Increasing retention of nursing staff at hospitals: aspects of management and leadership *.

Abstract

In a previous study by Naude and McCabe, the factors that motivate nurses to remain working in a specific hospital were explored and described. From that research it was evident that there are factors related to leadership, management and interpersonal issues that will motivate nurses to remain working at a hospital and therefore increase the nursing staff retention rate of the hospital. This article will focus on the factors that were among the top four mentioned in that study; these include friendly and supportive staff supportive and effective management, job satisfaction, and staff development including opportunities for new challenges. The aim of this article is to discuss leadership and management strategies to support the four most mentioned factors that will motivate nurses to remain at a specific hospital and therefore increase the retention rate at that hospital.

Introduction

Excessive staff turnover is costly for any organisation (North, Rasmussen, Hughes, and Finlayson 2005). Its impact goes beyond the financial costs inherent in recruitment, selection and (new employee) training. When a staff member leaves an organization, the knowledge, skill and experience that the person has brought to, and gained at, the organisation is lost. It takes newcomers to the organisation some time to become fully functional; depending on the complexity of the position, this can take as long as six months. This is costly to any organisation. Waldman, Kelly, Arora and Smith (2004) found that in a specific medical centre case study the turnover costs represent an expenditure of about five per cent of the annual operating budget. Larsen (2000) found that when the employees are highly satisfied, they will remain in the organisation, thus increasing the retention rate for that organisation.

Retention of nurses is a recognised issue for the health industry, as evidenced by the many studies undertaken on the reasons why nurses leave nursing (BIZTRAC 1998; Nowak 1998, 2000; Health Department of Western Australia 1997, Senate Community Affairs Committee 2002). There are, however, hospitals where nurses seem to be satisfied with their jobs, the turnover rates are lower than average and the quality of nursing care provided is higher than average. In the United States, the concept of 'Magnet Hospitals' reflects hospitals that attract and hold quality-nursing staff. These hospitals were considered by the nurses to be good places to work and places where consistent good quality nursing care was rendered (Bednash 2000; Buchan 1999). This prompted the following research questions:

   Why do nurses in a selected sample of Western Australian hospitals
   remain working at that hospital?

   What, from the nurses' perspective, increases the retention rate at
   hospitals?

In 2002 the researchers, with the assistance of three Western Australian hospitals, explored and described the nurses' perceptions of the factors that attract them to a specific hospital and motivate them to remain working at that hospital. Although this study was prompted by the idea of a Magnet hospital, it was very different from the original Magnet hospital research, as it focused on the retention issues as perceived by the nurses and not on the presence of key characteristics such as professional practice, professional development, and administration (Buchan 1999) in the original Magnet hospital research.

It was very clear from the Western Australian study that there are many factors that have an effect on the retention of staff. But the four most often mentioned factors are: friendly and supportive staff; supportive and effective management; job satisfaction; staff development and opportunities for new challenges. On closer analysis it was evident that effective leadership and management strategies underpin all these factors. The aim of this article is to discuss the management and leadership strategies related to those four most important factors stated by the nurses in the study to influence their decision to remain with the organisation.

For the Western Australian study, three metropolitan based hospitals were selected where the average annual turnover rate was lower than 20 per cent and the hospital was identified, through feedback/discussions with Western Australian nursing opinion leaders, as a place with a reputation for being where nurses seem to enjoy working. The hospitals included in the study comprised one large teaching hospital, one private corporate run hospital and one private church controlled hospital. The two non-public hospitals cater for a reasonably comprehensive range of hospital based services. The nurses in the sample surveyed were registered professional nurses, directors of nursing/nurse managers, clinical nurses and enrolled nurses registered with the Western Australian (WA) Nurses Board who had been working in the specific hospital for more than two years.

The researchers used a qualitative methodology to explore, capture and represent the multiple realities inherent in the study. This methodology is consistent with the knowledge claims associated with social constructivism, whereby individuals develop subjective meanings of their experiences and these experiences are varied and multiple (Creswell 2003). (1) That is, all participants would have their own perceptions and indeed, reality, in relation to the factors that motivate them to choose a place of work and to remain there. The question 'Please describe the factors (aspects, things) that are motivating you to remain working at the hospital' was posed as an open question as part of a questionnaire.

