Educational Preparation and Nurse Turnover Intention From the Hospital Bedside

Mary Jane K. DiMattio, PhD, RN; Adele M. Spegman, PhD, RN

Disclosures

Online J Issues Nurs. 2019;24(2) 

In This Article

Abstract and Introduction

Abstract

Evidence of an association between nurses' educational preparation and patient safety has prompted many hospitals to engage in preferential hiring of baccalaureate nurses or invest resources into tuition assistance. Meanwhile, the difficult nature of nursing at the hospital beside, demanding hospital practice environments, and the need for nurses in expanded roles are converging to create a situation whereby education might beget increased turnover from the hospital bedside. This article describes a study that examined the relationship between educational preparation and turnover intention from the hospital bedside in a sample of nurses from an integrated health system in Pennsylvania. The authors discuss the review of literature, theoretical framework, and study methods. Results indicated that educational preparation independently predicted turnover intention from the hospital bedside. In the discussion and conclusion, the authors suggest that to keep hospitalized patients safe and reduce costs, the hospital bedside should be re-envisioned as a specialty so as to retain baccalaureate nurses in this setting.

Introduction

Evidence of an association between nurses' educational preparation and patient safety has prompted many hospitals to engage in preferential hiring of baccalaureate nurses or invest resources into tuition assistance. Meanwhile, the difficult nature of nursing at the hospital beside, demanding hospital practice environments, and the need for nurses in expanded roles are converging to create a situation whereby education might beget increased turnover from the hospital bedside. The purpose of this article is to describe a study that examined the relationship between educational preparation and turnover intention from the hospital bedside in a sample of nurses from an integrated health system in Pennsylvania.

There is now ample evidence of a positive relationship between educational preparation of registered nurses (RNs) and desirable safety outcomes for patients in acute care hospital settings (Aiken, Clarke, Cheung, Sloane, & Silber, 2003; Aiken, Clarke, Sloane, Lake, & Cheney, 2008; Blegen, Goode, Park, Vaughn, & Spetz, 2013; Friese, Lake, Aiken, Silber, & Sochalski, 2008; Kutney-Lee, Sloane, & Aiken, 2013; Tourangeau et al., 2006; You et al., 2013). This evidence is among the rationales behind the policy recommendation for a greater number of nurses to hold a minimum of a baccalaureate degree (Institute of Medicine, 2011; Tri-Council for Nursing, 2010). In the wake of this policy recommendation and others related to patient safety (Illingworth, 2015; National Patient Safety Foundation, 2015), many hospitals now engage either in preferential hiring for baccalaureate nurses (AACN, 2017) or offer tuition reimbursement for their nurses to achieve baccalaureate degrees (Cheung & Aiken, 2006; Schuler, Johnson, Stallings, & Li, 2017; Warshawsky, Wiggins, Lake, & Velasquez, 2015).

Kutney-Lee and colleagues (2009) identified a large proportion of baccalaureate nurses as an essential dimension of a hospital's surveillance capacity, or organizational environment, conducive to the surveillance and rescue of patients. Other dimensions of optimal surveillance capacity include adequate staffing by experienced and expert registered nurses and a favorable nurse practice environment. Surveillance consists of ongoing observation, recognition, interpretation, and decision-making (Kutney-Lee, Lake, & Aiken, 2009). Meyer and Lavin (2005) applied the concept label of vigilance to the identification of clinically significant observations, calculation of risk, and readiness to take appropriate and efficient nursing actions. Whatever the label, surveillance capacity or vigilance allow for nurses to engage in what Nightingale (1860) recognized as the most critical aspect of nursing—informed observation leading to appropriate action on the patient's behalf. Based on their findings of better patient safety in hospitals with high nurse surveillance capacity, Kutney-Lee and colleagues suggested that hospitals could enhance surveillance by ensuring adequate staffing with experienced, expert baccalaureate nurses in a supportive practice environment. If RN educational preparation independently predicts turnover from the hospital bedside as a practice setting, however, this formula for patient safety will be compromised.

Despite the shift of care delivery to ambulatory settings (Bauer & Bodenheimer, 2017), approximately 61% of registered nurse jobs are in hospitals (Bureau of Labor Statistics, United States [U.S.] Department of Labor, 2018). As hospitals work to enhance the educational preparation of bedside nurses, the need for nurses in expanded roles provides an incentive for career advancement. In 2016, 75% of new baccalaureate and 65% of new associate nurses reported plans for degrees beyond the baccalaureate (Feeg & Mancino, 2017). The career mobility conferred by education (Gilmartin, 2013) might unwittingly contribute to turnover from the bedside in the acute care hospital (hereafter referred to as the hospital bedside) as a practice setting and confound the positive effects of education on patient safety outcomes in that setting.

Some might argue that the hospital bedside as a stepping stone to career advancement is neither surprising nor inappropriate. Evidence of the positive impact of RN education, experience, and expertise on patient safety outcomes in hospitals (Aiken et al., 2008; Benner, 1984; Dunton, Gajewski, Klaus, & Pierson, 2007; Kutney-Lee, Lake, & Aiken, 2009), coupled with the loss of "experience-based knowledge" (Hill, 2010) and the expense incurred by hospitals and the healthcare system from nurse turnover (Becker's Hospital Review, 2016; Li & Jones, 2013; Waldman, Kelly, Arora, & Smith, 2004) suggest it is important to understand better baccalaureate nurses' turnover intentions from the hospital bedside.

Such an understanding is the first step to inform strategies for keeping an adequate number of expert baccalaureate nurses at the hospital bedside long enough positively impact on patient safety. The purpose of this study was to examine the relationship between educational preparation and turnover intent, defined as intention to leave the hospital bedside as a practice setting, while accounting for other variables necessary for surveillance capacity, including years of experience, self-reported expertise, and practice environment.

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