Nurse turnover and retention

The definitions of nurse turnover and retention are inconsistent in research and reviews; turnover and attrition are often used interchangeably, making comparisons difficult [9,12]. For the purposes of our analysis, we have operationally defined turnover as nurses voluntarily or involuntarily leaving their position [3,8,12]. We acknowledge that turnover occurs for voluntary reasons, such as personal or professional decisions to leave or change a position, but also for involuntary reasons, including program closures, retirements, or termination of employment [12]. Conversely, the focus of nurse retention is to prevent nurse turnover and is defined as the intent to continue employment in a nurse’s current role [10,13]. In many research articles, including ours, these concepts are studied together.

Retention and turnover of nurses is a complex human resource phenomenon influenced by multiple intersecting individual and contextual factors. An individual’s sense of job satisfaction has been identified as a key factor in nurse retention and turnover [1,14]. Studies have also suggested that personal (personality, burnout), job (perceived empowerment, career advancement, remuneration), and organizational characteristics (management style, cultures of stress) are associated with nurse turnover [1,14–17]. A recent meta-analysis identified that a lack of supportive and communicative leadership, strong workplace connections, and organizational commitment are the strongest predictors of voluntary turnover [17]. These findings are reinforced by similar conclusions from studies of nurse retention, and many systematic reviews concluded that supportive relationships with co-workers and leadership, pay parity, and quality workplace environments are the most effective strategies and contextual conditions favourable to retaining nurses [9,18–23].

Although there is ample literature related to the human resources issues of turnover and retention in acute and long-term care health settings, little is known about these issues within community-based public health departments, including those that offer nurse home visitation programs [10,15]. Given increased demand for such nurses in the current and planned shifts to population health and primary health care and the ongoing context of nursing shortages, retention and turnover issues will become increasingly challenging for leadership and public health managers [11]. Public health nurses in Canada are baccalaureate degree prepared and vital in promoting, protecting, and preserving health for individuals, families, communities, and populations [2,24,25]. Issues of social justice, client advocacy, and health equity are paramount in public health nursing and require a high level of nursing skill and knowledge [24]. Yet public health nursing is not typical of traditional point of care nursing, adding to recruitment difficulties among new nurse graduates who have had limited exposure to community care environments during their undergraduate nursing education programs [26,27]. Jones and Gates [13] have called for more research on turnover and retention from different areas of nursing, such as public health, to highlight and minimize the costs and benefits of turnover.

Of the few studies focused specifically on public health nursing, many are from an American perspective. Yeager and Wisniewski [11] conducted a cross-sectional study in the United States (US) to examine nurses’ decisions to work in public health. They found that nurses were more likely to remain in public health positions when their values aligned with the organization’s mission, they were able to be innovative in a flexible environment and had access to continuing education opportunities. Findings from two studies conducted by Leider and colleagues [28,29] suggest that American public health workers enjoyed their roles but did not feel adequately compensated. Despite the differences between Canadian and American health systems, wages were also found to be an issue for public health nurses in two Canadian studies [10,30]. If new graduates are to fill employment demands, agencies must address the loss of institutional knowledge as turnover occurs and identify a means to retain new public health practitioners [28].

Existing Canadian studies found that public health nurses were most satisfied when they provided direct client care, received positive client feedback, and when they perceived that their work made a difference [30,31]. Henderson, Betkus, and MacLeod [10] surveyed public health nurses in British Columbia and learned that intent to leave was associated with factors of remuneration, retirement, and family needs more than job satisfaction. However, this cohort included only nurses delivering services in rural and small towns; a sector of the workforce known to have unique experiences specific to their geographical context [32]. In 2005, a comprehensive examination of Canadian community-based nurses uncovered that all sectors of community nursing (i.e., home care, public health, and community care access centres) were concerned with inadequate staffing, client complexity, providing nursing care to vulnerable families with multiple health issues, and “difficult clients” [25, p. 184]. Issues specific to public health nurses affecting retention included constant change and uncertainty associated with programs being offered [25]. However, it is unknown whether these concerns reflect nurses’ experiences in the current climate of Canadian public health nursing.

