives-journal 11. McNeese-Smith D and Crook M. Nursing values and a changing nurse workforce—values, age, and job stages. J Nurs Adm 2003; 33(5): 260–270, http://dx.doi.org/10.1097/00005110-200305000-00002 12. Ravari A, Bazargan-Hejazi S, Ebadi A, et al. Work values and job satisfaction: a qualitative study of Iranian nurses. Nurs Ethics 2013; 20(4): 448–458. 13. Hodgin R, Chandra A and Weaver C. Correlates to long-term-care nurse turnover: survey results from the state of West Virginia. Hosp Top 2010; 88(4): 91–97. 14. van der Heijden B, Ku¨mmerling A, van Dam K, et al. The impact of social support upon intention to leave among female nurses in Europe: secondary analysis of data from the NEXT survey. Int J Nurs Stud 2010; 47(4): 434–445.
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