Leaving Nursing:

Predictors of nursing drop-out and switching between sectors*

Audrey Laporte, Ruth Croxford, Andrea Baumann, Linda O’Brien–Pallas, Raisa Deber

* This project has benefited from funding support provided by CIHR (Grant # 64240, “Where do nurses work? Work setting and work choice”) and the From Medicare To Home and Community (M-THAC) Research Unit

Data SourceTo practice in Ontario, nurses must

register annually with the College of Nurses of Ontario (CNO)

CNO data for 1993-2002 were merged on a unique registration number.

Observed career paths of 191,916 nurses registered in Ontario.

DemographicsWorking as a nurse in Ontario

1993 (N=106,000)

2002(N=100,000)

Age 34, 51, 48 37, 45, 52RN (vs. RPN) 77% 77%Female 97% 96%Add’l Edu. 9% 20%Single Empl. 88% 84%Full-time 54% 56%HospitalLong-Term CareCommunityOther

66%11% 9%14%

60%12%13%15%

Proportion of Nurses by Sector 1997

0102030405060708090

Hospital LTC Community Other

RNRPNAll

A word about wages….

No wage info in the registration data base but unionization concentrated in sectors e.g. virtually all hospital and most long-term care nurses are unionized and are paid on an 8-step grid corresponding to year of experience Most home care nurses are not unionized

RPNs paid on a separate grid The ONA is the trade union representing

nurses in province-wide collective bargaining

Analysis 1 Dropping Out of the PoolThe pool of nurses can be variously defined as

including those who currently: Work as nurses in Ontario (‘actives’) Are registered but not working as nurses (‘eligibles’) Are registered but work outside Ontario Are NOT registered & are under 65 yrs of age

We focus here on predictors for the retention of those working in nursing in Ontario since policy change can more readily influence these workers in the short to medium term (i.e. active pool)

Included: 145,864 nurses who were either already nursing in Ontario in 1993 or registered for the first time in 1993-2002 and found nursing work in Ontario.

Excluded: Registered in Ontario prior to 1993 but did not work as a nurse in

1993/1994. New registrants who did not work as a nurse during the first two years.

Dropping out: a period of two consecutive years during which the nurse did not work as a nurse in Ontario.

Proportional hazard survival analysis to identify predictors of “time to drop out”.

Cumulative "Drop Out" Rate

00.050.1

0.150.2

0.250.3

0.350.4

0.45

0 5 10 15Time (years)

RN

RPN

Determinants of ‘Drop Out’ Training/Employer factors

Variable Hazard Ratio Notes

RPN 1.5

Additional Education

1.1 9% of the workforce in 1993, 20% in 2002

Multiple Employer& Full Time WorkSingle Employer &Part-time Work

0.47

2.1

3 – 6% of nurses

38% of both RNs and RPNs

Region: Southwest & Eastern

1.1

Baseline: RN with no additional education, only one employer, working full-time, living in the Central/Toronto region, aged 40-44 yrs, working in a Hospital

Determinants of ‘Drop Out’ Age at the start of observation

Variable Hazard Ratio55 Yrs over 7.450-54 Yrs 2.645-49 Yrs 1.340-44 Yrs baseline30-34 Yrs 1.2< 30 Yrs 1.4Males 1.4Baseline: RN with no additional education, only one employer, working full-time, living in the Central/Toronto region, aged 40-44 yrs, working in a Hospital

Determinants of ‘Drop Out’ Age at the start of observation

Variable Hazard RatioLTC 1.2Community 1.3Other Sector 1.7Hospital baseline

Baseline: RN with no additional education, only one employer, working full-time, living in the Central/Toronto region, aged 40-44 yrs, working in a Hospital

Interactions

Sector/Nurse Interaction

0

0.5

1

1.5

2

2.5

3

3.5

hospital LTC community other

Haz

ard

Rat

io

RN

RPN

Analysis 2“Stickiness”: Do nurses who remain stay in the same sector?

The two most recent years (2001 and 2002) were examined. Only nurses who worked in both years (N = 95,000) were included.

11.6% changed sectors. Hospital sector: 6% switched. Long-term care sector: 12% switched. Community sector: 15% switched. ‘Other’ sector: 23% switched. RNs (11%) versus RPNs (15%). Single employer (9%) versus multiple employers (22%).

Who Switches? Variable Odds Ratio

RPN RN with degreeRN with certificate (ref.)

1.4 (1.3, 1.5)0.89 (0.84, 0.95)1.0

Multiple Employers 2.1 (2.0, 2.2)

Part-time Employment 1.3 (1.2, 1.3)

Sector (ref. hospital) LTC Community Other

1.5 (1.4, 1.7)2.2 (2.1, 2.4)1.5 (1.4, 1.6)

Yrs Exper. in this job 0.98 (0.97, 0.98)

Variable Odds RatioAge in 2001 < 25 25 – 29 30 – 34 35 – 39 40 – 44 (reference) 45 – 49 50 – 55 55 – 59 60+

1.5 (1.3, 1.7)1.3 (1.1, 1.4)1.1 (1.0, 1.2)1.0 (0.95, 1.10)1.00.96 (0.89, 1.03)0.92 (0.85, 1.00)0.82 (0.75, 0.90)0.83 (0.72, 0.96)

Male 1.5 (1.4, 1.6)

Who switches?

Odds of Changing Sectors

0

1

2

3

4

< 25 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60+

Odd

s R

atio

hospital

LTC

Who switches?

Sector/Nurse Interaction

0

1

2

3

4

5

6

hospital LTC community other

Odd

s R

atio

RN

RPN

Analysis 3: Where do They go When they SwitchMultinomial logit regression analysis was used

to examine where nurses went when they left a sector.

Young nurses are the most likely to change sectors (23% vs. 16% of those age >= 30), and much more likely to leave Ontario (1.6% vs. 0.3%).

RPNs are more likely to switch into the LTC setting than are nurses, and less likely to leave the LTC setting if they work there.

RNs who have a university degree are more likely to switch into the community sector, and much less likely to leave it if they are there.

Conclusions (1)

More likely to drop out: RPNs Males Younger nurses (20-29 yrs) even after allowing

for temporary absences. Older nurses, with more experience Part-timers Nurses in the Community and Long-Term Care

sectors Those who obtained additional education after

they started working

Conclusions(2)

Less likely to drop out: Those with multiple employers

(may reflect increased need for income (i.e. family bread-winner)

Conclusions-Switching

Nurses more likely to switch: Multiple employers Males Casual and Part-timers RPNs Outside the Hospital sector

Conclusions (2)-Switching

LTC: RPNs and those with longer job tenure less likely to

switch More educated and multiple employers more likely to

switch

Hospital & Community: RPN, casual/PT, multiple employers more likely to

switch More educated in community less likely to switch but

more likely to do so in hospital sector

Policy Implications RPNs are more likely to ‘drop-out’ and they are important to

the LTC sector, which is itself associated with higher risk of ‘drop out’.

The non-hospital sectors are affected disproportionately by nursing departures

Policies designed to curb the loss of nurses to the profession must be sector specific.

Higher departure rates among younger nurses suggest that shortages may be perpetuated into the future.

Factors that affect retention in the profession are not the same as those that determine retention in a sector.