NFP is a community health program for first-time pregnant and parenting adolescent girls and young women coping with socio-economic disadvantage [33]. Within the Canadian context, since 2008, the program has been delivered within multiple research contexts in order to adapt then evaluate the program in this context [34,35]. Baccalaureate-prepared public health nurses regularly visit families starting early in pregnancy (<28 weeks gestation) and with visits continuing until the child’s second birthday [33,36]. Canadian public health nurses have historically been trusted to care for mothers and their infants [37,38] and have a range of knowledge and skills to address the complex health and social needs of families experiencing multiple challenges [24,37]. NFP supports building strong therapeutic relationships between nurses and clients to improve pregnancy outcomes, reduce child maltreatment, improve child mental health and development, and improve mothers’ life circumstances [33,36]. In British Columbia, with support from the Ministry of Health, through the British Columbia Healthy Connections Project, regional health authorities are implementing and delivering NFP with fidelity to the program’s core model elements [36]—as part of the first randomized controlled trial evaluating NFP’s effectiveness in Canada [35].

NFP has been extensively evaluated in the US and has demonstrated effectiveness in positively influencing a significant number of reproductive, child and maternal health outcomes [39]. In addition to establishing the evidentiary foundations to support the efficacy of this program in improving health outcomes among young first-time mothers and their children, research has also been conducted to develop and evaluate innovations to improve program delivery. Significant attention has been paid to understanding and then addressing issues that influence client retention in the program [40,41]. Through this work, it has been established that client retention in the NFP program is optimized by ensuring one consistent nurse home visitor throughout the length of the program; as a consequence nurse turnover is strongly associated with client attrition or lack of engagement in the program [42–45]. Therefore, nurse retention is vital to NFP success.

Our understanding of the contextual and program factors that influence NFP nurse home visitor retention and turnover is limited to a few studies conducted in the US and Canada. Zeanah and colleagues [45] conducted focus groups to study NFP nurses’ provision of mental health care to clients in Louisiana, US. They noted that retaining experienced NFP nurses who were able to form and maintain client relationships was crucial to program impact. They suggested that a loss of nurses from the program may increase organizational costs related to the subsequent training of new staff. Zeanah et al. recommended finding opportunities for nurses to formally and informally process the emotional work of NFP to potentially help with nurse retention [45]. In another qualitative study, Lewis [46] found that nurses were drawn to the NFP program because of a desire to work with pregnant/parenting young women and their children who were experiencing socio-economic disadvantage—as well as having greater role autonomy, job flexibility, and opportunities to develop relationships with clients [45,46]. The emotional toll, high caseloads, insufficient resources, and inadequate salaries were some of the challenges associated with NFP nursing in these two studies from the US [45,46]. Similarly, in Canada, a qualitative secondary analysis of data from an NFP pilot study in Ontario, augmented by additional interviews with nurses, found that workload and workplace factors increased their stress [47]. However, nurses were highly satisfied by their ability to develop strong client relationships and observe their clients’ successes [47]. This study identified program structure (including a model of reflective supervision), a shift in nursing philosophy, and the support of NFP colleagues as factors supporting nurse retention. Understanding the emotional labour involved in delivering NFP, Dmytryshyn and colleagues [47] recognized that turnover can be associated with burnout, fatigue, and vicarious trauma and acknowledged the need for strategies to better support nurses.

Currently, we lack an in-depth understanding of the organizational, team, and individual factors that influence the capacity of the NFP program to recruit, retain, and reduce the turnover of public health nurses employed within this targeted nursing intervention. Identification and exploration of these factors is a first and essential step in the process of developing human resource strategies to ensure that implementing public health agencies maintain their capacity to successfully deliver NFP. This analysis draws from a sub-set of qualitative data from the larger mixed-methods process evaluation conducted in the context of an ongoing trial to examine effectiveness. The focus of this analysis is to identify and describe NFP public health nurses’ perceptions of contextual, organizational and individual factors that influence the workforce cycle. We also documented their recommendations for how NFP implementing agencies can focus their efforts on nurse recruitment, retention and limiting turnover.