Leadership and Management Strategies to Increase Retention

Friendly and Supportive Staff as a Factor to Increase Retention

Where staff feel that they are supported by co-workers, retention rates are usually higher as job satisfaction is increased. Weinberg and Creed (2000) concluded, from a study of health care professionals and hospital staff, that positive support from supervisors and colleagues at work reduced absenteeism. Weinberg and Creed also argue that changing the psychosocial environment at work is a way of reducing sick leave. This is also applicable to the retention of staff. Butler (2000) stated that the best places to work have a sense of community where staff experience belonging to a team. Staff feel that they fit in and know each other, and people can be human and still focus on action. Butler added that fun is encouraged, all levels and positions are respected and staff treat each other with respect and know each other's passions.

Meyer, Naude and Van Niekerk (2004) argue that support is developed when positive relationships are built. This means that mutual respect, trust and integrity need to be created and maintained. Staff should be treated as unique individuals who can make unique contributions, and there should be effective interpersonal relationships and conflict management.

From the negative perspective, Hemingway and Smith (1999) note that specific factors such as work pressure, supervisor support, poor cohesion and autonomy may affect withdrawal behaviours (turnover and absenteeism) among.nurses, both directly and indirectly. Fagin (1992) reported that poor morale was one of the main reasons leading to an increase in absence in mental health nurses.

The comments from the nurses in this study supported the importance of this emphasis on a supportive and friendly working environment. The most important factor reported by participants in the research study related to support from staff and a welcoming atmosphere in the workplace. Participants contributed statements such as:

   My colleagues are a big factor as I enjoy the people I work with and
   have made some good friends.

   I work with other hard working staff who try to support one
   another.

   I find that the staff as a whole are very encouraging and caring
   people.

   I enjoy the friendliness in the hospital/workplace.

A study by Lacey (2003) found that nurses rated the nature of professional relationships with doctors as one of the top five reasons for staying in a health care setting. Morrison and Chan (2000), as well as Friedrich (2001), also found that nurses would remain in a hospital where there are positive relationships. Friedrich (2001) added that bullying and disrespectful behaviour should not be tolerated and that it is the responsibility of the manager to put strategies in place to change such behaviours.

Good relationships among health professionals also supported the atmosphere of friendly, supportive staff. It was evident from the participants' responses that good relationships among health professionals are a major reason why nurses remain at a given hospital. This is evident from the following statements:

   All the doctors (including the consultants) are great to work with.

   Have respect from colleagues and doctors (long time worker)

In a study including health care professionals, Weinberg and Creed (2000) found that positive support from supervisors reduced sick leave and absenteeism. This may have the added effect of increasing the retention rates long-term. Upenieks (2003a) argues that nurses do not experience as much stress from a long day of work if the job is fulfilling or if they receive positive feedback and support for the work done. A study by Centrella (2004) found that by providing a supportive environment to nurses, the retention rate was increased dramatically.

To be effective, the 'nurse manager' must act as a leader as well as a manager. Table l, derived from Waddell, Cummings and Worley (2004), very briefly summarises the differences between leaders and managers. There is a clear interaction and interrelationship between leadership and management, and the effective nurse manager needs to be able to integrate leadership and management in his or her role.

It is extremely important that the followers are motivated to follow the leader. Franklin D. Roosevelt remarked that it is a terrible thing to look over your shoulder when you are trying to lead and find no one there. Butler (2000) argues that effective workplaces have leaders that the followers can trust and respect. The followers need to believe that the leaders are able to lead the team and the organisation into the future. Leaders who value and recognise contributions of others are more effective.

Effective leadership has a considerable impact on staff empowerment and the realisation of the goals in the nursing unit. As individuals and teams are unique, the exciting and interesting challenge for the leader is to select the correct leadership style to implement for each individual, team and situation. The same leadership style will not be most effective in all situations and with all followers.

The leadership style of the manager will influence all the activities in the nursing unit. It is vital to select and implement the most appropriate leadership style for each situation.

