Electronic ISSN 2287-0237
Nurses are the largest group of health personnel who work closely with patients to provide the best care. Nurses are part of patients’ relationship with the hospital and take the responsibility to improve patient health care. The absence of nurses has an impact on the patient’s well-being and the quality of provision of health care. One direct negative effect is the cost of nurse recruitment and training of new nurses. This cost has to be borne by the hospital. In the USA, the total cost of recruitment of recently-graduated nurses is about $15,825 and this can reduce productivity, incurring a cost between $5,242 to $16,102.1 A working group investigated the following: type of hospital stay; degree of complication, degree of infection, degree of drug abuse directly related to the shortage of registered nurses (RNs).1 The result of this study shows that RNs who are willing to work but whose work performance is of a low quality is directly related to the turnover rate. The turnover rate is lower for registered nurses with a high level of social interaction. A study was undertaken at a private hospital in Bangkok in Thailand in 2007, to determine the factors involved in the decision to remain in a nursing career.2 It was found that the intention to stay in nursing as a career in a private hospital was high. Other factors included: the nurses’ age; how attractive the job was; getting involved in project work and in solving problems; and flexibility in having a more positive approach to working. The study investigated RNs’ intention to work and how deeply they pay attention to their jobs. Younger RN’s intention to work was (28.1%); while older RNs’ had a lower intention to work (1.5%).
The hospital CEO, the nursing director and the human resources department are responsible for retaining nurses. At this moment, the shortage of RNs, the high turnover rate, and retirement rate was high in 2009.1 The International Council of Nurses estimated a need for registered nurses over the next 10 years (2010-2020). Thailand currently needs one RNs per 400 patients, and the shortage in Thailand at present is still 41,100.3 From 2006-2010 the number of full-time RNs in private hospitals increased from 11,000 to 15,000. This is an increase of 36.36% in 3 years.
At present, RNs move to private hospitals at the rate of 1,000 nurses per year. The Thai Nursing Council of Nurses estimates that over the next five years the private sector in Thailand will need 20,000 nurses. This is partly due to the fact that larger private hospitals are qualifying for JCI qualification, a require- ment of which is for RNs to meet patient safety standards as set out by international codes. Thai RNs fall short by 30% in these patient safety requirements.
As reported by Chiu YL, et al1 RNs seek a new job 1.68 times. For new job seekers, the range is from 30-34 years of age. From 2000-2009, private hospitals saw a turnover rate of 1,283 jobs (6.84%), whilst the number of RNs moving from government to private hospital was 771 (4.11%). There was a small number of Thai RNs going abroad for a new job (2.60%). After graduating from the nursing course, a small number of nurses quit (1.4%). This was either because the nurses did not want to continue their studies, or because they failed the certificate examination. The most important factors in deciding to work abroad were a lack of alternatives in Thailand, personal health problems, or better pay, long hours, or longtime part-time job. No nursing school acts as a feeder to private hospitals in Thailand; therefore nurses need to be recruited elsewhere. To do so, private hospitals offer a relatively high salary and offer funding for study, or provide nurses part-time jobs during their nursing studies. After graduation, 45-57.7%3 of nurses resign during their first year of working as they are unable to adapt to their new work environment.4 The private hospital still does not has enough nursing staff; paying a higher salary is not a solution. This article’s author works in the private sector and has been willing to grant study leave to RNs who then resign during their studies abroad. So, the author interviewed and questioned why nurses chose to work in private hospitals? What is most attractive about working in a first-piority private hospital?
The author aims to provide recommendations to the nursing director and the human resources division to design a strategy to solve the problem of a shortage of RNs; it is argued that the approach to just keep increasing RNs’ salary is not the correct way to solve the problem.
The author has studied many research articles. The research by Daouk-Öyry L, et al. is particularly relevant.5 This paper reviewed the frequency of the words and phrases “nurse turnover, absenteeism, sick leave” used over the past six years from January 2007 to January 2013. It selected journals with peer-reviewed, quantitative and qualitative surveys of nurse professionals, and excludes nurses students, other medical personnel, and nurse agencies.5 The total research looked at 7, 169 papers, and selected papers from 41 studies, from North America, South America, Europe, East Asia, Africa, and Australia. The study reveals the main problems of nurses’ absenteeism and leave, categorized on five levels as follows:
The minor factors are shown in Figure 1 below, with more detail provided in Tables 1 to 5. The information shows that salary is not the cause of RNs’ sick leave and resignations abroad
Figure 1 : The JOINT concept model for explaining and predicting absenteeism and turnover among nurses.5
Table 1: Factors of individual level.