Evaluation of the NFP in British Columbia, Canada

Evidence of NFP effectiveness in Canada will support national extension of this service and therefore the employment of more public health nurses. Understanding the factors influencing nurse recruitment, retention, and turnover in this program is vital to sustainable establishment of NFP in Canada. In Canada, NFP was adapted and piloted for acceptability and feasibility between 2008–2012 in Hamilton, Ontario [34]. While NFP has been extensively evaluated in the US and has demonstrated effectiveness in positively influencing a significant number of reproductive, child and maternal health outcomes [39], the effectiveness of this early intervention program is unknown within the context of Canada’s universal healthcare system. As such, the British Columbia Healthy Connections project (BCHCP) was launched in 2012 and comprises a randomized controlled trial (RCT) [35] evaluating NFP’s effectiveness in a sample of 739 families from four participating regional health authorities. The BCHCP also involves an adjunctive process evaluation to document how NFP is implemented and delivered by five unique health authorities [36]. This paper reports on findings drawn from data collected from public health nurses who participated in the process evaluation. The specific research questions addressed by this analysis are:

1. What factors influence decisions to apply to, remain in, and leave NFP roles for public health nurses who exited the NFP program?
2. What recommendations do public health nurses have related to developing and sustaining a high quality NFP public health nurse workforce?

Study context

Public health services in British Columbia are delivered through five regional health authorities and are guided by mandates from the provincial Ministry of Health [48,49]. Each of these health authorities participated in the process evaluation and assigned PHNs and supervisors to complete the NFP education program and deliver the program to girls and young women who met the RCT eligibility criteria [35,36].

Design

Qualitative data were drawn from the BCHCP mixed methods process evaluation [36]. An interpretive descriptive approach was employed to guide all methodological decisions related to data collection and analysis because of its utility and practicality in qualitative health research [50,51]. Interpretive description draws on the disciplinary knowledge of the researchers to generate research findings that are clinically relevant and meaningful to applied practice [50,52]. The core research team for this analysis included four registered nurses with significant expertise related to public health nursing and home visitation programs including NFP (KC, LM, CKL, SJ) and a research coordinator with a graduate degree in public health (NV). The tenets of interpretive description do not restrict researchers to ill-suited theoretical frameworks but encourage the use of methods or theories that support the development of practical and applicable research outcomes [50,53].

Participants

The entire population of public health nurses delivering NFP in British Columbia were invited to participate in the process evaluation. Study eligibility criteria included: 1) completed or completing the NFP education; 2) delivering the NFP intervention to participants in the BCHCP; and 3) English-speaking [36]. From this population of nurses, the sub-sample for this analysis consists of public health nurses who subsequently left their NFP positions during the period of February 2015-May 2018. Changes in a nurse’s status was communicated by the NFP supervisor to the research coordinator for the BCHCP process evaluation, who then contacted and invited the nurse to participate in an exit interview prior to their last day in the role.

Data collection

The purpose of the exit interview was to explore nurses’ experiences and perceptions of their position in the NFP program, including motivation for applying to NFP and reasons for leaving, as well as to gather their recommendations for strategies to promote nurse retention within the program. Participants were interviewed via telephone at a private space in their workplace by the research coordinator. Telephone interviews can create challenges in qualitative research, particularly through the loss of nonverbal cues (e.g. anxious behaviours), inability to contextualize data (e.g. environment or participant characteristics), and difficulties building rapport [54]. To mitigate these potential risks, two authors (NV, SJ) visited work sites and had previously interviewed study participants, thus developing interviewer-participant relationships. Despite potential limitations, some research suggests that participants may have enhanced comfort via phone [54]. In addition, telephone interviews were cost-effective and convenient to rapidly schedule for participants who were leaving their positions. The interview guide was developed and edited by members of the BCHCP Process Evaluation team, which included an International NFP Consultant who provided content expertise. The guides were reviewed regularly for any potential changes (see S1 File). Interviews ranged in length from 33 to 85 minutes, were digitally recorded, and transcribed verbatim with all identifying information removed. Participants completed a short demographic form at the time of the interview.

