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Educational Preparation and Nurse Turnover Intention from the Hospital Bedside

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Mary Jane K. DiMattio, PhD, RN
Adele M. Spegman, PhD, RN

Abstract

Evidence of an association between nurses’ educational preparation and patient safety has prompted many hospitals to engage in preferential hiring of baccalaureate nurses or invest resources into tuition assistance. Meanwhile, the difficult nature of nursing at the hospital beside, demanding hospital practice environments, and the need for nurses in expanded roles are converging to create a situation whereby education might beget increased turnover from the hospital bedside. This article describes a study that examined the relationship between educational preparation and turnover intention from the hospital bedside in a sample of nurses from an integrated health system in Pennsylvania. The authors discuss the review of literature, theoretical framework, and study methods. Results indicated that educational preparation independently predicted turnover intention from the hospital bedside. In the discussion and conclusion, the authors suggest that to keep hospitalized patients safe and reduce costs, the hospital bedside should be re-envisioned as a specialty so as to retain baccalaureate nurses in this setting.

Citation: DiMattio, M.J.K., Spegman, A.M., (April 30, 2019) "Educational Preparation and Nurse Turnover Intention from the Hospital Bedside" OJIN: The Online Journal of Issues in Nursing Vol. 24, No. 2.

DOI: 10.3912/OJIN.Vol24No02PPT22

Key Words: Nursing, Education, Baccalaureate; Nursing Staff, Hospital; Personnel Turnover; Patient Safety; Patient Bedside

Evidence of an association between nurses’ educational preparation and patient safety has prompted many hospitals to engage in preferential hiring of baccalaureate nurses... Evidence of an association between nurses’ educational preparation and patient safety has prompted many hospitals to engage in preferential hiring of baccalaureate nurses or invest resources into tuition assistance. Meanwhile, the difficult nature of nursing at the hospital beside, demanding hospital practice environments, and the need for nurses in expanded roles are converging to create a situation whereby education might beget increased turnover from the hospital bedside. The purpose of this article is to describe a study that examined the relationship between educational preparation and turnover intention from the hospital bedside in a sample of nurses from an integrated health system in Pennsylvania.

There is now ample evidence of a positive relationship between educational preparation of registered nurses (RNs) and desirable safety outcomes for patients in acute care hospital settings (Aiken, Clarke, Cheung, Sloane, & Silber, 2003; Aiken, Clarke, Sloane, Lake, & Cheney, 2008; Blegen, Goode, Park, Vaughn, & Spetz, 2013; Friese, Lake, Aiken, Silber, & Sochalski, 2008; Kutney-Lee, Sloane, & Aiken, 2013; Tourangeau et al., 2006; You et al., 2013). This evidence is among the rationales behind the policy recommendation for a greater number of nurses to hold a minimum of a baccalaureate degree (Institute of Medicine, 2011; Tri-Council for Nursing, 2010). In the wake of this policy recommendation and others related to patient safety (Illingworth, 2015; National Patient Safety Foundation, 2015), many hospitals now engage either in preferential hiring for baccalaureate nurses (AACN, 2017) or offer tuition reimbursement for their nurses to achieve baccalaureate degrees (Cheung & Aiken, 2006; Schuler, Johnson, Stallings, & Li, 2017; Warshawsky, Wiggins, Lake, & Velasquez, 2015).

Other dimensions of optimal surveillance capacity include adequate staffing by experienced and expert registered nurses and a favorable nurse practice environment. Kutney-Lee and colleagues (2009) identified a large proportion of baccalaureate nurses as an essential dimension of a hospital’s surveillance capacity, or organizational environment, conducive to the surveillance and rescue of patients. Other dimensions of optimal surveillance capacity include adequate staffing by experienced and expert registered nurses and a favorable nurse practice environment. Surveillance consists of ongoing observation, recognition, interpretation, and decision-making (Kutney-Lee, Lake, & Aiken, 2009). Meyer and Lavin (2005) applied the concept label of vigilance to the identification of clinically significant observations, calculation of risk, and readiness to take appropriate and efficient nursing actions. Whatever the label, surveillance capacity or vigilance allow for nurses to engage in what Nightingale (1860) recognized as the most critical aspect of nursing—informed observation leading to appropriate action on the patient’s behalf. Based on their findings of better patient safety in hospitals with high nurse surveillance capacity, Kutney-Lee and colleagues suggested that hospitals could enhance surveillance by ensuring adequate staffing with experienced, expert baccalaureate nurses in a supportive practice environment. If RN educational preparation independently predicts turnover from the hospital bedside as a practice setting, however, this formula for patient safety will be compromised.

