Abstract
Nursing turnover remains problematic, yet research with nurses is scarce in India. Turnover intentions were examined in this study to identify the critical reasons of the problem and to provide hospitals with information regarding job satisfaction as it is associated with turnover intention. Interviews were conducted with 144 nurses and top management personnel from eight hospitals in southern India. Using critical incident technique, we compared high attrition hospitals (HAH) with low attrition hospitals (LAH) and identified three key themes that distinguished them: the nature of the organization, the nature of employees and human resources (HR) paradox for turnover intentions. The research results could help identify strategies for hospitals that will minimize the high turnover rates while optimizing the levels of staff retention by providing effective work environment and career advancements.
Introduction
Nurse turnover is an ongoing problem in most countries and has become an intense issue in recent years (World Health Organization, 2006a). A number of countries have been working hard to overcome the turnover issue. The turnover and retention of nurses seem to be entangled with one aspect affecting the other. Existing studies have identified various reasons for nurse turnover, including but not limited to job satisfaction (e.g., Andrews & Dziegielewski, 2005., Cortese, 2007, Hairr, Salisbury, Johannsson, & Vance, 2014, Palmer, 2014) work stress, low salary, lack of recognition (Nguyen et al., 2008); excessive work load to remaining staff (Rajan, 2013); and international job opportunities (Guardian News Service, 2004). More studies have been conducted about nurse turnover and related issues, mostly in Western countries with a few exceptions in Asia—Malaysia, Taiwan, Singapore, China and Philippines (Cai & Zhou, 2009; Fang, 2001; Lorenzo et al., 2007; Omar, Abdul Majid, & Johari, 2013). Although it is logical to expect that nurse turnover would affect patient care in hospitals, we know very little about nurse turnover in India. More importantly, research done in the past has examined the issue using only nurse’s responses and little effort has been made to interview hospital management to identify the retention strategies for nurses. Therefore, in our research, we contribute by examining turnover intention with nurses, while simultaneously examining retention strategies with the hospital management in India. Since there is no universal reason for nurses’ leaving the job, understanding the causes for turnover should provide an opportunity for hospital administration to address the issues and make appropriate changes to retain nurses. We summarize the above by presenting the following research questions for this study: (a) What combination of individual and organizational factors lead to turnover? Specifically, (i) What types of nurses are more likely to quit the job than others? (ii) What types of organizations are more effective in reducing turnover? (iii) What types of HR practices are more effective in retaining nurses? (b) What factors affect nurse turnover intentions in India (similar/different to other countries)? We first present a review of the literature regarding nurses’ intention to leave their job.
Literature on Nurse Turnover
One of the major problems confronting the health care organizations around the globe is nurse turnover. Turnover in this study is viewed as the nurses who leave their respective jobs from hospitals. The turnover issue has triggered many researchers to identify the associated reasons, as it not only interrupts the patient care, but also the hospital administration as they have to constantly recruit and train nurses. Most of the research has identified the important reason for turnover intention as (a) job satisfaction (e.g., Hairr, Salisbury, Johannsson, & Vance, 2014; Palmer, 2014) and (b) work related stress (Kumar, Sahoo, & Duari, 2015). The nurses’ intention to quit their jobs doubles when the level of job satisfaction passes from ‘very satisfied’ to ‘somewhat satisfied’ (Cortese, 2007). Furthermore, nurses leave their job assuming that low job satisfaction is unlikely in another hospital or in a different career. Nurse turnover is even worse in developing countries as trained nurses are hopping to international locations for better salary, benefits and working conditions (Omar, Abdul Majid, & Johari, 2013). As many developed countries face acute shortage of nurses, they poach nurses from developing countries. Existing studies have identified that the nursing profession experiences a higher turnover rate when compared to other professions. For example, turnover rates have been reported to be 10 per cent in Taiwan (Zurn, Dolea, & Stillwell, 2005), 15–39 per cent in England, 17 per cent each in Canada and Germany (Aiken et al., 2001), 20 per cent in Australia (Hogan, Moxham, & Dwyer, 2007), 23 per cent in the United States and 30 per cent in Scotland (Aiken et al., 2001). The turnover intentions across the globe differ among nurses. For instance, USA nurses reported low morale, job dissatisfaction and number of patients assigned to them as their reasons to quit (Griffeth, Hom, & Gaertner, 2000; Hairr, Salisbury, Johannsson, & Vance, 2014). In Uganda, nurses quit their jobs due to work stress, low salaries, desire for professional development (Nguyen et al., 2008). Ecuadorian nurses’ turnover intentions are associated with their salary dissatisfaction (Palmer, 2014). These results suggest that there is no universal reason for nurse turnover.