Analysis

Using the principles of interpretive description [50], initial analyses were conducted by two members of the research team (NV, LM) which included multiple readings of the transcripts and discussions between the researchers to make meaning of the data. The coding process began inductively through a process of open coding and categorizing. A codebook was developed and used to compare coding decisions and facilitate dialogue about emerging patterns. Individual codes were then collapsed into higher level categories to identify the main themes across all interviews. Each transcript was then revisited and narratives of experiences relating to recruitment, retention and attrition were extracted. Other analytical strategies used to bring meaning and abstraction to the data included journaling, building matrices, and diagramming.

Key narratives and quotations were extracted from the transcribed interviews and reviewed by all authors for consistency and consensus in analytical meaning. All members of the research team have significant experience in qualitative research and were involved in determining relationships and patterns in the data used to conceptualize the findings in a way that is meaningful for public health nurses and illuminates the factors associated with NFP nurse turnover, recruitment, and retention issues. Findings were substantiated through the thoughtful clinician test, which included a variety of public health nurses and other individuals familiar with NFP reviewing outcomes and recommendations for clinical relevance [50].

Ethics

The BCHCP mixed methods process evaluation received research ethics board approvals from ten institutions: the five participating health authorities, four universities where BCHCP researchers are affiliated, and the Public Health Agency of Canada. All study participants provided written and verbal consent prior to the interview and were informed that their participation in the study was voluntary. Public health nurses did not receive compensation for their participation in the study and completed the interview during assigned work hours.

Recruitment: Joining the NFP team

Participants emphasized that the opportunity to deliver an “evidence-based program” and potentially have a long-term impact on families’ lives motivated them to join the NFP team. Throughout the interviews, nurses referred to NFP as an “evidence-based program,” even though the effectiveness of the program in British Columbia has not yet been established. An experienced, end-of-career nurse described what motivated her in this role,

I really felt like I wanted to do something in my career that I felt would really be able to make a difference and I felt a real connection with just core values and then the NFP client-centered principles, and just the social impact that NFP had not only for the client's family but even then through generations.

This perception of NFP being a program that “makes a difference” for families is underpinned in the NFP core education where NFP nurses in British Columbia are introduced to the positive outcomes measured in the US trials. Nurses expressed fulfillment in working in the area of maternal-child health and with high-priority populations, such as adolescent girls and young women experiencing complex, chronic health and social issues. A nurse explained the connection she had to the clientele in NFP as a draw to this type of work,

I love young moms and the connection I was making with some of the vulnerable ones … Knowing that that was basically my clientele was a huge draw for me. Providing evidence-based nursing care to young mothers was a motivating factor for nurses who applied to work in NFP.

Previous experience working in public health parenting programs without adequate time, clear guidelines, and resources to address complex client needs piqued nurses’ interest to apply to work in the NFP program. An experienced public health nurse shared her discontentment with prior practices,

One [reason for applying to NFP] was maybe the dissatisfaction of my ability to work with vulnerable populations in general public health. I just found that it was getting more challenging to find the time to be available to the families that needed us most because we were spread so thin with other duties. And also, there was no template for which to work with these families, so everybody did their own thing and I just felt that there was a better way but just didn't know what that better way was.

In contrast to having limited guidelines to structure their home visiting practices in general provincial home visiting programs, some nurses expressed frustration about previous experiences that did not allow for them to consistently apply their nursing skills, judgement, or work at their full scope of practice. The lack of autonomy within their previous nursing practice and its increase in scripted responses and “checklist nursing” was described in this quotation:

I had done the other jobs in public health for a long time and it was getting more narrow and narrow all the time. We were told what to do and when to do it. A lot of it was like phones and scripts. So, it wasn't a very interesting job.

Participants hoped NFP would provide them with the opportunity to complete a robust program of nurse education, improve their knowledge and skills, and have access to visit-to-visit guidelines, tools, and resources to integrate into home visits.

Nurses found the potential to become home visiting experts and experience a sense of personal and professional fulfillment in providing a program informed by theory, based in evidence, and guided by focused client-centred principles appealing. Furthermore, they valued the education and support offered by the NFP program model. Participants, even those with significant maternal-child expertise, viewed NFP as an opportunity to increase their skill set working with high priority populations, “I was very interested in the program because it was an opportunity to learn new skills and to become a bit of an expert in this area.” Nurses appreciated the advanced education they received. Even more significant, nurses highly valued that the program model allowed for, even encouraged and provided support, time, and flexibility, for nurses to do whatever was required to establish, build and maintain a strong, consistent therapeutic relationship with the client. Nurses new to public health practice were also drawn to NFP for similar reasons:

There's a lot of support and backing from supervisors and management to get education to broaden ourselves, and also to do self-care. You don't see any of those things in the hospital really. So that was what I was lacking and what I needed and so it totally fit the need for me in NFP.

Nurses exiting the program provided insights into recruitment strategies and stressed the importance of job fit. They perceived that the personal qualities necessary to be successful in the NFP role included being flexible with how they implemented program elements and exhibiting openness and self-awareness. The necessity of job fit was explained:

If [a nurse] doesn’t fundamentally have the right attitude—if they're not open, if they're not able to roll with the punches, if they're not able to really critically look at themselves, their boundaries, their reaction to things, if they don't have that insight or aren't willing to develop it, they won't get, or last in, the program.

Additionally, there was a set of past professional nursing experiences that participants identified as critical considerations when NFP teams or nurse supervisors were advertising and recruiting for new nurses to join the team, including: 1) practice with populations experiencing adversity or marginalization; 2) confidence and competence in home visiting; 3) demonstrated abilities to establish professional boundaries with clients; 4) understanding of system level facilitators and barriers to meeting multiple client health and social needs; and 5) the ability to frame and deliver care and services from a strengths-based, rather than a deficit-focused, approach.

Retention: Developing relationships

The nurses were all asked to reflect on their time delivering NFP to pregnant/parenting girls and young women and their experiences working with other NFP team members, and then to identify the key factors that they perceived, to influence nurses in general, to want to remain working in the program. There was broad consensus that the two primary reasons public health nurses are motivated to continue to work in this program are the opportunities to develop genuine therapeutic relationships with families as well as to work at their full scope of nursing practice. As one nurse concluded: “I loved the fact that it was a long-term relationship that you’d be building and that there were so many educational opportunities that came with NFP.” Within these two conditions, nurses expressed a deep commitment to making a difference in the lives of their clients and were encouraged by the opportunity to have a greater impact through their work in the NFP program.

Nurses identified that the nature and depth of the nurse-client relationship established within the context of this program contributed to their overall job satisfaction. NFP nurses valued building trusting relationships with clients and recognized the importance of establishing foundations for a therapeutic relationship: “I'd say the relationships and getting close to people that are usually very guarded and don't trust a lot of people. That they trust you and then they work with you.” In addition to relationship building, nurses were highly satisfied when they were able to witness positive client outcomes: “When you have success with your clients, it’s brilliant… When you have those moments where your clients do something amazing and maybe I had a part in that. Look at this—I’ve made a difference!” Observing mothers becoming more confident in their parenting skills, infants meeting their developmental milestones, and families breaking inter-generational cycles of poverty or trauma were valued by nurses. These factors were identified by nurses as retention factors (for the time they remained in the program).