The career mobility conferred by education might unwittingly contribute to turnover from the bedside in the acute care hospital... Despite the shift of care delivery to ambulatory settings (Bauer & Bodenheimer, 2017), approximately 61% of registered nurse jobs are in hospitals (Bureau of Labor Statistics, United States [U.S.] Department of Labor, 2018). As hospitals work to enhance the educational preparation of bedside nurses, the need for nurses in expanded roles provides an incentive for career advancement. In 2016, 75% of new baccalaureate and 65% of new associate nurses reported plans for degrees beyond the baccalaureate (Feeg & Mancino, 2017). The career mobility conferred by education (Gilmartin, 2013) might unwittingly contribute to turnover from the bedside in the acute care hospital (hereafter referred to as the hospital bedside) as a practice setting and confound the positive effects of education on patient safety outcomes in that setting.

Some might argue that the hospital bedside as a stepping stone to career advancement is neither surprising nor inappropriate. Evidence of the positive impact of RN education, experience, and expertise on patient safety outcomes in hospitals (Aiken et al., 2008; Benner, 1984; Dunton, Gajewski, Klaus, & Pierson, 2007; Kutney-Lee, Lake, & Aiken, 2009), coupled with the loss of “experience-based knowledge” (Hill, 2010) and the expense incurred by hospitals and the healthcare system from nurse turnover (Becker’s Hospital Review, 2016; Li & Jones, 2013; Waldman, Kelly, Arora, & Smith, 2004) suggest it is important to understand better baccalaureate nurses’ turnover intentions from the hospital bedside.

Such an understanding is the first step to inform strategies for keeping an adequate number of expert baccalaureate nurses at the hospital bedside long enough positively impact on patient safety. The purpose of this study was to examine the relationship between educational preparation and turnover intent, defined as intention to leave the hospital bedside as a practice setting, while accounting for other variables necessary for surveillance capacity, including years of experience, self-reported expertise, and practice environment.

Review of Literature

The relationship between educational preparation and turnover intention, defined as intention to leave or stay, depends on the way in which turnover is defined. One study found that baccalaureate education mitigated turnover intention at the unit level (Kovner et al., 2016), whereas another found that master’s level education predicted turnover intention from the intensive care unit, while baccalaureate education predicted retention (Fitzpatrick, Campo, Graham, & Lavandero, 2010). When turnover was defined as intention to leave an employer, nurses with a baccalaureate degree were less likely to stay than those with less education (Kovner, Brewer, & Green, & Fairchild, 2009). Similarly, when turnover was defined as actual retention one year after hire, a significantly smaller number of baccalaureate than associate degree nurses was retained at one year despite higher job performance ratings among the baccalaureate nurses (Weathers & Raleigh, 2013). Perhaps even more concerning is when turnover was defined as intention to quit working or to leave the profession, baccalaureate nurses were more likely to report these intentions in two studies (Brewer, Kovner, Greene, & Cheng, 2009; Daniels et al., 2012).

For both groups, the most frequent reason was the desire to pursue more education and other job opportunities. Only one published study was identified that defined turnover as intention to leave the hospital bedside as a practice setting. DiMattio and colleagues (2010) found that baccalaureate nurses who intended to leave within the next three to five years scored lower on dimensions of the practice environment than those who intended to stay in that setting. Baccalaureate nurses who had already left the hospital bedside had done so after a median of 5 years. For both groups, the most frequent reason was the desire to pursue more education and other job opportunities.

Qualitative studies conducted in the United States and abroad have described the particularly challenging aspects of the hospital practice environment that drive nurses to leave that setting (MacKusick & Minick, 2010; Valizadeh et al., 2016; Zhu, Rodgers, & Melia, 2014). Pellico and colleagues (2009) reported that nurses seek to advance their education as a means to leave or “escape” the hospital bedside. Education as a means of escape, particularly early on in nurses’ careers, is a troubling idea because nurses will not accrue the experience and expertise necessary to achieve optimal patient outcomes. Further, it suggests that hospitals offering tuition reimbursement might be educating their nurses out of the door, so to speak, leaving behind a less-educated workforce in this setting (DiMattio, Roe-Prior, & Carpenter, 2010).