Table 2: Factors of interpersonal level.
Table 3: Factors of job level.
Table 4: Factors of organization level.
Table 5: Factors of national level.
The information shows that salary is not the cause of RNs’ sick leave and their decision to resign when abroad. In Canada,8 RNs aged from young to old (from three generations) are given the opportunity to choose as they wish in an acute care hospital. Nurses were allowed to choose the most attractive factors to the least attractive (see Table 6) and list the reasons why nurses resign in Table 7. From Table 6, all three generations stay in the work place because they have a suitable job and the appropriate RNs take care of patients. On a third level, generation X and Baby Boomers (BB) both need support from the director. Generation Y shows that a high salary keeps them in post. Currently, there are three generations of nurses in the workforce. Generation Y nurses are the youngest generation, were born in 1980 and more recently. They have a collective, cohesive and collaborative approach to work, expect to use tecnology, are confident, desire immediate feedback and recognition, want to be coached and mentored, and strive to maintain a balance between work and family.6 Generation C nurses are born between 1965 and 1979. They are comfortable with change, technology, diversity, are self-directed and are motivated by favorable working conditions. Generation X nurses value career security over job security and organizational commitment.7
The oldest nurse generation is Baby Boomers (BB), who are born between 1946 and 1964. They are characterized as workaholics, concerned with work performance, promotions and titles. Although they are creative and risk takers, BB adjust slowly to new information and technology, are motivated by compensation and benefits as well as by workplace advancement.6
Table 7 shows absenteeism across all three generations, as well as the level of inadequacy of nurses unable to manage and take care of the patient. All generations welcome opportunity to improve. Thus this study investigated registered nurses across two generations with no connection to the work place. They are able to resign at any time. This study supports the idea that current RNs or nurses with the intention to resign, are not paying attention to the salary offered. The author presents nursing orientation classes for new nurses at Samitivej Hospital and asked them to write the reason why they left their previous hospital (Table 8).
Table 6: Frequency of incentives selected from most frequent to least frequent by generation.
Table 7: Frequency of dis-incentives selected from most frequent to least frequent, by generation.
Table 8: Reasons given by new RNs who had left previous hospitals between January 2013 and July 2014. (n = 238)
Table 9: The new RNs who selected Samitivej Hospital as a place to work between January 2013 and July 2014. (n = 238)
Table 8 shows that 29.41% of registered nurses resigned from their previous hospital because they had to serve too many patients, and therefore they were unable to provide adequate care and appropriately work with patients. The hospital working system caused 10.92% of RNs to leave. Being too often on call is also listed as a cause of leaving 10.50%, the same percentage applies to RNs who choose to study abroad. A significant factor in the choice to resign is an excessive workload and too many patients to attend to. The attractive reasons to apply for the new career appear in Table 9. One of the main factors determining the choice of a new employer is a good reputation and referral from a friend (accounting for 18.91%). A good system with good quality care accounts for 10.92% of nurses’ choice of employer. A high salary, therefore, is not the main cause for selecting a new employer.
The author reviewed the literature of nurse leave, over a period of five years both in Thailand and aboard. In Thailand, we found the topics of nurse commitment and engagement. Abroad, we frequently found articles on nurse turnover.8 The author recommends to hospital administrators, nurse executives and human resource division and the organization to find the problem of nurse turnover as a current reality and to create strategy goals for a nurse retention plan that extends beyond raising their salaries. The International Council of Nurse (ICN) suggests that healthcare providers’ retention be increased through financial and non-financial incentives. The ICN advocates a strategy such as increased remuneration, tuition funding, improvements to benefits, increased vacation, job flexibility, mentoring program, and recreational facilities in 2008.9,10 This will create five dimensions of a work environment for the workplace. The nurse adminis- trators could implement these measures in the workplace to retain nurses.11 The recommendations are:
I. Communication Dimension:
II. Leading Dimension:
III. Changing Dimension:
IV. Team-building Dimension:
V. Developing /Growing Dimension:
A high nurse turnover is a serious problem in our health care system. In order to retain nurses, the author recommends the hospital administrator, nurse executive and nurse leaders to consider multiple aspect of nurses’ work environment and find a way to maintain the right work environment for them. What constitutes a positive work environment and how can all nurse administrators institute all that is positive? Many successful work environments are characterized as follows:
