The perception discrepancy of nurse turnover in hospital

Abstract

Objective

The objective of this study was to explore the meaning of turnover under the perception of nurses, managers, and institutional director and board.

Method

The design used in this study was qualitative with case study approach. The data were collected from three participant groups: (1) nurses left hospital X in Bogor, West Java, Indonesia through an in-depth interview; (2) managers through Focus Group Discussion (FGD); and (3) institutional director and board through an in-depth interview. The total participant was 17, consisting of 6 nurses, 6 managers, and 5 institutional directors and board. Colaiizi's method was applied for the analysis.

Results

This study resulted in 10 themes, consisting of three themes from nurse participants, one theme from manager participants, three themes from the institutional director and board, two themes from nurses and managers, and one theme from the manager and institutional director and board. The themes were as follows: (1) the existence of nurse regulation and management; (2) the lack of optimal regulation socialization; (3) the cause of voluntary turnover; (4) the workload increase as the impact of turnover; (5) the nurses’ perception and expectation to hospital management; (6) the internal and external factors that influence nurse turnover; (7) the implementation of vision, mission, and policy from the institution; (8) the requirement and expected nurse competence; (9) the vigilance of turnover and its consequences; (10) the material and non-material effort and innovation.

Conclusion

There were some similarities and differences of themes identified about nurse turnover based on the perception of nurses, managers, and institutional director and board. The result of this study suggested that equalizing perception is necessary to build togetherness among co-workers.

Introduction

Turnover occurred globally. Nurse turnover happened in many countries around the world. Turnover could be a serious problem for the hospital. There were many types of research about nurse turnover, i.e. in the United States, Canada, Australia, and New Zealand. Some papers reported that the cost charged to the hospital due to nurse turnover in 2014 ranged from US$ 20,000 to 49,000 per nurse.¹ In the previous paper, in 2010, from a study conducted in Australia, the nurse turnover even cost the hospital for US$10,000–88,000 per nurse.¹ It clearly caused financial loss to the hospital. Meanwhile, from a non-financial perspective, turnover could increase the work overload, reduce productivity, increase complain from the patients, and the most dangerous was it could affect the patients’ safety.²

The phenomena of turnover also happened in hospital X Bogor. In 2015, there were 20.47% of nurses leaving their job, and in 2016 the number increased to 25.87%. Based on the data from the Human Resource Division (HRD), there was a regulation from the institution of not allowing two staffs of husband and wife working in the same institution. This regulation aimed to extend the institution benefit as an Islamic non-profit institution for poor people and to avoid conflict of interest. It was the policy from the institutional director as a policy maker. This policy was contradictive with the retention strategy to reduce nurse turnover. Therefore, a study to explore the perception of nurses, managers, institutional director, and board about nurse turnover in hospital X Bogor, West Java, Indonesia, was necessary to be conducted.

Method

The design of this study was qualitative with case study approach. This method was selected in order to explore the meaning of turnover from different perspectives.

The primary instrument used was the researcher itself. The tools utilized for the data collection were such as voice recorder, stationary, interview guideline, and field notes. The key questions were: how is the participant's perception about nurse turnover? What is the reason for the turnover, and how is the impact of nurse turnover?

There were 17 participants involved in this study (P1–P17), consisted of three different groups, namely group of nurses who left hospital X as many as 6 persons (P1–P6), group of managers as many as 6 persons (P7–P12), and group of institutional direction and board as many as 5 persons (P13–P17). All participants were selected by using purposive sampling method.

The research was started from the proposal planning from February to April 2017, ethical consent on May 2017, and permission request to the hospital and institution from June to August 2017.

The data were collected through an in-depth interview with the nurse participants and the institutional direction and board participants; and FGD to the manager participants. The data collection and analysis were conducted from August 2017 to April 2018. This research has approved ethical consent from ethical committee FIK UI. This research has obeyed the ethical research, namely beneficence, respect for human dignity, and justice.³ This research was started after the informed consent been signed by all participants.

This research was conducted in Institution X in South Jakarta, and any other places as requested by the participants; the FGD was conducted in hospital X in Bogor, and the interview was conducted in participants’ house, or their current work place in Depok and Bogor.

After completing the voice-recorded data, the researcher then wrote the transcript. The verbatim transcripts were read repeatedly to find the key words. After finding the key words, the researcher did the data coding. The data analysis applied was Colaizzi's Method.

Result

This study has reached saturation on P6 for nurse participants, P12 for manager participants, and P17 for institutional director and board. The researcher has identified 10 different themes; 3 themes from the nurses, 1 theme from the managers, 3 themes from the institutional director and board, 2 themes from nurses and managers, and 1 theme from the institutional director and board. The themes were as follow:

• (1)

  Nurse regulation and management

These two supporting themes, regulation since the first day of working and nurse management was good. The statement from the participant for this theme was as follows:

“To make us motivated at work, they used to do an assessment, like a logbook, we filled the logbook, and the manager looks after it. Every day, we made notes of what we did to patients in that logbook, submitted every month for the manager to check, and every six months, we used to get a reward” (P3)

• (2)

  Lack of optimal regulation socialization

This theme consisted of three categories: the socialization of regulation, the implementer of socialization, and lack of understanding towards the regulation. The statement from the participant that represented this theme was:

“Some regulation like not allowed to get married or pregnant during contract period was unclear. One-time, my kids (nurse) worked less than a year and got pregnant, and then could not continue their contract, and they said that they did not know it was not allowed, they just knew that in one year they only could not have annual leave, just that.” (P5)

• (3)

  Voluntary nurse turnover

This theme consisted of two categories, namely family reason and other personal reason. Participants’ statements that represented this theme were:

“Because I don’t have anybody else to take care of my child, so I left” (P5)

“It was because some friend uploaded from friend to friend and it made me annoyed, and it got worse by day, so I thought I’d done with it” (P1)

• (4)

  Work overload as the impact of turnover

This theme was supported by two categories, namely over workload and new job/task for the nurse. Participant's statement that represented this theme was:

“Sometimes the schedule was uncertain, probably because lack of nurses, so managed to make it sustain … and filled. So, sometimes after a night shift, we have to continue until morning, sometimes like that” (P2)

• (5)

  Nurses’ perception and expectation to hospital management

This theme was supported by two categories, namely nurse perception upon the hospital and their expectation of management and welfare improvement. Participants’ statements that represented this theme were:

“It's like they did nothing (effort), just let it flow like it used to, in my opinion” (P2)

“I hope there's nothing like that anymore (high turnover), hospital policy should be better in the future” (P6)

• (6)

  An internal and external factor that influence nurse turnover

This theme was supported by two categories, namely external and internal factors. The statement that represented this theme was:

“Family problem that I’ve found like she's married and then her husband asked her to take care of their children, and they resigned from work, it was common to happen, mostly among female nurses” (P7)

• (7)

  Vision, mission, and policy of the institution

This theme was supported by the category of policy to leave the job if had family under the same institution and the implementation of hospital vision and mission. The statement that represented this theme was:

“Because this hospital was built from collected grant fund, a donation from society, so this hospital should be managed based on the initial vision and mission, and also need better management. It was the initial function to oversee all of it” (P16)

• (8)

  Requirement and expected nurse competence

This theme was supported by two categories, namely applicant requirement and expected nurse competence. Participant's statement that represented this theme was:

“In term of the specification, it was just like usual, like age. There is a maximum level for some level, like maximum age for staff, the age for manager level, age requirement. And the second, value requirement, so they were motivated to share, that is commonly required” (P17)

• (9)

  Vigilance towards turnover and its consequences

This theme consisted of the category: nurse turnover was common to happen, and turnover increased recruitment job as stated as follows:

“Turnover is an undeniable problem, it is common to happen” (P17)

“Insha’Allah still under controlled, its just there will be nonstop work in HRD. Recruitment, and more recruitment … which in case if there is not too many recruitments, we could use it to focus on human resources development” (P13)

• (10)

  Material and non-material effort and innovation

This theme consisted of the category: the retention strategies materially and non-materially and the expectation to reduce turnover through hospital innovation. The statement that supports this theme was:

“So basically, if there is a process… some adjustment has worked well, and we could feel settled financially, it could be an opportunity for the management to give more rewards, some financial rewards” (P13)

Discussion

After identifying the themes above, every theme would be discussed under this part.