There is an abundance of quantitative evidence on why nurses leave their jobs (Hayes et al., 2012) with practice environment emerging as a strong predictor of turnover and turnover intention (Breau & Rheaume, 2014; Nei, Snyder, & Litwiller, 2015; Van den Heede, et al., 2013), often through satisfaction (Kutney-Lee, Wu, Sloane, & Aiken, 2012; Park, Gass, & Boyle, 2016; Roche, Laschinger, & Duffield, 2015; Unruh & Zang, 2014), and burnout (Boamah & Laschinger, 2016). Even salary does not fully mitigate the effect of practice environment on turnover and turnover intention (McHugh & Ma, 2014; Nei et al.). Missing, however, is a clear understanding about turnover from the hospital bedside as a particular setting for practice, the extent to which education plays a role in turnover intention from that setting, and the relationship between education and practice environment on turnover intention from the hospital bedside. It is important to generate evidence about nurses’ disposition toward the hospital bedside as a practice setting according to their educational preparation because of the harms known to occur to patients in hospitals (James, 2013); the costs to the healthcare system related to turnover; and the strategies to increase the educational level of the hospital nurse workforce.

The research questions for this study were:

  1. What is the intention of hospital nurses to leave the hospital bedside, according to educational preparation and enrollment in an educational program (i.e. school)?
  2. What is the difference in intention to leave the hospital bedside according to years of experience, self-reported expertise, and practice environment?
  3. Which RN and practice environment characteristics predict intention to leave the hospital bedside?
  4. What is the interaction of practice environment and education on intention to leave the hospital bedside?

Theoretical Framework

This study was framed within the context of nurse surveillance capacity (Kutney-Lee et al., 2009), which is influenced by RN characteristics or “prepossessed abilities, knowledge, or training that the RN holds” and the work environment defined as “contextual influences of the practice environment” (Kelly & Vincent, 2011, p. 6). RN variables of interest in this study were as follows: educational preparation (highest degree in nursing and current school enrollment); years of experience; and clinical expertise. The work environment variables of interest were: access to opportunity, information, resources, and support, as well as overall structural empowerment. Neither nurse staffing nor patient outcomes were examined in this study.

Study Methods

Design and Sample
Data for this study were taken from a larger study of career trajectories of nurses at an integrated health system based in central Pennsylvania. The parent study had a response rate of 25%. The current study employed a cross-sectional, comparative design to address the research questions, using a non-probability sample of registered nurses who identified their primary work setting to be at the point of care (i.e., bedside) in the setting of the acute care hospital. Nurses in managerial, administrative, or support roles were not included.

Data Collection and Human Subjects
The health system’s institutional review board deemed this study as exempt research. Self-report data were collected using an electronic survey that included 60 items and required 15-20 minutes to complete. Submission of the survey implied consent. Responses to the survey were stored on an SQL database behind a corporate firewall and then downloaded to a spreadsheet. There was no ability to link study data with specific participants.

Measures
Turnover intent. The dependent variable for this study was assessed using a question about nurses’ intention to remain at or to leave bedside nursing in the acute care hospital setting. For the larger study, this question had nine categories, which were collapsed into three: “I intend to remain as a bedside nurse for the remainder of my career; I intend to leave bedside nursing within the next 1-2 years; I already left bedside nursing.” This study only examined results from nurses who selected either of the first two of the three categories.

Educational preparation. Nurses were asked to identify their highest nursing degree from seven choices (diploma, associate’s degree, baccalaureate, master’s, DNP, PhD, EdD) and to respond to a dichotomous variable assessing whether or not they were currently enrolled in a nursing education program. If they responded in the affirmative, they were then prompted to indicate the program type.

Clinical expertise. As was reported by Kutney-Lee et al. (2009), nurses were asked to rate their nursing expertise according to definitions of Benner’s (1984) categories of advanced beginner, competent, proficient, and expert.