For example, the transactional leader focuses on the day-to-day aspects and planning and the leadership actions are task oriented (Waddell et al. 2004). When the developmental levels (maturity levels) of the followers are different, the situational leadership model (Hersey and Blanchard 1972; Robbins et al 2001) may be most effective. During the implementation of change, transformational leadership (Bass 1995; Eisenbach, and Kotter 1995; Waddell et al 2004) will be most appropriate.

Upenieks (2003a) pointed out that hospitals would attract and retain more qualified nurses if they provided the nurses with open communication channels to nurse leaders and if the hospital made sure that there were enough nurse leaders present. In return, nurses will accomplish their jobs more successfully and obtain greater job satisfaction. Upenieks (2003b) stated that decentralised decision making and shared governance increase nurses' control over their work environment, as it supports autonomy and decision making and also improves relationships. Upenieks (2003a) argued that aspects such as empowerment and the opportunity to function autonomously add to job satisfaction.

In the authors' study, supportive and effective management was frequently reported as a motivating factor in remaining at a hospital. It is interesting to note that the behaviours which the nurses draw on in their comments are a mix of management and leadership behaviours. The nature of supportive and effective management described by participants included management implementing new initiatives, effectively working with nurses and engaging them in participative decision-making. Also mentioned were comments regarding management's good problem solving strategies. The following comments from participants denote this:

   Manager of the ward is understanding and pleasant. Makes working
   conditions pleasant and this encourages staff to remain committed
   long term.

   Clinical nurse manager working along side staff promotes staff
   appreciation so staff don't feel isolated from the management.

   The manager has been fair and flexible.

   Successful business people running the establishment.

   I have the support of management.

   An understanding and supportive Director of Clinical Services

In the study, there was a strong suggestion that nurses appreciate a manager who is both willing and able to work alongside staff and prepared to 'roll up the sleeves'. The importance of this seems to be twofold: firstly, in facilitating a team situation rather than a manager/staff relationship and, secondly, in establishing a sense among nurses that their manager understands the role and workload of his/her nurses, who thus have greater confidence in the actions taken by managers. It is important that the manager encourages and implements innovative ideas and practices and engages the staff in participative decision-making. While staff cannot be involved in all decision-making all the time, it is advisable that they be involved in the aspects that will impact directly on their practice or in the area where they have a lot of knowledge and experience.

The nurses in the study highlighted the importance of a manager's personal touch. This can be as simple as acknowledging a staff member on his/her birthday by a phone call or card or personal good wishes or a phone call or card to congratulate a staff member after a specific accomplishment, for example promotion, support and follow-up on a staff member who has been on sick leave. Other strategies that the nurses regarded as important were informal get-togethers, for example a morning tea in a nursing unit. This should not be to 'check up' but just to spend time together to get to know the staff. Points of particular note were the introduction of social programs and the encouragement of social events by the management, the personal touches and 'little things' (i.e. cards and gifts, free meals, cakes on special days) that were valued and appreciated. Ross (2001) added that two-way communication, feedback, management that keeps staff informed and in the big picture, participation, consultation, decentralisation and empowerment are important aspects of the supportive workplace.

Job Satisfaction

Increased job satisfaction leads to increased retention rates (Ross 2001; Larsen 2000). As seen from the earlier discussion, by the implementation of effective leadership and management strategies, job satisfaction may be enhanced greatly. Moss and Rowles (1997) found that a participative management style improved job satisfaction. In a study in Hong Kong, Sui and Donald (1995) found that 'relationships to superiors' was a strong indicator of the incidence of health complaints and job satisfaction.

In recent years, organisational culture and climate has been found to be a potential source of job stress or job satisfaction (Adams and Bond 2000; Fagin 1992; Hemingway and Smith 1999). Jain et al (1996) stated that it is possible for work-related stress to result in physical, mental, emotional and depressive symptoms that contribute to job dissatisfaction. They make the case for workplace counselling services for distressed nursing staff in order to enhance their job satisfaction.