Indian Context: Nursing Turnover and Retention
The Indian culture is often labelled as an amalgamation of various cultures which influences the working style of individuals (Srinivasan & Chandwani, 2014). India is unique in many aspects related to health care services, and particularly nursing continues to be seen as a female dominated profession (Rajan, 2013). The rapid developments in the health care sector in India attract more foreigners for the excellent health care service at affordable prices when compared to their home countries. To cater more patients, many new hospitals are being set up and existing ones have been expanded. This has created a huge demand for nurses. Although more nurses are available in the country, hospitals are facing acute shortage of nurses as most of them quit their job for better salary in the domestic as well as in the international market. Employee turnover has increased over the last decade especially in hospitals. In addition to the recruitment of nurses, meeting their needs to retain them is a huge challenge for the HR personnel (Srinivasan & Chandwani, 2014). The major reason for this tremendous change is the growth of health care industry in recent years, from a level of mere survival in the past to a current demand for excellence. In urban areas, many hospitals provide unique health care services which has created a tough competition among hospitals. This competition has forced the hospitals to have adequately skilled manpower for such services.
Officially, India has a surplus of nurses (8 million today against 3.8 million in the last decade (Guardian News Service, 2004). As a result, many developed countries are poaching nurses not only because India has more nurses, but also because they speak fluent English, and they are predominantly young (under the age group 30). For instance, Britain is one among the many countries that imports nurses from India (Guardian News Service, 2004). Although surplus nurses are available in India, nurse shortage occurs at every level of the health care system (Bulletin of World Health Organization, 2010).
Despite the challenges faced by health care administration to deal with attrition of nurses in India, there is relatively little empirical research done to identify the nurses’ intention to leave, and the hospitals retention strategies. A thorough understanding of why nurses leave their jobs requires the knowledge of the nurses’ perceptions regarding the decision to leave their respective jobs. The nurse turnover research done so far has mostly focused on Western countries and very few attempts have been made in India, most of it in rural areas (e.g., Dasgupta, 2015; Rajan, 2013). This study focuses on hospitals in urban and semi-urban areas. It is worthwhile to do research in India to identify the reasons for turnover as the leaving intentions differ greatly from one location to another. Also, existing research has focused only on one side, namely, nurses to identify their turnover intentions and no measures have been taken so far to identify the retention strategies of hospitals. To our knowledge, studies such as ours have not been done in India. Therefore, our research aims to identify the turnover intention of nurses and the retention strategies of hospitals.
Methods
In consideration of its descriptive purpose, this research has been pursued within a qualitative perspective, based on the use of narrative interviews (Gabriel, 2000). Additionally, qualitative research provides a deeper understanding and insight into the everyday realities of the nurses’ experiences from the perspective of nurses themselves. The research aim is to detect patterns and develop theory on nurses’ intention to stay or leave their respective jobs; hence we used an inductive approach. Eight hospitals (various sizes, locations, private sectors and urban location) were included in this research, for which data were collected through semi-structured interviews which included open-ended questions. All the participated hospitals were located in Southern India, and have been providing different kinds of health care services to both domestic and international patients. To maintain the confidentiality of the hospitals, we assign them codes such as ALA, BA … AP. The profiles of the hospitals are detailed in Table 1, and the number of participants is detailed in Table 3.
Themes Identified from Content Analysis of Interviews
Number of Respondents in Participating Hospitals
Demographic Characteristics of Participants
Initially, twelve hospitals were contacted of which eight hospitals agreed to participate in our research. The management personnel were contacted first to seek permission to conduct interviews, and to explain the objective of this research before data collection. The interviews then took place with both managers and nurses within the hospitals. Seven management personnel were interviewed (one was not available; Table 2) in addition to 137 nurses of different levels including novices and experienced staff such as superintendent (see Table 2). Demographic data showed that the average age group of nurses (79.7 per cent) was in 20s and 84 per cent were female. Most of the nurses (75 per cent) were between entry level and mid-career stage in their profession. 86 per cent participants were working as staff nurse. These statistics showed that most of the nurse participants were young, had worked at the hospitals for a considerable amount of time (Table 2).