Years of experience. Nurses were asked to choose from one of 6 categories indicating years of experience as an RN (0-2, 3-5, 6-10, 11-15, 16-20, 21 or more).

Practice environment. This study used the Conditions for Work Effectiveness Questionnaire [CWEQ II] (Laschinger, 2012) to examine nurses’ perceptions of their practice environments in terms of structural empowerment. Structurally empowering practice environments afford access to opportunity and power to “get things done” (Laschinger, 2012). The CWEQ II has 12 items that assess access to opportunity, resources, information, and support on four subscales, which are conceptually similar to the following three subscales of the Practice Environment Scale of the Nursing Work Index, used by Kutney-Lee at colleagues (2009): nurse participation in hospital affairs; staffing and resource adequacy; and nurse manager ability, leadership, and support of nurses. CWEQ II’s developer established its validity, and many studies have confirmed the instrument’s reliability (Heather K. Laschinger Research Tools, 2017). In this study, Cronbach’s alphas were used to assess reliability, and all were consistent with the literature. They were as follows: overall structural empowerment, a = 0.89; Resources, a = 0.84; Support, a = 0.84; Opportunity, a = 0.85; and Information, a = 0.93.

Analysis
Data were analyzed using SPSS® software version 22 and SAS® version 9.4. Descriptive, parametric, and non-parametric statistics were used to describe study variables and to explore bivariate relationships. Logistic regression analysis was used to regress the dependent variable, treated as dichotomous (intent to leave bedside nursing or intent to remain as a bedside nurse) on the independent variables of educational preparation, years of experience, clinical expertise, and practice environment. In addition, interaction effects were tested in the regression analyses modeling the odds of leaving predicted by the independent variables.

Results
Four hundred twenty-four RNs identified their primary area of nursing practice as at the bedside. Nearly 63% of these nurses (n = 266) intended to remain at the bedside for the duration of their careers, whereas 30.4% (n = 129) indicated an intention to leave bedside nursing in 1-2 years. Twenty-three (5%), however, reported they had already left bedside nursing. Three of these nurses were also employed in other settings, suggesting they maintained their hospital practice at least part of the time. It was not clear, however, why the remaining 20 answered this way, so data for these 23 nurses along with 6 who did not answer the intention question were removed, leaving 395 cases for analysis.

RN Characteristics
Table 1 displays RN characteristics, including demographics, years of experience, and clinical expertise. Over a quarter of the sample had 21 or more years of experience, and most nurses self-reported as proficient. Nearly 43 percent (42.8%) had a baccalaureate degree, whereas 55% had less than a baccalaureate degree as their highest level of educational preparation (21.5% diploma and 33.2% associate’s degree). Two percent had a master’s degree, and none reported higher than a master’s degree. Twenty-two percent (n = 85) of the sample were enrolled in a nursing education program. Analysis of enrollment in an educational program by highest educational preparation revealed that associate degree nurses represented the highest proportion of nurses enrolled in an educational program (48.2%). The next highest proportion of nurses enrolled was those with a baccalaureate degree (37.6%), followed by nurses with a diploma (9.4%) and master’s degree (3.5%).

Table 1. RN Characteristics: Demographics, Years of Experience, and Clinical Expertise (n =395)

Variable

Frequency

Percent

Age
20-30
31-40
41-50
51- 56 or over

 
          n=138
          n=79
          n=69
          n=109

 
          34.9%
          20.0%
          17.5%
          27.6%

Race
White
Non-white

 
          n=385
          n=10

 
          97.5%
            2.5%

Gender
Female
Male

 
          n=356
          n=39

 
          90.1%
            9.9%

Years of Experience
0-2
3-5
6-10
11-15
16-20
21 or more

 
          n=90
          n=62
          n=66
          n=35
          n=29
          n=113

 
          22.8%
          15.7%
          16.7%
            8.9%
            7.3%
          28.6%

Clinical Expertise
Advanced beginner
Competent
Proficient
Expert

 
          n=62
          n=66
          n=161
          n=106

 
          15.7%
          16.7%
          40.8%
          26.8%

Practice Environment
The average score for overall structural empowerment on the CWEQ II was 19.43 (SD = 3.64), representing “moderate” empowerment (Laschinger, 2012). Subscale means were as follows: Resources (M = 3.07, SD = 0.84); Information (M = 3.15, SD = .91); Opportunity (M = 3.91, SD = 0.74); and Support (M = 3.11, SD = 0.88).