Upenieks (2003a) stated that aspects such as empowerment and the opportunity to function autonomously add to job satisfaction. Meyer et al (2004) are of the opinion that specific management strategies can enhance job satisfaction. These strategies include participative management, problem solving and decision making. This means that the staff must be totally involved in the processes, rather than being consulted but with their input not having a bearing on the final decision made by the manager. They argue that managers should show respect for the input, ideas and uniqueness of staff members and provide clear, realistic and practical goals, objectives and expected outcomes for individuals and for nursing units. Goals and objectives should be challenging but attainable. They also argue that managers can motivate their staff by supporting them in their push for better conditions such as creches, safe parking areas, tearooms, adequate equipment and supplies.

Saltzstein, Ting and Saltzstein, (2001) found that flexible scheduling has positive links to job satisfaction. They also found that part-time employment has no direct effect on job satisfaction but has a positive effect on work/family balance. It was evident that flexible scheduling increases productivity. A perceived lack of work/family balance, and the reduction in job satisfaction linked to it, also produce other negative job behaviours such as increased absenteeism, impaired performance and increased turnover. Upenieks (2003a) concurs on this point, noting that when it comes to job choice, the majority of nurses would rather select a hospital that provides flexible hours than one that does not. Ross (2001) added that there is a range of financial and lifestyle services that will lead to job satisfaction. Included in these are aspects such as flexible work hours.

Since flexible rostering allows nurses to attend to family and personal needs, the nurses' productivity and commitment will also improve because they are allowed to work the hours that they feel comfortable with. The challenge to the manager is to allow for flexibility to staff but also to ensure that quality nursing care is provided to the patients.

Much of the feedback found by the authors correlated with the discussed literature regarding job satisfaction of nurses as indicated by the following statements:

   Have worked and been happy here for the whole of the past 26
   years.

   I am thoroughly enjoying my work.

   The nursing skill/patient care provides me a sense of satisfaction
   and hopefully my role makes a difference.

   I'm in my comfort zone. I love midwifery; I enjoy and delight in
   every delivery.

   Love the job. Love the people.

According to Centrella (2004), it was found at the Oklahoma Heart Hospital that nurses felt a lot of frustration because they have to do more with less and were sometimes unable to provide the level and type of nursing care that they want. By introducing a mostly paperless system, the hospital was able to save a lot of time, allowing nurses to focus on nursing care and to do the part of their job that they loved and really wanted to do. This increased the job satisfaction for the nurses and therefore increased the retention rate at the hospital.

Barbian (2001) stated that a very important factor in job satisfaction is to achieve a work/life balance. It seems that this is extremely difficult to do, but management which is open-minded to each individual, and tries to accommodate his or her needs, is valued.

Staff Development and Opportunities for New Challenges Increase Retention Rates

Upenieks (2003b) argues that improved opportunity, information and resources will empower staff and also create an improved job satisfaction among nurses. Butler (2000) adds that the best places to work are where staff are provided with the needed training to succeed in the market place and where there are plans to build capacity. Growth is encouraged by doing exciting and leading-edge work and by challenging the old ways of working. Staff" prefer to learn and grow. Ross (2001) adds that staff need to be challenged and stretched, but within their capability.

Curran (2003) stated that one of the key reasons that employees leave hospitals is a perceived lack of career development. Curran (2003) added that it seems that baby boomers often stay with an organisation out of loyalty while members of Generation X report opportunities for skill building and learning as key motivators in the decision to stay or to leave an organisation, reflecting their perceived commitment to continuing development and learning. Investment in mentoring programs and training and development programs can be an effective response to these needs.

Participants in the authors' study identified opportunities for new challenges and additional experiences through skill variety and task significance as motivating factors to remain at their hospital. This is evident by the following statements from the participants:

   Opportunity to move within the hospital while remaining attached
   to a clinical area. That is jobs within the hospital are being
   created to allow nurses to work 50 per cent clinical in their area
   of speciality and 50 per cent within other area of healthy care
   system i.e. research and management, education and development and
   temporary project positions.

   Opportunities given to challenge myself professionally

   Opportunities available for those who seek them

   Opportunity to develop a position over time

Participants also mentioned that they were attracted by the fact that the hospital offered a career path and not just a job.

   Very good support in terms of staff development.

   As a new graduate, the program I am in is very supportive.

   The unit gives the opportunity for study and encourages you to
   study.