Two separate interview guidelines were used, one each for nurses and management personnel. Primary questions guiding the interview were supplemented with sub-questions that served as prompts in order to enable participants’ to relate their responses in their own words. We asked identical (main) questions to all the respondents, but the responses were open-ended, which enabled the participants to provide detailed information based on their experience, while at the same time enabling us to pose follow-up questions. The follow-up questions were asked to obtain more clarity and in-depth coverage of responses. The interview guidelines were developed on the basis of a broad review of theoretical and empirical literature on nurse turnover. By asking managers about different HR practices and different ways in which they manage the work environment, we aimed to unearth several factors related to job satisfaction, work stress identified in the literature review. Similarly, by asking nurses their perceptions of available career opportunities, work environment, participation in decision-making in work (see appendix for interview questions), we aimed to discover factors related to job satisfaction, intention to stay or quit job, etc. identified in the literature review.
The hospitals of different sizes were chosen randomly through personal contacts in southern India over a month period. One time face to face interviews with 144 individual interviews with nurses and top management were conducted, with an average duration per interview of one hour. All the interviews were conducted in English. Detailed notes were taken during the interviews and transcribed in unabridged form (Miles & Hubermann, 1994). The interviews were entered in a spreadsheet first and were subsequently coded. Words or short phrases were assigned codes that best captured the meaning of the participant’s expressions. Codes emerged during several readings of the responses and labels were assigned based upon the text and revised accordingly as new data were analyzed (Miles & Hubermann, 1994). The coding process entailed extracting relevant categories, themes and concepts from the data. The aim of content analysis was to identify the most frequent reasons for turnover intention by nurses, and the retention strategies by hospitals. This analysis resulted in developing narratives, quotes, which served as exemplars (Sommer & Sommer, 1991). In explaining the nurse turnover, we used relevant codes to rearrange the evidence into categories that facilitated the comparison of evidence within and between interviews. For instance, we searched for themes in the interviews which occurred with the nurse turnover intentions. These themes are (a) the nature of the organization, (b) the nature of the employees and (c) HR paradox. Throughout the data analysis, we identified new emerging themes and explored new relationships between the concepts. The results which we have identified in this research were shared with the hospital administrators. In general, they agreed with our conclusions and interpretations. They also suggested some minor modifications which were included in the final analysis. Two researchers coded the data independently in most of the cases, and any differences (initial agreement = 95 per cent) that arose in the themes were identified and reconciled, ultimately achieving agreement in all the cases.
Findings
Our intention was to distinguish nurses’ feelings and intentions to stay or quit in LAH and HAH. For this, we used traditional conventional method called the critical incident method. This method is based on the assumption that respondents such as subordinates, peers and superiors can provide description of effective and ineffective behaviour for a person or an organization (Yukl, 2006). We used this critical incident approach to separate the hospitals into low, average and high attrition categories using the following procedure. First, we interviewed the top management and asked them the following question: “Relative to other hospitals, what is the level of turnover in your hospital?” Additionally, we asked the nurses in the same hospital about their tenure and the average turnover of nurses in that hospital. We then matched the responses to these two questions. Through such procedure of cross validation, we were able to classify the hospitals into low, average and high categories. In other words, where top management said that there is low attrition rate, we found that nurses had worked in that hospital for longer duration (e.g., 5 nurses in AL hospital each working there for 20 years). Based on these classifications, we identified two hospitals in low attrition, five in average and one in high attrition rate. Based on the 144 interviews with top management and nurses, we identified three themes: (a) the nature of the organization, (b) the nature of the employees and (c) HR paradox, associated with nurse turnover intention. We describe the three themes below (refer Table 1).