Research Question 1
Nearly a third of the sample (32.7%) reported the intention to leave hospital nursing within the next 1-2 years. Nurses whose highest preparation was a baccalaureate degree or more were significantly more likely to intend (42.9%) to leave hospital nursing than those with less than a baccalaureate degree (24.5%) (2 (1, n = 393) = 14.94, p < .001). Similarly, nurses who were currently enrolled in school were also significantly more likely to intend to leave (58.8%) than those who were not enrolled (25.5%) (2 (1, n = 395) = 33.72, p< .001). Table 2 illustrates the degrees to be awarded. Of the nurses (n = 46) enrolled in a baccalaureate degree program, 21 (45.7%) intended to leave in 1-2 years.

Table 2. Degrees to be Awarded (n = 85)

Degree

Frequency

Percent

BSN

          n=46

          54.1%

MSN

          n=33

          38.8%

DNP

          n=2

            2.4%

PhD

          n=3

            3.5%

RN-MSN

          n=1

            1.2%

Research Question 2
In terms of experience, the category of 0-2 years had the highest proportion of nurses who intended to leave (31%), and the category of 11-15 years had the lowest (7%). Nurses with 0-10 years of experience were significantly more likely to intend to leave (71.3%) than those with 11 to >20 (28.7%) years of experience (2 (1, n = 395) = 20.15, p < .001). The category of clinical expertise with the highest proportion of nurses who intended to leave was Proficient (35.7%), but more of the Proficient nurses intended to stay (43.2%). Slightly more Expert nurses intended to stay (27.4%) than to leave (25.6%), but there were no statistical differences on this variable.

After Bonferroni correction for multiple comparisons, nurses who intended to leave reported a significantly lower mean score for Opportunity (M = 3.75, SD = 0.75) than those who intended to stay (M = 3.99. SD = 0.73), t (393) = 3.07, p = .002. The same was true for Support where nurses who intended to leave had a lower mean score (M = 2.95, SD = 0.88) than those who intended to stay (M = 3.18, SD = 0.88), t (393) = 2.51, p = .01). Mean scores were also lower for nurses who intended to leave on Resources and Information, but these differences were not significant after correction. Finally, nurses who intended to leave reported significantly lower overall structural empowerment (M = 18.49; SD = 3.70) than those who intended to stay in hospital nursing (M = 19.88, SD = 3.53), t (393) = 3.63, p < .001.

Research Question 3
Nurses with a baccalaureate degree or more and those who were enrolled in school had significantly higher odds of intention to leave the hospital bedside... Variables on which there were significant differences between nurses intending to leave and those intending to stay (highest degree in nursing; enrollment in school; years of experience, and overall structural empowerment) were entered into the binary logistic regression model. Nurses with a baccalaureate degree or more and those who were enrolled in school had significantly higher odds of intention to leave the hospital bedside than those with less education and who were not enrolled in school. Nurses with 11 or more years of experience had significantly lower odds of intention to leave than those with less experience, and every unit increase in structural empowerment was significantly associated with lower odds of intention to leave.

Because of the strong relationship between satisfaction and turnover intent demonstrated in the literature, as well as the relationship between job satisfaction and the practice environment (Al Maqbali, 2015), four items assessing job satisfaction collected for the larger study were combined and added to the model as a predictor of turnover. The four satisfaction items included a global assessment of satisfaction on a 4-point scale and three items assessing whether or not the respondent would do the following: take the same type of job again given current knowledge of the job; choose the type of job again given the choice of any job; and recommend the job to a friend. When entered into the model, every unit increase in satisfaction predicted lower odds of intent to leave, and structural empowerment was no longer a significant predictor. Further, the removal of structural empowerment as a predictor and addition of job satisfaction improved the overall model fit (AIC = 419.44) compared to the original model (AIC = 427.31).

Table 3 shows the final predictive model in which nurses with a baccalaureate degree or higher had almost 3 times greater odds of intention to leave than nurses with less than a baccalaureate degree, and nurses enrolled in school had almost 5 times greater odds of intention to leave than nurses who were not enrolled in school. Nurses with 11 or more years of experience had lower odds of intention to leave, as did nurses with higher scores on the composite of the 4 items assessing job satisfaction.