Barbian (2001) noted that many companies found that offering training and development courses allowed staff to deal better with change. These courses include leadership, management, time management and public speaking. By training the staff, companies also had more confidence to decentralise decision making, and this in turn provided motivation for staff. It is important that creativity and innovation are encouraged.

Conclusion

Many of the factors cited as influencing nurses to remain at their hospitals relate to interpersonal relations, and leadership and management style and action. It can be seen also that action to improve job satisfaction, to provide challenges and to create opportunities for staff development are ultimately the responsibility of managers and leaders in the organisation Therefore, it is possible for the organisation to attract and retain nurses by strengthening the interpersonal leadership and management skills within the hospital. This is supported by other studies which found that, although nurses' pay is important, it is not as critical in enhancing retention of nurses as a positive work place or a culture that promotes teamwork and encourages continuous learning, trust, respect and flexible scheduling (Chan et al. 2004).

It must always be remembered that nursing retention is the result of a combination of factors. There is no easy solution and managers and leaders should select the combination of factors that will be effective in their specific hospital as there is also no one range or combination of strategies that will fit all hospitals.

References

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* The authors wish to acknowledge: Margaret Nowak for her continuous support and encouragement of the WA Magnet Hospital project; Curtin Business School for the Tier One research grant which partially funded the WA Magnet Hospital project; and Diederick Naude for his research assistance in compiling reports on the Magnet Hospital Project. and his contribution to the literature searches.

Endnotes

(1) The term 'knowledge claims' reflects the assumptions that researchers hold about what will be learned and how during the research process, and therefore how the research should be designed. These knowledge claims encompass: what is knowledge (ontology); how we can know about it (epistemology); how it can be written about (rhetoric); what values are within that knowledge (axiology); and the process for studying it (methodology) (Creswell 2003:6).

Marita Naude and Rebecca McCabe, Graduate School of Business, Curtin University

Table 1: Comparison of managers and leaders

Aspect                     Managers                   Leaders

Motivation         Use extrinsic motivation   Enhance intrinsic
                   and reward systems         motivation ame try to
                                              create purpose and hope
                                              through involvement,
                                              participation and
                                              sharing

                                              Empower the followers

Approach           Focus on policies and      Focus on motives anti
                   procedures and ask         ask what and why through
                   how and when; mostly       thinking laterally and
                   work with what is by       non-sequentially
                   thinking logitally
                   and sequentially

                   Seek standardisation       Challenge the status
                   and uniformity; seek       quo; seek unity and
                   stability; re-organise     empowerment; redevelop
                   and refine                 and revolutionise

Characteristics    Usually analytical,        Leaders usually are
                   structured, controlled,    experimental, visionary,
                   deliberate and orderly,    flexible, unfettered and
                   think rivals as well       creative, think partners
                   as competition and use     as well as collaboration
                   the power of logical       and use the power of
                   thinking                   intuitive thinking

                   Focus on practical         Focus on possible issues
                   issues                     and question assumptions

Relationship       Relate to followers        Relate to followers on
with followers     according to their roles   a personal level and
                   and jobs                   according to shared
                                              values and the strength
                                              of the follower and
                                              try to enhance job
                                              satisfaction

                   Compensate followers
                   according to the systems
                   in the organization

Planning           Focus on the present and   Focus on the future
                   operational/day-to-day     planning or strategic
                   planning; reactive         planning; proactive
                   thinking and short-term    thinking and long-term
                   results                    results.

                                              Interested in exploring
                                              new ideas and take
                                              calculated risks
                                              regarding a future
                                              vision

                   Aim to do things right     Aim to do the right
                                              things

                   Acts as the "Dressmaker'   Act as the "designer'
                   who follows the pattern    who designs the pattern
                   and implements ideas to    others follow and guides
                   turn ideas into reality    followers towards new
                                              ideas

Organisation and   Plan and organise staff    Allocate staff to
allocation of      based on organisational    enhance their maximum
staff              needs.                     potential.

                   Control, solve problems    Inspire and
                                              motivate--keep followers
                                              moving in the correct
                                              direction

This table was adapted from Waddell et al. (2004)