LAH: 14 nurses (10.2 per cent) reported the following reasons for their continued loyalty: flexible working hours, good management, no hierarchy and extended help to family members; reasons unique to Indian hospitals. These factors (extended help to family members and flexible working hours) were not found in studies outside India. For instance, one respondent working in ALA hospital made the following comment: “My daughter is studying in 10th grade. To support my daughter in her exams, management allowed me to work on flexible hours the whole year.” Another respondent commented: “My son was going from school to college. The hospital management provided references and financial assistance.” These factors are unique to India and one of the principal reasons for high loyalty. We identified that there is a good relationship maintained between management and the nurses. Based on this mutual understanding and strong relationship, nurses are just monitored on their performance, there is no formal performance evaluation. Nurses were assigned a variety of tasks, and were actively involved in all the hospital activities (broad job description). These are characteristics of flexible organizations. Therefore, we classified the nature of the hospital as flexible. For instance, the nurses’ working in ALA and BA hospitals have documented the following:
We like to work for this hospital as we have good relationship with the management. The doctors are very good and treat us well.—ALA 3 I like this job as we have good understanding with the management; and the doctors are very good.—BA 13
From the above statement, we can understand that the nurses are happy working for the good working environment, and better understanding between the management and nurses.
Average Attrition Hospitals (AAH): 33 nurses (25 per cent) documented other factors for working in the hospital: flexible duty hours, family reasons, hostel facilities (unique to India) and to learn more in job. Under this category of hospitals, the nurses were working for long hours (72 hours a week). Although the working environment was good; there is a power distance between management and the nurses. Also, the administration lacks in providing basic facilities (coffee breaks, toilets and rest area). Hence, we classified this category of hospitals as semi-flexible. For instance, the nurses working in hospitals SM, SP and LI remarked the following:
I like this job only because the working hours are flexible.—SM 34. There is a lot of stress in this job as we have to work for 12 hours a day, with only 15 minutes break for lunch. The doctors and management sometimes show their tantrum on us.—SP 30. I prefer to work for this hospital because it is close to my house, and the working hours are flexible. But management still did not provide the basic facilities in hospital.—LI 4.
From the above quotes, we can identify that the nurses are working in the respective hospitals due to the convenient location and flexible working hours. At the same time, a nurse (e.g., SP 30) reported that they work for long hours and the management is somewhat rigid with the employees.
HAH: 67 nurses (49 per cent) reported the reasons for working in the hospital: International brand name, technological advancements and the unique health care services. Nurses were assigned specific tasks and they were evaluated on their performance on frequent basis to identify the training needs, and to check their competency level. Some nurses’ (n = 17 per cent) reported that the hospital has strict guidelines (protocols) and the working environment is unfriendly. To some extent, the above statement suggests that the working environment is rigid. Therefore, we classified the nature of this hospital as bureaucratic and mechanistic. Most of the nurses documented below their willingness to work for the hospital:
We work in this hospital for JCIA accreditation, super brand name, good environment, technological advancements in healthcare; apply for job abroad with the experience gained here.—AP 55, 63, 65, 76 and 85. There is no respect for nurses. We don’t like to work here because of the pressure by superiors, more stress at the job and unfriendly atmosphere.—AP 68, 83 and 72.
The above quotes suggest us that the hospital has a super brand name and nurses like to work for the technological advancements in health care and JCIA accreditation. At the same time, some nurses reported that the nurses have more stress in their job and the working environment is unfriendly. Based on the preceding discussion, we understand that there are significant differences in the nature of the organization between hospitals of different attrition rates. Specifically, LAH were more organic (e.g., flexible, broad job description and informal performance evaluation) whereas HAH were more bureaucratic (e.g., rigid, formal performance evaluation and strict protocols). The nature of the organization (e.g., degree of flexibility and/or mechanistic/organic) has a strong relationship with nurse turnover. Therefore, the more organic an organization is, the less turnover it experiences. Conversely, the more mechanistic an organization is, the higher the turnover it experiences.
LAH: We identified that most of the nurses were working for a long time (20 Years) in the same hospital. They provide good patient care and help the hospital achieve its objective. They were partially involved in making the decision along with doctors. But the nurses worked in the same level since their joining and there were no career advancement opportunities except increases in pay. We observed that the nurses working in LAH do not have high career aspirations. There were relatively less opportunities for nurses to grow within the organization. Hence, we identified the nature of employees as with low career aspirations. Some nurses from ALA commented below:
Career advancement opportunities are stable in this hospital. Based on seniority and experience, promotion will be given.—ALA 6 and 7.
The nurses were happy working for this hospital, but the opportunities for career advancement are limited. Hence, the nurses have low career aspirations. Therefore, career aspirations influence the nurse’s intention to stay or leave. Nurses working for LAH are likely to have low career aspirations.