Table 3. Final Logistic Regression Model for Predictors of Turnover

Variable

B

SE B

Wald x2

p

OR

95% CI OR

Highest degree in nursing

0.53

0.13

17.28

< .0001

2.87

1.75 – 4.71

Current school enrollment

0.78

0.14

29.77

< .0001

4.77

2.72 - 8.36

Years of experience (0-10 yrs.)

0.41

0.13

10.31

.001

2.26

1.37 – 3.72

Job satisfaction

-0.30

0.06

23.45

< .0001

0.74

0.66 – 0.84

Research Question 4
There were no differences on overall structural empowerment between nurses with a baccalaureate degree or more (M = 19.60, SD = 3.55) and those with less than a baccalaureate degree (M = 19.34, SD = 3.69), t (391) = -0.72, p = 0.47. There were also no differences between the groups on any of the subscales assessing the dimensions of structural empowerment. Nurses with a baccalaureate degree or more had a higher score for job satisfaction (M = 10.10, SD = 1.93) than nurses with less than a baccalaureate degree (M = 9.81, SD = 2.08), but this difference was not statistically significant t (391) = -1.45, p = 0.15). Interaction effects on intention to leave were examined between educational preparation and structural empowerment, as well as between educational preparation and satisfaction. Neither interaction was a significant predictor of intention to leave.

Discussion

Turnover of baccalaureate nurses from the hospital setting has cost implications... In this study, having a baccalaureate degree or more and current enrollment in school independently predicted turnover intention from the hospital bedside as a practice setting. Hospitals attempting to maximize surveillance capacity according to the organizational variables recommended by Kutney-Lee and colleagues (2009) might unwittingly set themselves up for turnover if this finding is replicated in other samples. In addition to loss of the direct benefits associated with baccalaureate nurse staffing, the turnover of nurses with more education contributes to staff “churn” (p. 104) and very likely has implications for diminished continuity of care, adverse events (Duffield, Roche, O’Brien-Pallas, & Catling-Paull, 2009), and inadequate staffing, which is independently associated with adverse events. Turnover of baccalaureate nurses from the hospital setting has cost implications both in terms of turnover and when hospitals offer tuition reimbursement for nurses to earn the baccalaureate degree.

In this sample, nurses with 11 or more years of experience intended to stay, further supporting earlier findings in the literature that nurses with more years of experience are less likely to turn over (Hayes, et al., 2012). It is unclear whether or not the turnover of nurses with more education is offset by the retention of nurses with more experience, but studies demonstrating the independent effect of nurse educational preparation on patient outcomes suggest this is not the case.

...the question of whether or not a superior practice environment can retain nurses with more education and in which types of units remains to be studied. McHugh and colleagues (2011) documented higher dissatisfaction among hospital nurses in direct care roles compared to nurses in other roles. Their findings are likely a reflection of the “hard” (p. 379) work that is the nature of hospital bedside nursing (Bogassian, Winters-Chang, & Tuckett, 2014) and the vulnerabilities it entails (Choi, Pang, Cheung, & Wong, 2011). Insofar as work environment can mitigate job dissatisfaction among hospital nurses (McHugh, Kutney-Lee, Cimiotti, Sloane, & Aiken, 2011), the current study did not find interactions between either educational preparation and practice environment or educational preparation and satisfaction on intent to leave, and the question of whether or not a superior practice environment can retain nurses with more education and in which types of units remains to be studied. It is particularly noteworthy that one study identified vigilance—the very activity that is enhanced by baccalaureate nurses at an organizational level-- as contributing to exhaustion and turnover among bedside nurses (MacKusick & Minick, 2010).

Career mobility and the need for nurses in expanded roles might put hospitals at a growing disadvantage as more nurses achieve the baccalaureate degree and beyond. Weathers & Raleigh (2013) foresaw this dilemma and suggested it might be more cost-effective for hospitals to hire associate degree nurses and offer tuition assistance than to incur turnover costs associated with baccalaureate nurses. The findings of the current study that almost half of those enrolled in a baccalaureate program intended to leave suggest Weathers and Raleigh correctly predicted the potential “tradeoff” (p. 473), or that these nurses might choose to leave once they have earned their degrees.

