REASONS FOR TURNOVER AMONG THE NURSES WORKING AT BPKIHS

Mehta*1 RS, Karki*2 P, Paudel *3 BH, Chaudhary*4 R

B.P. Koirala Institute of Health Sciences Dharan, Sunsari, Nepal

Abstract:

Introduction: Conflict is a natural phenomenon and is inevitable in any organization. Conflict in nursing organizations leads to turnover of nurses. Conflict, however, can also be valuable to an organization since it promotes innovative and creative problem solving, clarifies issues, and allows underlying problems to rise to the surface. The Objectives of this study were to explore the factors influencing Job satisfaction among the nurses working at BPKIHS, to investigate the reasons which have influences nurses in their decision to leave BPKIHS and to suggest recommendations for a more satisfying working environment by aiding staff retention.

Methodology: It was hospital based cross sectional Analytical study, conducted among the nurses working at BPKIHS for more than six months at the time of study and those who have resigned from BPKIHS. Stratified simple random sampling method was used to select the nurses working in BPKIHS and purposive for the resigned nurses. Total 150 nurses were included in the study. Using pre-tested questionnaire the data was collected, fulfilling all the ethical considerations. The collected data was analyzed using SPSS-4 package.

Results: It was found that majority of nurses (68.7%) were less the 25 years, Unmarried (49.3%), have job experiences less than 5 years (54.7%), from sunsari (48%), and living in quarter of BPKIHS (86%). Career opportunity elsewhere, Chance for further education, Negative attitude of nursing leaders, In-adequate salary and poor promotion opportunity are the Major reasons of nurses to leave or resign from BPKIHS. Conclusion: To retain the nurses or decrease turnover there is need of increasing salary, Job security provisions, Immediate starting of BN programme, fair evaluation system and clear promotion policy. This study is useful for nursing leaders as well as BPKIHS authority to take corrective action in time to improve the situation and prevent the future consequences.

* 1 Mr. Ram Sharan Mehta,( Corresponding Author) Assistant professor, Medical-surgical nursing dept. College of Nursing, Email: ramsharanmehta@yahoo.com, * 2 Prof. Dr. Prahlad Karki , HoD, Dept. of Medicine and Hospital Director, *3 Dr. Bishnu Hari Paudel, Asso. Professor, Dept. of Physiology, *4 Mr. Ramanand Chaudhary, Master in Nursing, Paediatric Nursing dept. B.P. Koirala Institute of health sciences, Dharan, Sunsari, Nepal.

Introduction: Health care delivery system, both curative & preventive, heavily depends on nursing profession. The nurses are to pass on to a strong, socially relevant, vocationally satisfied profession for future generation of nurses and citizens 1. Twentieth century saw nursing as a profession, and a distinct discipline. Many nursing theories were propounded, research work was undertaken, standards were set by different nursing associations, and educational levels of nursing were streamlined, current issue and trends found their place in nursing and expanded roles of nursing practice paved the way towards new directions for nursing with increased autonomy 2. Job satisfaction is a critical issue for nurses and hospital administrators. However, nurses job satisfaction has not been measured adequately in most hospitals of Nepal. Since the onset of restructuring measures, despite numerous and conflicting comments from nurses and nursing managers about satisfaction and dissatisfaction with these measures. A shortage of nurses negatively affects the safety and effectiveness of services provided. Job–satisfaction varies intensively with staff turnover. The desire to care for people, a family history of professional health care work, and security in career choice are documented reasons for entering nursing. Reasons for leaving include: workload, unsafe work environment, and harassment 3. As per the annual report of BPKIHS, the number of nursing staff working in BPKIHS in 1993/1994 to 2003/2004 was 67, 94, 105, 116, 151, 224, 282, 257, 244, 327 and 415. The accurate record of resignation of nurse’s year wise from 1993 was not available but as per the mentioned record number of nurses (staff nurses and nursing officers) resigned for BPKIHS were: in BS 2056–1, 2057–17, 2058–52, 2059–68, 2060–35 and in 2061 BS 7. This evidence shows high turn over of nurses working at BPKIHS. Objectives: The Objectives of this study were to explore the factors influencing Job satisfaction among the nurses working at BPKIHS, to investigate the reasons which have influences nurses in their decision to leave BPKIHS and to suggest recommendations for a more satisfying working environment by aiding staff retention. Methodology: It was Hospital based cross sectional Analytical study design, conducted among the nurses working at BPKIHS and the nurses who resigned from BPKIHS. All the nurses working in BPKIHS for more than 6 months, at the time of study and who have resigned during the study period constitute the target population of the study. Total population of the study was 256. Sample was comprise of all the nurses working in BPKIHS who fulfill the set criteria and all the nurses who resigned during the study period and willing to participate in the study were included and 150 Nurses were included in the study. Nursing faculties and ANMs were not be included in the study. Nurses who give consent to participate were only included in the study. Stratified simple random sampling method was adopted to select the sample from the working nurses and purposive sampling technique were used for resigned nurses. Semi-structured Questionnaire (Job satisfaction and communication survey Questionnaire)

developed, tested and used by Bonnie W4, Kunaviktikul5 (Turn over of Professional Nurses tool), and Brannon D6 (Job satisfaction and Turn over tools) were used after modification to collect the data

The tool was given to nursing service administrators, hospital administrators, psychologist and nurse-researchers for content validity. Necessary modification was made after the feedback from the concerned experts. Pre-testing was done among 20 subjects and found practicable. Some modifications were also made after pre-test. Written permission was obtained from the concerned higher authority. Lists of nurses working in all the units/wards were prepared separately. By using stratified simple random sampling technique the specified numbers of Nurses were selected from each ward. Using purposive sampling technique all the nurses resigned during the study period was also included in the study. After taking verbal consent from them individually a questionnaire and blank self addressed envelope was given. They were requested to fill up the Questionnaire and put in envelope and seal it; and return to the Investigator. Individual responses were scored. A total score was then obtained for each factor on the questionnaire by adding the numerical responses on the Likert scale. Once all the data were collected then, focus group discussion was arranged. Focus groups i.e. one group for nursing officers, one group for senior staff nurse and four groups for staff nurses were arranged. In-depth discussion was made on focus group on various components of Job satisfaction and turnover. Feedback and suggestions were collected and analyzed. Verbal informed consent was obtained from each subject before giving her Questionnaire. The information given by subjects was kept confidential and used only for this study. Anonymity in the Questionnaire was maintained. Self-addressed envelope also facilitates confidentiality. The data collected was based on the opinion of the working nurses, hence it might not reflect true picture, but there is not feasibility of contacting each nurses, who left. Hence, we have to rely on data/opinions given by currently working nurses. Results:

Socio-demographic profile of the subjects: The majority of the nurses i.e. 68.7% were of less than 25 yrs of age; only 14% were of more than age 35 yrs. About half of the subjects were unmarried. Among the married only 52% was living with their husband. About half of the nurses had experiences of nursing for less than 5 yrs. and only 9.3% had experiences of more than 20 yrs. Majority of the nurses i.e. 86% were staying in the residence / Quarter provided by BPKIHS as this institute is residential institute having very good facility of quarter for employees. About half of the subjects were from sunsari district, as there is three municipalities i.e. Dharan, Ithari and Inruwa lie in this district. Motivating factors to work in BPKIHS: The main motivating factors to work in BPKIHS are Big institution or university (51.3%), Quarter facilities (48%), safe place (48%), chance of further education (32%), educational benefits (25.3%), Non-

transferable job (23.3), whereas only 9.4% only mentioned that pay scale is motivating factor. Only 48% subjects reported that they would stick to nursing profession in future. These findings clearly illustrate the reasons for turnover of nurses. Majority of the subjects (66%) mentioned that they joined nursing profession, as they are intrested to be nurse; where as 55.3% mentioned the reasons for joining nursing is easy access to job and 35% mentioned the parental force to join nursing. In contradictory to this only 48% reported that they want to stick to this profession. Job satisfaction among the nurses: Twenty-six items of job satisfactions were analyzed using four point likert scale. Very few percentages of subjects were fully satisfied with the components of job-satisfaction. Majority of the subjects were moderately satisfied or just satisfied with the available facilities. The percentage of not satisfied at all with various comments of job-satisfaction is also high. With pay scale none of the subjects were fully satisfied, 24.7% were moderately satisfied, 40% just satisfied and 35.3 were not satisfied at all. Which clearly shows the need of incensement of salary. The positive motivating factors to work in BPKIHS are, prestige of organization, work it self, responsibility, quarter facilities and achievements. The satisfaction with pay scale/salary, monetary benefits, recognition of good work done, promotion opportunity, general administration, nursing administration, job description and evaluation system is not good. More than half of the subjects (56.7%) mentioned that they want to serve in BPKIHS Less than 5 yrs only. About 15% reported that they want to serve more than 15 years; this picture clearly illustrates the higher incidences of nurses to leave BPKIHS. About 77% nurses were intrested to go abroad to serve, which clearly illustrate the scope of nursing in world and may create manpower crisis in future. Majority of the nurses (80%) were only just satisfied with nursing profession as carrier and 48% wants to stick to this profession in future, where as 66% nurses became nurse with their own intrest. This picture clearly illustrates the poor motivating job factors, which needs detailed exploration. Reasons influence nurses to leave BPKIHS: The Turnover of nurses at BPKIHS is very high. The major reasons influencing nurses to leave BPKIHS are: Career opportunity else where, further education opportunity, Attitude of nursing leaders, frequent night duty, attitude of medical team., stress at work place, pay scale / salary, poor promotion opportunity, and administrative problems. Suggestions to improve nurses’ retention at BPKIHS: At present the high turnover of nurses is a burning issues for nursing administration. It is crucial time to initiate the appropriate nursing action to take corrective action, to retain the nursing manpower at BPKIHS. The main action needed for initiations are: Increase the pay scale / salary, immediate starting the BN course at BPKIHS, investigate and eradicate partiality and favorism, fair evaluation system, starting continuous in-service education program in each specialty areas, routine clinical supervision system, strengthen inter and intra department communication, and increase the moral of the nurses.

Improved communication, feedback both positive and negative, increasing socializing amongst the unit members and the creation of a more relaxed working environment were suggestions proposed to overcome the turnover found by mathew8 in her study. Similar suggestions were reported by the nurses in this study to increase Job satisfaction and decrease turnover. The details of the results are mentioned in table-I to IV. Discussion: Nurses’ turnover is expensive. It affects the safety and effectiveness of service in hospital. Recruitment and retention of sufficient number of nurses to work is a major challenge for nursing administrators 8. A recent survey of nearly 1,000 nursing homes estimated the annual turnover among nurses is almost 1 in 5, or 20% according to American nurse’s association9. A study conducted by Irvine 16, reported that, a strong positive relationship was indicated between behavioral intentions and turnover; a strong negative relationship between job satisfaction and behavioral intentions, and a small negative relationship between job-satisfaction and turnover. Variables related to nursing job satisfaction, work content and work environment has a stronger relationship with job satisfaction than economic or individual difference variables. A study conducted by Davidson 18 among 736 hospital nurses reported that, important determinants of low satisfaction were poor instrumental communication within the organization and too great a workload. Intent to leave was predicted by the perception of little promotional opportunity, high routinization, low decision latitude and poor communication. Predictors of turnover were fewer years on the job expressed intend to leave, and not enough time to do the job well. A study conducted by Symes 19 among 183 new graduates reported that, 47% new graduates had unspecified personal stressors related to lack of confidence and discomfort, 35% with dying patients, 46.5% with personal finances, and 43% reported traumatic life events before the age of 16 and 50% after the age of 16. Mathews 8 found in her study that frequent night duty considered the highest scoring factors, influencing nurse’s decisions to leave hospital. Which is similar to this study. Psychological effects are immense, lack of participation in social activates leads to a feeling of Isolation, for some nurses a good self image is hard to maintain due to chronic fatigue, anxiety results from going to work in shift busy duty and feeling of neglect arise from inadequate time spent with family and friends mentioned by Mathews8 in her study, which are similar to this study. Similar findings were reported by Irvine16 and Davidson18 .

Implications: Nursing practice is based on mixture of research, anecdote, tradition, theory, and hunch. Job satisfaction is a key indicator of good working environment, employee retention and management of the institute. This study help to implement policies and practices to optimize staff satisfaction, staff retention, quality care provision and co-ordination. The study also gives the insight and feedback to nursing administrator and authority of BPKIHS to think the problem seriously and take corrective action. The study also helps supervisors to change their attitude so that quality patient care can be provided. This study emphasis the need of continuous in-service education in their respective specialty. The study explores the immediate need to start BN Nursing programme at the institute. Regular interactions between the supervisors and their subordinates are essential in fostering employee relationship that increases the likely hood of productivity of organizations. The effective communication is essential in any institute to eradicate the misconceptions and raise satisfaction. Finally, the result can be used for planning and implementing the remedial measures to improve nursing service at BPKIHS, and decrease the turnover rate of nurses. Recommendations:

1. This study can be conducted in similar setting hospitals like: TUTH, BPKMCH, Bir-hospital, Patan hospital, Manipal and others to compare the results.

2. This study can also be conducted at similar government hospitals to find the differences in results.

3. Periodically, conducting this type of study gives insight to take corrective action in time. Hence, this type of study must be repeated every 3-4 years.

4. This study can be conducted among nursing faculties and ANMs working at BPKIHS as well as other institutions.

5. Similar study can be conducted among doctors and other technicians and paramedics to compare the differences.

Problem Faced During The Study: Following problems were encountered during the study:

1. Few respondents were hesitated to give the answers of the questions. 2. It was found difficult to grade the satisfaction level and perception level because

different individual perceives it differently. 3. Measurement of individual differences found difficult to grade. 4. It was found difficult to grade the facilities available with the subjects and to

recall the past events. It is also difficult to measure quantitative form exactly. 5. Some problems were encountered for arranging the focus group discussion,

because of busy schedule of nurses and shift duty. Limitations of the study: The limitations of the study are as follows: Subjects: the staff nurses, senior staff nurses and nursing officer / sisters were only included in the study. The nursing faculties, senior nursing officers and ANMs were not included in the study. Period: The data collection period was from 1 August 2005 to 30 August 2005. Sample size: Only 150 nurses were involved in the study.

References:

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Table: - I

Distribution of subjects according to the various motivations Factors to work in BPKIHS

N=150

S. N. Item/Particular Percentage (%) 1. Motivating factors to work in BPKIHS (MR)

a. Pay scale 9.3 b. Quarter facilities 48.0 c. Safe – place 48.0 d. Non – transferable job 23.3 e. Big institution /university 51.3 f. Educational benefits 25.3 g. Chance for further education 32.0 h. Others 10.0

Table: -II

Reasons for choosing nursing profession (MR):

N=150 S. N. Item/Particular Percentage (%)

1. Reasons for choosing nursing profession (MR): a. For easy access to Job 55.3 b. Because my parents wanted me to join nursing 36.0 c. I was very interested to become a nurse 66.0 d. There is glamour in this profession 8.0 e. Due to financial problems 4.0 f. Thinking I would join other profession later 4.7 g. Due to peer pressure 4.0 I. Others. 8.0

Table – III

Reasons for turnover /resignation of nurses at BPKIHS

N=150

S. N. Reasons for turnover of nurses Percentage (%) 1. No Responses (N = 35) --------- 2. Responses (N = 115) 100

a. Carrier opportunity else where 60 b. For further education 55 c. Permanent in HMG 52 d. Poor cooperation & attitude of nursing leaders 48 e. Unfair evaluation 43 f. Poor promotion opportunity 42 g. Favorism and partiality from supervisors 41 h. Rules and regulations not transparent 35 I. Salary/pay inadequate 32

Table – IV

Suggestions to improve staff retention at BPKIHS

N=150 S.N. Suggestion for staff retention Percentage (%) 1. No response (N=36) ........... 2. Responses (N=114) 100

a. Increase salary/pay scale 80 b. Job security (permanent) 75 c. Avoid partiality & favorism 62 d. Immediate starting of BN course 60 e. Fair and proper facilities for nurses 57 f. Adequate further education opportunities 57 g. Regular & impartial evaluation system 56 h. Continuous in-service education in related are as 55 I. Establish transparent rules for promotion 42