Factors affecting nurse turnover in Iran: A qualitative study.

Introduction

Iran is facing nursing shortage (1). The highest rate of nurse turnover has been found among nurses with three years of work experience or less, so there is a need to focus on employing new nurses (2). Employee turnover is costly, as is coordinating the employment and training of new nurses (3). Nursing shortage poses a serious problem, as nurses are the main source of patient care and play an essential role in the provision of high-quality care and patients’ health promotion (3,4). This further highlights the importance of nursing staff retention.

Nursing shortage results in low motivation among nurses, frustration, fatigue, excessive work pressure, task interference, excessive and compulsory overtime work, stress during shifts, and a subsequent turnover (5,6). Health service organizations incur high human resources and financial costs due to excessive working hours; and these are associated with sick leave, absenteeism, fatigue, and reduced productivity (7).

Various factors including organizational, social and cultural aspects influence turnover. A deep and comprehensive understanding of factors that affect turnover in organizational and in certain socio-cultural contexts in addition to identifying the existing barriers and problem-solving strategies through a qualitative study could contribute to nursing staff retention strategies. Thus, this study aimed to identify and describe factors affecting nurse turnover.

This qualitative study employed a content analysis approach. The participants included 20 nurses working in educational general hospitals and 10 nurses who had resigned. Purposive sampling was used to identify participants who had resigned from the hospitals through nursing offices. Data were collected through field notes, face-to-face and semi-structured interviews. Interview questions included but not limited to the following questions: “Why did you leave the nursing profession?”; “Why do you intend to resign?” We asked probing questions (can you explain further?) based on the participants’ answers. Data were analyzed using conventional content analysis based on Graneheim and Lundman’s approach (8). Of the participants, 78% and 65% were female and married, respectively. The mean age and work experience of the nurses working in hospitals were 33.7 ± 5.8 and 9.3 ± 3.8 years, respectively. Of these participants, 55.2% were contractual employees, and 75.9% and 62.1% were female and married, respectively.

The theme of factors affecting nurse turnover included policies of the Ministry of Health. This theme comprises of two categories including the Health Ministry’s policies on staffing and policies that promote customer satisfaction.

1. Staffing Policies

The Iranian Health Ministry policies aimed to eradicate staff shortages and support compulsory employment of nursing graduates for a specific period in clinical centers. However, these expectations are inconsistent with the graduates’ previously acquired abilities. This is obviously due to failure in the education system to address the gap between nursing theory and practice, which negatively affects new graduates’ intentions to continue practicing nursing. Evidently, new graduates feel frustrated when disparaged by their colleagues for mistakes due to their questionable clinical incompetency.

A morning shift nurse with many years of service stated, “… when a new graduate comes to our ward, we experience many problems at the beginning because of their inefficiency in practical work, which is due to the shortcomings of their internships.”

2. Policies for Promoting Customer Satisfaction

The Iranian Health Ministry’s policies for the promotion of external and internal customers’ satisfaction are less than a decade old. These policies are aimed at enhancing social justice and service quality, and addressing issues such as the productivity system, policy-making for the admission of patients to the emergency ward, and implementing organizational excellence models.

2.1. The Productivity System

Although most participants believed that the productivity system is a Ministerial policy that addresses staff shortages and unequal salary scales for hospital medical teams, the system’s implementation is partial and non-standard. According to the participants, a significant challenge of this policy is the dissatisfaction of nurses with long years of service. A nurse with 17 years of service said, “Since the implementation of the productivity system, my salary as a senior has been less than that of a junior because the system favors those employees working on night shifts and holidays. I worked night shifts throughout my service so I could be comfortable after long service and decrease physical agility, but now I can no longer work night shifts to benefit from the productivity system.”

2.2. Policy for Admission of Patients to the Emergency Ward

The Health Ministry passed a policy on the admission of all injured patients to the emergency ward. Participants believed that authorities failed to consider appropriate contexts for implementing this policy. Unassessed programs related to this policy have resulted in unfavorable outcomes for patients, including unsuitable care and a higher workload for the nurses. One nurse working in the emergency ward said, “When the emergency ward is crowded, patients are transferred to any ward that has vacant beds regardless of their diagnosis. Sometimes, we have to transfer a patient with an orthopedic condition to the internal medicine ward.”

2.3. Challenges related to Implementation of Excellence Models

The participants cited the application of organizational excellence models including clinical governance and accreditation as an important factor in nurse turnover. They believed that nursing personnel and managers struggle with problems such as ambiguous concepts, incomprehensible definitions, and partial and inefficient implementation of these models. Failure of the management and other stakeholders to concentrate on accountability against service recipients and failure to ensure quality of service, instead of being accountable against the authorities, may negatively affect the efficient implementation of the policy. This is demonstrated by insufficient or lack of supervision of the personnel by the managers, which may be due to immersion in the time-consuming, administrative duties. A nurse with 15 years of service said, “Since the addition of accreditation to the head nurses’ tasks, they cannot supervise the personnel. They are required to distribute a new form around the ward daily and work on it; and this means filling out forms after forms and doing instructions after instructions. I think the quality of our work has decreased since such tasks commenced.”

The participants stated that it is a challenge to implement the Health Ministry’s policies to address staff shortages, and at the same time increase the quality of care, job satisfaction, and patient satisfaction. Almost all of those involved in clinical governance at different organizational levels typically focus on appeasing the authorities by requiring them to prepare documents, task reports, and checklists, attending meetings, seminars, and various commemorations instead of promoting the quality of care. This is concerning for those interested in the development of the health system. Inefficient implementation of Ministerial plans, including failure to prepare for such hurried and non-reviewed implementation are among the causes of work overload, burnout, and consequently, turnover (9).

According to the participants, the professional standards and physical, mental, and social abilities of the nurses are not considered when they are recruited to enter the nursing field. Moreover, new recruits are exposed to high workloads, consecutive, non-standard shifts, mental and physical problems, and excessive fatigue, resulting in burnout and turnover. Moreover, according to the nurses in our study, managers employ newly graduated nurses to overcome nursing shortages. Furthermore, managers are required to assign nurses to different wards regardless of their specialty, interests, mental and physical power, level of experience and skills, and patients’ care needs. Results from previous studies revealed that enhancing nurses’ professional experiences in the workplace, clinical, and caring competencies resulted in reduced job change among nurses (10).

The findings of this study can be used by the Ministry of Health and Medical Education and by the nursing managers to deal with the important issue of nurse turnover. Organizational excellence models and health care quality improvement some policies are faced with many challenges in developing countries like Iran, and this calls for further researches to help strengthen these models and policies.

Acknowledgments

Authors would like to acknowledge all those who cooperated with us in this research project. In addition, our thanks go to Ministry of Health and Medical Education for their coordination and financial support.