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Calls to regain some control

Nurses are leaving rural hospitals in alarming numbers as employers stray from core values of the profession, writes Susan Bragg.

Worldwide, nursing is facing a significant challenge in recruiting people into the profession and then retaining them in the workforce. This is especially true for Australian rural areas that are experiencing one of the greatest nursing shortages since settlement.

As a registered nurse who had resigned from a rural hospital, I became increasingly alarmed at how many nurses were leaving these hospitals and I became concerned about the efficacy of current retention strategies. It appeared that we could recruit nurses, but not retain them; an exercise that I saw as fruitless.

In order to understand the reasons why registered nurses resign from NSW rural hospitals a qualitative grounded theory study was conducted; this would allow for a substantive theory of rural nurse resignations. Twelve registered nurses who had resigned from a rural hospital were interviewed in semi-structured face-to-face interviews.

The study found that nurses resigned because their values and the hospitals’ values were not aligned, resulting in a conflict of values. Nurses held the value of providing a high standard of patient care but found it increasingly difficult to carry this out. At some point in the nurses’ employment there was a sharing of values between nurse and hospital; a time of job satisfaction for the nurses who found their work immensely satisfying.

However, the study identified certain events that caused a decrease in value alignment between nurses and hospitals. These events included restructuring and centralising of health services; out-dated and inflexible patient care systems; cumbersome hierarchies; a negative management culture; bullying; an attitude that nurses are expendable; different priorities; inadequate resources and, insufficient and inexperienced staff.

Unless nurses’ values and hospitals’ values are in alignment, nurses will continue to resign. Effective retention strategies must address contributors to the decrease in value alignment, give nurses back control of nursing, and create an environment that is patient focused and conducive to nursing.

Hospitals need to have clear ways to articulate and imbue the organisations’ values and be explicit in how these values accommodate nurses’ values. Managers who provide leadership at the ward level need to ensure that the organisations’ values (both explicit and implicit) are incorporated into the culture of the ward. The strongest recruitment strategy that a hospital can employ is public perception and evidence of strong nurse retention within that hospital.

The critical underpinning strategy to enhance nurse retention lies in the sharing of values between nurse and hospital. Nurses are more likely to remain in nursing if they and their employer share similar values. Nurses wish to provide patient care based on nursing assessments and not budgetary restrictions. Nurses become frustrated when they do not have access to adequate resources for patient care such as food, adequate linen, dressings, beds, staffing, etc. They need to feel they have control over these matters so that they can provide appropriate patient care in accordance with responsible stewardship of financial resources.

Nurses expressed concern about lack of consultation between themselves and managers who make decisions that impact on nurses’ work conditions, particularly in relation to inflexible and out-dated patient care systems. Nurses also seek intrinsic rewards in their work such as being thanked by managers, having a sense of pride in their work, and being able to provide a standard of nursing care that they are happy with. Nurses seek this rather than extrinsic rewards of money. Rewarding senior staff, both nursing and non-nursing, for cost cutting and “coming in under” budget should be discouraged. Rather, rewards should be based on patient and staff satisfaction feedback.

The study also identified two interesting findings in relation to rural nurse resignations. First, there is a “window period”; a period of time after the nurse resigned and prior to the last day of employment. In this timeframe neither the nurse nor the hospital engaged with each other to try and resolve the problems. Nurses acknowledged that if they had had some avenue to address the problems that led to their resignation and nurse managers were more approachable about addressing these problems that were causing them to resign, then they may have considered staying.

This window period may be a critical time for addressing the reasons why nurses resign - before they walk out of the door. Second, there is a lack of options for nurses to continue to work in nursing once they have resigned from NSW rural locations. Smaller rural towns may have only one hospital and if a nurse resigns from this hospital they inadvertently leave the profession of nursing.

It is clear that we need to change our current way of thinking in order to implement effective retention strategies and it is also vital that we start collecting data at nurse exit interviews as to why they are resigning; only one nurse I interviewed was actually offered an exit interview.

Implementing policy and procedures for nurse exit interviews or surveys and ensuring that data collected from these interviews is analysed may drive more effective and evidence-based retention strategies; if possible have the exit interview performed by a third party. The employment of Nurse Retention Officers within Area Health Services to perform the data analysis of these nurse exit interviews may also assist in driving retention strategies.

The nursing shortage in rural Australia is expensive to both hospitals and communities and also impacts on the delivery of a high standard of patient care. As more rural nurses leave the workforce, there is increased pressure on those who remain; this is not sustainable.

The issue of nurse retention will always be complex and multifaceted and nurses will continue to move to other jobs for various reasons – natural attrition of the nursing workforce is normal. What remains clear, however, is that nurse turnover in many cases is avoidable and for the current rural nursing workforce to be viable and strong, evidence-based retention strategies must be implemented that allow nurses to carry out a high standard of care that aligns with their personal values and concurrently promotes a supportive work environment that is conducive to nursing.

Dr Susan Bragg recently completed her PhD at the school of nursing, midwifery and indigenous health at Charles Sturt University.

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