AAH: Nurses working in these hospitals were willing to learn new things in their profession such as assisting in deliveries, surgeries and so on. The hospitals provide little opportunities with additional responsibilities for the nurses, but without any upgrade in the position. Nurses were making basic decisions for first aid and emergencies. Other decisions were taken by the top management. We observed that the nurses working for AAH were seeking for more opportunities to learn in their career, whereas limited growth opportunities were provided. Some of the nurses working under these hospitals stated that there is a “Glass Ceiling” which prevents them to obtain upper level positions. As a result, many of them were likely to quit their respective jobs in search of better career opportunities. Based on the above, we categorized the nature of employees as average career aspirations. Some nurses working for the hospital documented the following:
Career advancement opportunities are given in the form of additional responsibilities in the task. But there is no upgrade in the position.—SP and SR hospital nurses.
From the above comment, we can identify that hospitals provide career opportunities to nurses in the form of additional responsibilities. Hence, the nurses are somewhat motivated to work and have average career aspirations. Therefore, career aspirations influence the nurse’s intention to stay or quit. Nurses working for AAH are likely to have average career aspirations.
HAH: In contrast to the above two categories of hospitals, nurses working for HAH were found highly enthusiastic. Some (20 per cent) nurses were making efforts to go abroad and pursue higher studies for better career advancement opportunities. As the hospital meets international standards, provides unique health care services in the region, more opportunities were available for nurses to grow within the organization through on-going training programmes and staff development programmes (e.g. attendance at international seminars and conferences). The hospital provided more opportunities for them to learn and move up in their career ladder. Empowerment is given to the experienced nurses for making decisions holding them responsible and accountable for outcomes of their actions, which contribute to their competence and satisfaction. As the employees were always looking for challenges, additional responsibilities in their career, we classified the nurses in this hospital as having high career aspirations. Nurses wanted to work for this hospital mainly because it served as an excellent launching pad for their international career. These nurses compared themselves with people in other professions where salary levels were relatively higher. Therefore, although this hospital provided higher career opportunities than LAH or AAH, these were not sufficient enough for the nurses with relatively high career aspirations. Many nurses working in HAH quoted below:
If we work in this hospital for 3–4 years, promotions are given. Experienced nurses involve in making decisions. Selected nurses are given opportunities to attend international seminars. Parallel growth is given such as nurse education, wound management which is sponsored by the hospital.—AP nurses.
From the above comment, we can understand that nurses working for this hospital are having high aspirations. Experienced nurses were authorized to make important decisions; additional responsibilities were given to nurses to motivate them who look for challenges and advancement in their career. Hence, the nurses have high career aspirations. Therefore, career aspirations motivate the nurse’s decision to stay or leave. Nurses working for HAH are likely to have high career aspirations.
Selection Criteria of Nurses: Based on the interviews with the top management, we observed that there is a huge difference in selection criteria of nurses across the three types of hospitals. Some nurses in LAH do not have required qualification to perform nursing tasks. Opportunities were given to those who were dedicated and committed to this profession. This situation is mostly true for hospitals located in tier 2 cities as it is difficult to find qualified nurses to work in these locations. Hence, the hospitals provided opportunity to those who were interested and passionate to work in this profession. The hospitals provided many benefits such as: (a) flexible working hours for those who travel from long distance; (b) provide educational support to employee’s children and (c) offer free food, computer courses and accommodation for the needy to motivate and retain the nurses. The story is slightly different in AAH. All the nurses working for these hospitals had the required qualification. Additionally, more experienced nurses were selected for senior positions, and less experienced were recruited for general nursing positions. These hospitals provide some benefits for the nurses: (a) flexible working hours for employees with kids and (b) free food, accommodation and transportation. In contrast to the above cases, HAH followed formal selection procedure to select nurses. These procedures involve various components such as written test, skills assessment, critical thinking test and knowledge assessment to select the right talent for the position. It is common in India that most of the hospitals provide free food, accommodation and transportation to the nurses, which is a unique factor in Indian hospitals.
Training: Training is an important tool used by hospitals to improve nurse’s productivity and performance. Intense training was given to all the employees except for those who have previous experience in all the three types of hospitals. Despite the commonality in the areas of training, there were clear differences across hospitals in the nature and scope of training. In LAH, job content training was offered to all non-qualified people. In HAH, training was given to all the nurses, with or without prior experience. Additionally, training was an on-going process and it was provided when nurses’ performance was not meeting the standards based on the needs assessment resulting from performance appraisal. For instance, the Nurse Director from HAH documented the following:
Career path is clear for nurses. We show various avenues for meeting their needs through staff engagement program and provide competitive salary. Nurse Counselor is kept exclusively for training, and makes the nurses comfortable at work.—Nurse Director, AP Hospital.
