Nurses' turnover: reviewing the evidence, heeding the results?


There is a clear sense that the world is changing; that nursing will have to respond, and that nurses themselves will have to adapt. Demographically driven change has been joined recently by economic change, as the world struggles with the impact of the global financial crisis and recession.

Healthcare demand continues to increase, but healthcare funding in many countries is restricted, or reducing; and the nursing workforce in much of the developed world is ageing. In a labour intensive sector, such as health care, staffing costs are under scrutiny. Nursing numbers in some countries are reducing (Buchan & Seccombe 2012). Nurses' job-seeking behaviour is changing, as they seek to hold on to jobs in challenging labour markets (Buchan & Seccombe 2011, Staiger et al. 2012) or respond to reductions in their pay, status and job prospects by leaving nursing, or their current country of practice (EFN 2012).

Nursing, as never before, needs good evidence to support sound arguments about the value of its contribution, to counter skill dilution, and a driving down of quality of care (Noyes 2012). One key aspect of this is to develop a better understanding of nurses' job satisfaction and turnover intentions. Health workforce stability can contribute to better care delivery (Buchan 2010), and health organizations incur significant nurse turnover costs (Bland-Jones 2004). Policy makers must have a firm grasp of what makes nurses want to nurse, even in challenging circumstances, and what will retain and motivate them.

A review of recent issues of JAN gives some helpful pointers. In the last 2 years, there have been a good range of articles published in JAN covering various aspects of nursing workforce. The few selected for this editorial are just some that have focused on job satisfaction and turnover.

A good starting point is the review by Flinkman et al. (2010) which emphasizes the richness and variety of research on nurses' intention to leave the profession, and the difficulties in generalizing the findings or deriving a single clear cut take-away message for policy makers. They identified 31 studies that met stringent inclusion criteria, and highlighted demographic, work-related and individual-related variables that influence nurses' intention to leave the profession. They also argued strongly for more in depth research that ‘give nurses opportunities to explain in their own words the reasons for their intentions to leave' (p. 1422).

JAN has helped meet that need by publishing a range of country-specific studies, using a range of methods, that examine aspects of nurses' job satisfaction and turnover. Simon et al. (2010) looked at the leaving intentions of more than 2000 nurses in Germany. Reflecting Finkman et al., (2010) they found that leaving intentions were strongly associated with personal and work/home factors. They recommended that retention initiatives had to address the ‘work- home interface’, and that future research in turnover had to use comprehensive definitions of turnover. Delobelle et al. (2010) looked at the relationships between demographic variables, job satisfaction and turnover intent among 143 primary care nurses in rural South Africa. The nurses were satisfied with work content and relationships with their co-workers but dissatisfied with pay and work conditions. Half were considering a move in 2 years, of which three in ten were thinking about moving abroad. The authors recommended that retention strategies had to consider financial rewards but also aspects of human resource management.

Many developed countries have an ageing nursing workforce, which is focusing policy attention on how to retain older workers. Shacklock and Brunetto (2011) remind us that, while the age profile may be shifting, there will continue to be the need to take account of the priorities of different age groups in the workforce. Their research in Australia highlights that these different ‘generations’ of nurses will have different perspectives on the world of work, and that this means that retention strategies need to be ‘tailored’ to meet different generational priorities.

In examining nurses' job satisfaction and intent to stay in four hospitals in Shanghai, China, Wang et al. (2011) concluded that there was scope to improve occupational commitment. Their recommendations covered a range of strategies covering salaries, workload organization, and personal and career development. A similar conclusion was reached by Brewer et al. (2011) in their panel sample of 1653 newly licensed nurses in US hospitals. They identified ‘multiple points of intervention’ for policy makers aiming to decrease turnover, and stressed that turnover problems were complex with no single solution. Carter and Tourangeau (2012) who looked at nurses’ intention to remain in nursing roles in a large national sample of 16,707 nurses in England echoed the findings of the other two studies in advocating for the necessary monetary and physical resources to enable nurses to perform effectively. They found that nurses who were engaged with their jobs reported lower intentions to leave, and that availability of developmental opportunities and ability to achieve good work-life balance were factors that influenced turnover intentions.

A brief editorial cannot do justice to the range of evidence that emerges from these articles, and others, that JAN has published recently. They remind us that much is known already about what makes the profession tick, but that the knowledge base is uneven, biased towards developed countries and acute care. It also highlights that part of the task is synthesizing what is known and disseminating it effectively into the policy arena. It is clear that in relation to the scale of the challenge, the available research remains limited and with inevitable constraints related to context and country specificity. At the risk of sounding like someone in search of a grant, this is one issue where there really is need for more research: for the sake of nurses' jobs, nursing careers, and effective use of health care resources in challenging times.