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

Discussion

In this study, having a baccalaureate degree or more and current enrollment in school independently predicted turnover intention from the hospital bedside as a practice setting. Hospitals attempting to maximize surveillance capacity according to the organizational variables recommended by Kutney-Lee and colleagues (2009) might unwittingly set themselves up for turnover if this finding is replicated in other samples. In addition to loss of the direct benefits associated with baccalaureate nurse staffing, the turnover of nurses with more education contributes to staff "churn" (p. 104) and very likely has implications for diminished continuity of care, adverse events (Duffield, Roche, O'Brien-Pallas, & Catling-Paull, 2009), and inadequate staffing, which is independently associated with adverse events. Turnover of baccalaureate nurses from the hospital setting has cost implications both in terms of turnover and when hospitals offer tuition reimbursement for nurses to earn the baccalaureate degree.

In this sample, nurses with 11 or more years of experience intended to stay, further supporting earlier findings in the literature that nurses with more years of experience are less likely to turn over (Hayes, et al., 2012). It is unclear whether or not the turnover of nurses with more education is offset by the retention of nurses with more experience, but studies demonstrating the independent effect of nurse educational preparation on patient outcomes suggest this is not the case.

McHugh and colleagues (2011) documented higher dissatisfaction among hospital nurses in direct care roles compared to nurses in other roles. Their findings are likely a reflection of the "hard" (p. 379) work that is the nature of hospital bedside nursing (Bogassian, Winters-Chang, & Tuckett, 2014) and the vulnerabilities it entails (Choi, Pang, Cheung, & Wong, 2011). Insofar as work environment can mitigate job dissatisfaction among hospital nurses (McHugh, Kutney-Lee, Cimiotti, Sloane, & Aiken, 2011), the current study did not find interactions between either educational preparation and practice environment or educational preparation and satisfaction on intent to leave, and the question of whether or not a superior practice environment can retain nurses with more education and in which types of units remains to be studied. It is particularly noteworthy that one study identified vigilance—the very activity that is enhanced by baccalaureate nurses at an organizational level-- as contributing to exhaustion and turnover among bedside nurses (MacKusick & Minick, 2010).

Career mobility and the need for nurses in expanded roles might put hospitals at a growing disadvantage as more nurses achieve the baccalaureate degree and beyond. Weathers & Raleigh (2013) foresaw this dilemma and suggested it might be more cost-effective for hospitals to hire associate degree nurses and offer tuition assistance than to incur turnover costs associated with baccalaureate nurses. The findings of the current study that almost half of those enrolled in a baccalaureate program intended to leave suggest Weathers and Raleigh correctly predicted the potential "tradeoff" (p. 473), or that these nurses might choose to leave once they have earned their degrees.

In addition to the difficulty of the work and the shortcomings of many hospital practice environments, many new nurses likely enter the hospital setting with little intention of remaining there for any length of time. Often, nurse faculty recommend starting out in hospital nursing when there is no evidence to support this advice. Perhaps their guidance emanates from nursing's history of educating nurses in hospitals for later independent practice in the community. It is tacitly understood that the hospital is the launching point for nurses. The movement of more care to the outpatient setting, leaving the sickest and most vulnerable patients in hospitals, warrants a reevaluation of this understanding. Nurse faculty and other nurses to whom new nurses turn for career advice should refrain from dispensing advice that is not evidence-based.

One possible solution for the turnover of baccalaureate nurses from the hospital bedside might be an intentional re-envisioning of the acute care hospital setting as one specialty among others with commensurate hiring practices, recognition, and advancement opportunities that include salary adjustments. Higher salaries for nurses who demonstrate a commitment to the hospital bedside might offset turnover costs of nurses who only intend to accumulate experience and move on, but they must be coupled with favorable practice environments. This study, like many others, found that a positive practice environment and higher satisfaction scores predicted less turnover intent. A focus on leadership development will be crucial to improving practice environments (AMN Healthcare, 2017).

Research is needed to elucidate the particular competencies necessary for excellent hospital bedside nursing, the temperaments of nurses who are more successful in this environment, and the effects of advancement opportunities, such as meaningful clinical ladders. More research is also needed about the interaction between nurse experience and educational preparation on patient outcomes.

If nursing at the hospital bedside is treated as a specialty, then nurse educators must reflect on curricula, which are often acontextual in terms of the settings in which care is delivered. For example, adult health or traditional "med-surg" courses often cover topics from primary care nursing through post-discharge nursing. This may contribute to unrealistic expectations for the scope of care that nurses can reasonably expect to deliver at the bedside in the setting of the acute care hospital.

Additional research is needed to replicate these findings and overcome the limitations of this study, which include a cross-sectional design and non-probability sample of respondents. Sampling nurses from one health system in a rural geographic location limits the study's external validity. Finally, the dependent variable of turnover intent does not necessarily capture actual turnover, but Brewer and colleagues (2015) did document a clear relationship between turnover intent and actual turnover at the unit level.

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