Domain 6: Monitoring and Ensuring the Quality of Health Care Practice

- Introduction -

Now more than ever, there is a demand for skilled nurses. COVID-19 has the demand for nurses in the workplace even more prevalent now than ever. With the overflow of wards filled with patients with high acuity levels and COVID-19 patients, nurses are starting to feel burned out by working with more with less. This paper will analyze nursing retention and burnout using the Walker and Avant method of concept analysis (Rodgers, 2018). Hospitals and clinics are finding it hard to retain nurses for a myriad of reasons.

In order to analyze nursing retention and burnout, empirical referents and antecedents will be at the forefront through recognizing and analyzing consequences. This paper will overview the relevance of addressing nursing retention and its effect on patient outcomes. This paper will also explore nursing shortages throughout hospitals nationwide and how nursing burnout affects staffing methodology. The author of this paper will provide background, definition, and provide cases to bring forth information on this topic.

- Background -

- Definition -

By definition, nursing retention or turnover is when any nurse departing from an organization reduces staffing ratios that may affect patient care (Kovner, Brewer & Fatehi, 2017). Nurses have tremendous responsibilities, ranging from patient care, patient education, and patient advocacy. Nurses daily face outstanding obligations that lead to stressful situations. With the lack of staffing and the added stress of being a nurse, nurses may feel "burned out" and need a break from the profession. According to the World Health Organization (WHO), burnout, as defined by ICD-11, is as follows, "Burnout is a syndrome conceptualized from chronic workplace stress that has not been successfully managed" (World Health Organization, 2019). Healthcare professionals deal with issues of burnout that may affect their job performance and job retention. The constant stress that accompanies the feeling of being overwhelmed and burned out by nurses may affect how patients are cared for (Griffiths, Saville, Ball, Jones, Pattison & Monks, 2020). Retention in the nursing profession is affected by the stress that nurses have to endure.

Wippold, G.M., Nmezi, N., Williams, J.L., Butler, J., Hodge, T.M. (2020). An Exploratory study to understand factors associated with health-related quality of life among uninsured/underinsured patients as identified by clinic providers and staff. Journal of Primary Care & Community Health 11, (1-9). https://doi.org/10.1177/2150132720949412.

Literature Review

Using the Walker and Avant method to analyze a concept, close examination of a specific aspect must occur (Kapaale, 2018). Nurses face staffing shortages, turnover, the overabundance of stress and anxiety in the workplace, and the constant changes in healthcare policy (Garcia-Moyano, Altisent, Pellicer-Garcia, Guerro-Portillo, Arrazola-Alberdi, & Delgado-Marroquin, 2019). According to the National Institute of Health (NIH) (2020), the national average nursing turnover rate in 2020 ranges from 8.8% to 37%. With almost one million nurses nearing retirement in the next ten years, the nursing profession is looking at even more of a deficit, causing a strain on staffing in many organizations nationwide (Haddad & Toney-Butler, 2020). It is hypothesized that a range of factors drives changes in nursing staffing, including overworking, understaffing, high mental and physiological pressure (Yuan & Xu, 2020).

Using the Walker and Avant method to investigate different aspects of a concept, the ease of the holistic process of analyses allows for macroscopic studies of a notion. Studies by Kapaale (2018) and Yuan & Xu (2020) acknowledge the relationship between the recruitment of new nurses and the retirement of older nurses. The research indicates that nursing turnover is happening much faster than nurses entering the profession (Haddad, Annamaraju, & Toney-Butler, 2020). In addition, nurses are not the only ones feeling the fallout from the nursing shortage; hospitals bear the cost of constant turnover (Barlow & Zangaro, 2010). According to Jones (2008) and Smith (2018), nursing turnover is highly costly to organizations. Research shows that it costs employers $88,000 a year when a nurse leaves their position, and these costs are associated with the burnout associated with being overstaffed and overworked.

Defining Attributes

Defining attributes help to determine the focus of the concept to analyze (Rogers, 2018). These attributes appear throughout literature as they help provide a sense of simplicity in determining intellectual thought on a concept. When researching nursing retention, several reoccurring refrains occur throughout the text. The literature overwhelmingly These attributes include worth, burnout, and environment.

Worth

Employees need to feel like they matter in the workplace. It is vital to ensure employees feel that they are valued, and their skills are needed. The focus on retention and recruitment of nurses in the workforce has an economic impact. Nurses are an integral part of providing care to individuals in all areas of the life span. Nurses have positions of responsibility within healthcare organizations. Working in such an environment can lead to "feeling lost," unappreciated, and undervalued. When nurses feel like they value an organization, they are less apt to leave their current working environment. In turn, organizations may retain their nurses, leading to retention (Horton, Tschudin, & Forget, 2007)

Burnout

Nurses have exposure to patient loads that are over the acceptable limit. Burnout and constant stress lead to compromising patient safety. Nurses are inundated with stress, excessive patient workloads, anxiety, and emotional exhaustion with constant staff turnover. Often nurses work through lunch, take no breaks, and do not participate in self-care. Nurses have reported working in a toxic environment with little to no support from the organization's leadership in which they work (Kapaale, 2018).