• (1)

  Nurse regulation and management

Regulation and nurse management was under management function. The function was related to staffing or resourcing. In the resourcing function, there were some activities, such as planning, recruiting, selection, orientation, placement, and development.^4,5 In hospital X, many divisions were involved in nurse management. In term of qualification, there were three components that made a decision, namely the director, nurse manager, and medical manager. As previously stated, nurse performance determined the quality of service to the patients. The good human resource management could influence the service quality given to the patients.⁶

• (2)

  Lack of optimal regulation socialization

The regulation that oftentimes changed with or without socialization also increased nurse intention to leave. It was related to job satisfaction. Nurse with low job satisfaction would be likely to have turnover intention.⁷

• (3)

  Voluntary nurse turnover

This cause of turnover was also supported by the previous study that stated turnover was caused by too much work overload, irregular work schedule, pay gap, ambiguity at work, less accommodative supervisor, low chance to get a promotion, and family conflict.⁸ Furthermore, inadequate remuneration would also affect nurse turnover.⁹

• (4)

  Work overload as the impact of turnover

Turnover caused financial loss to the hospital due to the requisite to call and pay the replacement worker.¹⁰

The impact of turnover needs serious attention as stated in the previous research that turnover could reduce the productivity of the nurses who were still working and it related to the patients’ safety.

• (5)

  Nurses’ perception and expectation to hospital management

Nurses’ poor perception of the hospital would give a negative impact on their performance. It was inline with Borkowski's statement that somebody's perception towards something would likely affect his/her attitude towards that thing.¹¹

• (6)

  An internal and external factor that influence nurse turnover

Nurses leaving could be influenced by internal and external factors of the hospital. It supported the previous research which identified some factors that influenced nurse turnover, namely work overload, irregular work schedule, pay gap, ambiguity at work, less accommodative supervisor, low chance to get a promotion, and family conflict.⁸

• (7)

  Vision, mission, and policy of the institution

Institutional director and the board always oversee the purpose, vision, and mission of the hospital. The decision makers of the hospital had an important role in all functions and organization effectiveness.¹² Vision, mission, and policy needs to be communicated well because good communication related to nursing performance. Communication could be endeavoured through supervising and briefing.¹³

• (8)

  Requirement and expected nurse competence

Hospital X had determined the standard qualification and competence for every applicant. It was already good in order to filter the appropriate human resources. The requirement and expected competence would contribute to low turnover intention. Competence was determined based on work experience and education.¹⁴ These two aspects need to be considered in determining nurse qualification.

• (9)

  Vigilance towards turnover and its consequences

According to the institutional director and board, turnover was common to happen, and its consequence was the increased work of recruitment. Turnover conveyed financial and non-financial impacts. The non-financial impacts were such as reducing the productivity of the still working nurses and also affecting the patient safety.¹⁵ In order to boost nurse performance, some clinical supervision needs to be conducted as it could influence the nurse job satisfaction and performance.¹⁶

• (10)

  Material and non-material effort and innovation

According to the institutional director and board, material and non-material efforts were necessary to reduce nurse turnover in hospital X, and turnover became a challenge for the hospital to create innovation in resolving nurse turnover.

Nurse retention was strongly influenced by career level clarity. Every nurse surely expects career level development. Thus it makes management have an important role in maintaining staff retention. As previously stated that staffing is one of the manager functions. It comprised the activities of recruitment, selection, orientation, placement, work socialization, and staff development.¹⁷ Some staff retention strategies were such as organization supervision and motivation, financial fulfilment, and internal discussion of policy.

Organization supervising and motivation were part of manager function, that is actuating and actuating function covered manager duties in leading the organization, comprising staff motivating, staff supervising, selecting the most effective communication, and conflict resolving.¹⁸ Furthermore, another study stated that transactional leadership model was related to nursing retention.¹⁹

Conclusions

There were 10 different themes resulted, namely 3 themes from the nurses, 1 theme from the managers, 3 themes from the institutional director and board, 2 themes from the nurses and managers, and 1 theme from the manager and institutional director and board. The theme of turnover increase work overload was from the nurses and managers. This theme was different from the perception of institutional director and board that considered turnover as a common thing and undeniable, yet need to be alerted and ready for the consequences.

The theme of reducing nurse turnover by fulfilling material and non-material aspects and the need for innovation were the same theme from the manager and institutional director and board.

Therefore, it could be concluded that there were some perception difference and similarity of nurse turnover among nurses, manager, and institutional director and board's point of view. It is suggested to equalize the perception and provide socialization of regulation to the executors.

Conflict of interests

The authors declare no conflict of interest.

Acknowledgments

This work is supported by Hibah PITTA 2017 funded by DRPM Universitas Indonesia No. 382/UN2.R3.1/HKP.05.00/2017.