Participants also pointed out the importance of contextualizing the concept of success in the NFP program. One nurse shared how NFP changed her nursing practice: “It’s liberating as a nurse to be able to do that [strength-based work] because [in comparison to other programs] … I always felt the emphasis as a nurse [was] you're always looking for problems.” At the individual client level, participants reported successes including positive parent/child attachments, leaving abusive partners/negative influences/toxic relationships, quitting or reducing their use of substances (i.e. alcohol, tobacco), attending/completing school, acquiring employment, and receiving mental health support. For one public health nurse, the connection that she had to her client and the ability to focus on, and celebrate, her strengths were evident:

Just watching my girls succeed and it looked different for each one of them. I mean one of my girls, the baby was apprehended multiple times and I think permanently after the [NFP] program, but her baby was born with an intact brain and that's something she [the client] wasn't given. She avoided drugs and alcohol throughout her entire pregnancy. And her baby got a normal brain, and this is a mom that was born with FAS [fetal alcohol syndrome]. So even though she didn't successfully parent maybe in the way we look at, I saw her breaking the cycle and it was so neat to see those little changes and how that will impact not only her daughter but her daughter's children too.

The repetition of the term “my girls” in this participant narrative reflects the commitment and connection that the nurse felt towards her clients. Despite a child apprehension, the nurse was able to identify client strengths that she attributed to NFP exposure. Client success in NFP was not an all or nothing binary outcome. Because NFP is client-focused and strength-based, public health nurses could celebrate all successes.

Positive working relationships with the NFP team and supervisor were generally experienced as supportive and encouraged participants to remain in their position. Required weekly reflective supervision was consistently mentioned as a benefit to being in NFP: “Some of the things that are very helpful to retaining nurses, I think, are supportive supervision and regular reflective [supervision].” Engagement in reflective supervision provided dedicated time to critically reflect on situations and receive essential support from supervisors to advance nursing practice. One nurse shared why reflective supervision and a supportive environment was so important: “NFP is a program where, as the practitioner, you need a ton of support because it's heavy work.” The notion of team cohesion and positive working relationships as a means to deal with the challenging work of NFP was echoed: “I think the team meetings and the reflective practice are huge for retention and, well, decreasing burnout. But also, for growth as well, the case conferences that we do are really engaging, and I actually miss them.” Regularly reflecting, discussing, and debriefing with supportive colleagues and an assigned NFP supervisor who understand the nature and stresses of the program allowed nurses to feel connected and supported in their work.

Retention: Developing new skills

Participants recognized that professional development, such as the completion of NFP core education and the availability of ongoing learning opportunities, supported them to advance their professional nursing knowledge and skills. Nurses attributed their clinical successes to the intensive educational opportunities provided and suggested that it may be a factor for ongoing retention of NFP nurses: “I really enjoyed the ongoing learning and education that was part of the NFP; that was a real retention piece for me.” Opportunities to gain and apply knowledge were found to enhance professional growth for public health nurses: “Using that research base and developing knowledge and skills more intensely in a way of applying theory and research … to develop as a professional.” Being in a role that supported professional growth and development was important to nurses.

With advanced knowledge and in a supportive environment, nurses were able to work at their full scope of nursing practice. This milieu allowed for regular, in-depth nursing assessment, planning, intervention, and evaluation: “I felt like I was using all my nursing muscles instead of just a few of them.” The ability to learn new assessment techniques used in NFP and apply them in their public health nursing practice was professionally stimulating. Another nurse reflected on her time in NFP: “It's been a really interesting role that I will definitely take a lot from.” Many nurses noted that NFP was the most challenging nursing position they had experienced: “[During training] I was like, ‘oh it can't be that hard’. It can't be any harder than what I've already had to deal with as a nurse. And, no … I've lived that.” Providing complex nursing care to NFP clients using an array of new resources, skills, and knowledge was meaningful to nurses.

Turnover: Deciding to leave

Participants identified a variety of voluntary and involuntary/external factors (Table 3) that contributed to their decision to leave the NFP program. Contributing factors are presented and described in this section.

Download:

• PPT
  PowerPoint slide
• PNG
  larger image
• TIFF
  original image

Table 3. Circumstances that contributed to PHNs leaving an NFP position.

https://doi.org/10.1371/journal.pone.0237028.t003