Performance Appraisal: Although the appraisal is used to assess an individual’s performance and productivity in jobs, the hospitals in our sample followed different procedure to evaluate the nurses. In LAH, as there was a good relationship between management and nurses, and most of them were working for a long time, the nurse’s performance was informally monitored and there was no formal procedure. This approach to managing people in India is unique and is influenced by culture. In contrast, HAH evaluate nurses once in 3–6 months to check for (a) training needs, (b) competencies and (c) reassessment, if the management is not satisfied with their tasks. In between these two types of hospitals, the AAH evaluate employees mostly in informal way (not in documents) for making important decision related to increment and promotions. The founder of LAH, the HR head in one of the AAH, and Nursing Director from HAH commented their voices about performance evaluation:
All nurses working here are good, experienced, and staying with us more than 10 years. As a result, we monitor their performance and no formal evaluation is done.—Founder ALA Informal evaluation is done once a year (not in papers). It is purely done for increments and promotions of nurses.—Head HR, SP hospital Performance evaluation is done end of 1st month for fresher’s. Evaluation is done once in 1 month, 3 months, and 6 months to check competencies, and training needs. Re-assessment is done if the nurse work is not satisfied.—Nurse Director, AP hospital
Benefits: As health care organizations face acute shortage of nurses; hospitals provide some kind of benefits to retain the talent in competitive market. AAH offer attractive and innovative benefits ranging from retirement schemes (mostly for public sectors) to benefits such as employee provident fund (EPF), employee savings insurance (ESI), educational support to children and so on. The nurses in AAH receive benefits in the form of free food, accommodation, transportation and subsidized health care prices for family members. The HAH support nurses’ international conferences, sponsored certified programme for career development in addition to free food and transportation.
Retention Practices: Retaining the employees is the biggest challenge faced by health care sectors in India. Hospital management is taking efforts to minimize the nurses’ turnover thereby decreasing recruitment costs, loss of talent and training costs. We identified various strategies adopted by hospitals to retain the talent: LAH provides good working conditions; fulfil nurses’ needs, benefits and maintains a good relationship with them. In comparison, AAH provides good salary, safe work environment and benefits. HAH provides competitive salary, comfortable working environment and on-going training to upgrade the knowledge. As can be seen from above, whereas competitive salaries are offered in HAH, the salary offered in LAH is relatively lower. Next, whereas in HAH sufficient opportunities were provided for knowledge enhancement and job engagement, these were missing in LAH. Overall, whereas the higher levels of attrition were characterized by a professional or comfortable working environment, those with lower levels of attrition were characterized by increasingly higher levels of friendly and familial working environments. The management respondents remarked below the retention strategies they practice in their hospitals:
We provide family atmosphere, pension, meet their needs, maintain good relationship with the employees, very flexible, and understanding.—Founder ALA and BA hospitals We provide good salary, free food, healthcare, and accommodation, friendly to nurses, encourage them and warn if they do something wrong.—Head HR and SP hospitals Provide competitive salary; career advancement program; on-going training program to improve the skill level of nurses; and make the environment comfortable.—Nurse Director, AP hospital
Based on additional analysis, we identify and highlight key reasons for nurse’s intention to quit. The hospital administrations sometime believe that nurses quit their jobs mostly for money. Although this is partially true, there are other factors as well. A significant factor is that most people leave because of their supervisors and working conditions. An inefficient boss creates poor work culture, which is one of the frequent reasons for quitting. There are also cases when people leave their jobs for family reasons. This is common in India where women employees leave their jobs when they get married and migrate to another place. Employers often fail to understand the importance of providing opportunities for development of their employees or their career growth. Hospitals have limitations in providing a robust career progression plan. When employees realize that there is no advancement in their career, they are likely to quit their jobs. A conducive working atmosphere, good culture, training and career growth with adequate salary are some provisions that control attrition.