Environment

Working environments factor into nurse retention. When nurses feel that they are do not have support from nursing leadership and hospital leadership, their environment proves to be challenging. Nurses complain of working in toxic environments that prove to be mentally exhausting, and those environments are not ideal for delivering safe and effective patient care. Considering the location of one's environment is also critical, and it is hard to retain staff in rural settings (Smith, 2018).

Empirical Referents

Walker and Avant recommend using data to provide evidence of the explored concept (Walker & Avant, 2010). When using the Nurse Stress Inventory (NSI) and the Maslach Burnout Inventory (MBI), the concept of nurse burnout is measurable. NSI measures the incidence of stressor occurrences that help to interpret exhaustion among nurses. MBI, on the other hand, measures the three characteristics of job-related burnout. These characteristics are EE, DEP, and PA (Yuan & Xu, 2020).

Model Case

David is a registered nurse (RN) in school working on becoming a family nurse practitioner (FNP). David works on a hectic med-surg floor unit. Last month several of his nursing colleagues left the med-surg unit to take on travel nursing assignments for more money. In addition to the nursing staffing shortage, the unit only has two nursing assistants to help with all patients. David also acts as the charge nurse in addition to his large patient load. David feels as if his hospital does not value his worth as a nurse. He feels unappreciated and overworked. David must take the following new patient to admit, and he feels burned out from doing more with less staff. David's floor is a hectic unit, and the staff is tight. David is physically tired from taking care of all of his patients and being the charge nurse on the unit. David is mentally tired and works double shifts to help with staffing. With nurse staffing being low, David has no relief to get off of work on time. David has had to work over his shift time until relief could come. David is noticing that his patient workload continues to increase each shift. David feels that hospital leadership does not care about staffing issues. He feels that there is no support for the nurses on his unit, and he believes that he is working in a toxic environment. Every day another nurse quits, and the remaining staff gets even more disgruntled. David is planning on turning in his notice of resignation after his current shift. He is tired and burned out from the stress of working with no relief and not enough nursing staff.

Contrary Case

David is a registered nurse and a family nurse practitioner student. David works on a med-surg unit that is not very busy. Last month the hospital hired several new nurses to float throughout the hospital to help with staffing issues. Each nurse has a nursing assistant assigned to work with them throughout each shift. David feels as if the hospital values his worth as a nurse. He feels appreciated. David and his nurse colleagues take a turn working in the charge nurse capacity. Spreading the responsibility allows for each nurse to gain experience as well as keep down the stress. Stress can create burnout, and the nurses on the unit do not want to lose anyone from nurse burnout. David is assigned to take the following new patient to admit. His colleagues know that David has an exam for school tomorrow morning. One of his colleagues offered to take the following new patient to admit so that David could leave on time to go home to study and get a good night's sleep. David is very thankful for his job and his co-workers. He feels lucky to work on a unit that hospital and nursing leadership supports.

Related Case

David is a registered nurse and a family nurse practitioner student on a busy med-surg unit. Last month several nurses on his unit quit their jobs at this hospital to take travel assignments. Up until this shift, David has not complained about staffing. This is the first shift that he has worked with no relief. David does not want this to become a regular occurrence. He has voiced his concerns via email to his nurse manager. David does have a nursing assistant assigned to work with him, so he does not feel as stressed as some of his colleagues. David knows that he is next to up to take the new patient to admit. He is tired and wants to go home on time tonight. David's manager asked him if he could work a double or at least until they find some relief for him tonight. David is stressed because he has an early morning class that he has to attend. David and his nursing colleagues have set up a meeting with the hospital and nursing leadership. They are concerned that staffing will get worst. David is tired from working multiple shifts, but he knows that his co-workers are experiencing the same thing. David is considering leaving his job and going back to school full-time. He does not want to wait until he feels completely burned out from nursing.

Antecedent & Consequence

According to Walker and Avant (2010), antecedents occur before the concept. One antecedent to nurse burnout is cognitive competence (Yuan & Xu, 2020). The perception of the characteristics that may cause exhaustion may affect one's reaction. When exhaustion is present, nurses have a hard time controlling their reactions to stressful situations. According to Russell (2016), another antecedent is "role overload." When nurses have increased patient loads results, there may be emotional fatigue, As a result of the concept analysis, consequences occur. As a consequence of being burned out from the nursing profession, nurses leave their jobs, thus impacting retention. Burnout can lead to chronic headaches, depression, anxiety, and the overwhelming feeling of not wanting to stay at their place of employment. Employers feel the consequences of nursing burnout the same way that employees do. According to Yuan and Xu (2020), hospital costs for bedside nurses can cause the hospital to lose anywhere from $4.4million to $7.0 million annually.

Summary

Hospitals and clinics are finding it hard to retain nurses, and nursing retention affects organizations, the staff, and the patients. If nurses feel that they are not appreciated and overworked, they may first try to address their concerns to nursing leadership. If they feel that hospital leadership is not addressing their concerns, they may leave their current job, thus creating a hole in the staffing matrix. By exploring this concept to analyze, the author of this project has gained additional knowledge to understand nursing retention better. In conclusion, nursing retention is a challenge that plagues the healthcare industry. Staffing has always been an issue throughout hospitals everywhere, and the Covid-19 pandemic did not help the situation. Patients are becoming sicker, hospital beds are becoming fully occupied, and nurses are beginning to leave the profession for various reasons. When burnout occurs, staffing issues arise, thus leading to issues with nursing retention.

References

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