Often, nurse faculty recommend starting out in hospital nursing when there is no evidence to support this advice. In addition to the difficulty of the work and the shortcomings of many hospital practice environments, many new nurses likely enter the hospital setting with little intention of remaining there for any length of time. Often, nurse faculty recommend starting out in hospital nursing when there is no evidence to support this advice. Perhaps their guidance emanates from nursing’s history of educating nurses in hospitals for later independent practice in the community. It is tacitly understood that the hospital is the launching point for nurses. The movement of more care to the outpatient setting, leaving the sickest and most vulnerable patients in hospitals, warrants a reevaluation of this understanding. Nurse faculty and other nurses to whom new nurses turn for career advice should refrain from dispensing advice that is not evidence-based.

It is tacitly understood that the hospital is the launching point for nurses. One possible solution for the turnover of baccalaureate nurses from the hospital bedside might be an intentional re-envisioning of the acute care hospital setting as one specialty among others with commensurate hiring practices, recognition, and advancement opportunities that include salary adjustments. Higher salaries for nurses who demonstrate a commitment to the hospital bedside might offset turnover costs of nurses who only intend to accumulate experience and move on, but they must be coupled with favorable practice environments. This study, like many others, found that a positive practice environment and higher satisfaction scores predicted less turnover intent. A focus on leadership development will be crucial to improving practice environments (AMN Healthcare, 2017).

Research is needed to elucidate the particular competencies necessary for excellent hospital bedside nursing, the temperaments of nurses who are more successful in this environment, and the effects of advancement opportunities, such as meaningful clinical ladders. More research is also needed about the interaction between nurse experience and educational preparation on patient outcomes.

If nursing at the hospital bedside is treated as a specialty, then nurse educators must reflect on curricula, which are often acontextual in terms of the settings in which care is delivered. For example, adult health or traditional “med-surg” courses often cover topics from primary care nursing through post-discharge nursing. This may contribute to unrealistic expectations for the scope of care that nurses can reasonably expect to deliver at the bedside in the setting of the acute care hospital.

One possible solution for the turnover of baccalaureate nurses from the hospital bedside might be an intentional re-envisioning of the acute care hospital setting as one specialty... Additional research is needed to replicate these findings and overcome the limitations of this study, which include a cross-sectional design and non-probability sample of respondents. Sampling nurses from one health system in a rural geographic location limits the study’s external validity. Finally, the dependent variable of turnover intent does not necessarily capture actual turnover, but Brewer and colleagues (2015) did document a clear relationship between turnover intent and actual turnover at the unit level.

Conclusion

The relationship between educational preparation and nurse turnover from the hospital bedside threatens patient safety in that setting by diminishing surveillance capacity. In order to keep hospitalized patients safe, the hospital bedside should be re-envisioned as a nursing specialty so as to retain a segment of baccalaureate nurses in this setting.

Authors

Mary Jane K. DiMattio, PhD, RN
Email: maryjane.dimattio@scranton.edu

Mary Jane DiMattio is a nurse educator with a passion for preparing and retaining excellent nurses at the point of care. Her program of research focuses on innovative models for clinical education and retention of baccalaureate nurses in the hospital setting. With her colleagues, she was the recipient of the NLN’s Ruth Corcoran Grant for Nursing Education Research in 2012 and has co-authored articles on topics pertaining to academic-practice partnerships and the clinical learning environment. She currently chairs the Board of Trustees at Regional Hospital of Scranton, a Commonwealth Health Hospital.

Adele M. Spegman, PhD, RN
Email: amspegman@geisinger.edu

Adele Spegman is a nurse researcher at an integrated health system, where she promotes nurse-initiated studies, assists novice researchers, and leads clinical research teams. Dr. Spegman’s current research focuses on nurses’ work environments, strategies to sustain healthy behaviors, and use of electronic data to examine nursing outcomes.

References

AACN. (2017). Employment of New Nurse Graduates and Employer Preferences for Baccalaureate Prepared Nurses. Retrieved from http://www.aacnnursing.org/News-Information/Research-Data-Center/Employment/2017

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© 2019 OJIN: The Online Journal of Issues in Nursing
Article published April 30, 2019


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