Discussion and Implications
As nurse turnover is challenging for many hospitals, very little is known about nurse turnover in India. More importantly, research done in the past has examined only the nurse’s perspective, and little effort has been made to interview hospital management to identify retention strategies. Our results show that there are three main factors associated with nurse turnover and satisfaction related to three main themes: the nature of organization, the nature of employees and HR investment paradox. These findings were derived on the basis of interviews with both nurses and top management which contributes to the literature. Our first finding is about the nature of the organization. Extant literature has hitherto not addressed the nature of organizations related to nurse turnover. Our findings suggest that turnover increases with the level of bureaucracy in the hospitals. Therefore, the nature of organizations in hospitals is a critical influencing factor in the context of nurse turnover. We contribute to the literature on nurse turnover which has hitherto not addressed this factor.
Our second finding is about the nature of employees. Our findings suggest that nurses with low career aspirations stay in the hospitals. Such people do not change jobs frequently. In contrast, nurses with high career aspirations, do not stay in the hospitals especially when career advancement opportunities are relatively low. Hence, the match (mismatch) between career aspirations and the career advancement is a critical factor. These nuances have not been identified before. Gender is a critical factor when discussing the nature of employees. In India (but not in other countries), it is common for women employees to leave their jobs at the time of their marriage. It is also true that these women nurses have low career aspirations relative to others who are not subject to societal restrictions. Although some studies (Collins et al., 2000; Dawson, Stasa, Roche, Homer, & Duffield, 2014) have identified the lack of career prospects as a critical factor in nurse turnover, our findings focus on the match/mismatch between career aspirations and career prospects.
Our third finding is about HR investment paradox. Our findings suggest that hospitals that make more investment (not simply expenses) in a broad range of HR practices (e.g., recruitment, selection, training and development, employee empowerment, performance appraisal, compensation and benefits) also face higher levels of nurse turnover. This finding is critical because of the nature of the labour market in India relative to most developed nations. India is unique in which hospitals draw from an unskilled labour pool but compensate for the lack of skills with intensive training. Additionally, the hospitals engage these nurses in multiple task domains which contribute to job enlargement and subsequently to their satisfaction. These hospitals are able to retain the nurses without investing in sophisticated performance management, compensation and retention strategies. Some studies have focused on nurses’ compensation (Palmer, 2014) and very few studies have examined other HR practices such as selection, performance appraisal and retention strategies. We contribute by examining all HR practices together.
In general, hospitals now realize that nursing turnover not only affects the patient care but also interrupts the administration activities. Therefore, hospitals should provide salary that matches their experience, recruit more nurses to meet the demand in the market. As a result, nurses may not work for long hours as that was one of the major reasons they were unable to cope with work and family. Hospitals should consider this fact and take fair steps to retain skilled employees. Based on our analysis, we suggest that hospitals should provide a balanced emphasis on growth versus recruitment strategies.
Nursing turnover is one of the biggest challenges for hospital administrators. The current study has identified a few factors which would warrant most attention in controlling turnover among nurses. At the top is a limited career advancement opportunity that is not matching with career aspirations of nurses. In this study, career advancements directly and significantly influence nurses’ turnover intention. HR investments should be matched with career aspirations of the available talent pool. It is important to track employees who are enthusiastic and excellent in their performance. Hospital management should motivate nurses by providing career advancement, compensation on par with the market standards to counter attrition. HR should carry out in-depth analysis of candidates’ backgrounds, adaptability, likes and dislikes, and make the organization flexible to minimize nurses’ attrition. Hospitals should create good work culture and work out different strategies in line with organizational philosophy. HR has to find a balanced approach between growth and recruitment strategies, and involve the nurses in making decisions.
This study has certain limitations which can be eliminated in future research. This study includes participants from one region, restricted geographical scope to Southern India. Also, all the participant hospitals were private sector. This raises some concern regarding the generalizability of results to other hospital sectors. One other limitation is with respect to the hospitals that were reluctant to participate due to the bureaucratic restrictions in obtaining clearance to participate. Two of these hospitals were known to have high attrition rates and have characteristics that are similar to one of our participants, namely, AP hospital. Since our study had only one high attrition hospital, more participants in this category would have added strength to our results. Future should include all hospital sectors and other regions in India to document turnover in nursing. Future research should also sample hospitals of different attrition levels.
In conclusion, recruiting and retaining nurses is becoming a major challenge in India. Attrition rate among nurses were the highest because of their high demand in foreign countries. The reason for nurses’ intention to leave is mainly a result of the tensions between nurses’ aspirations and the opportunities available for advancement. The reasons for nurses’ intention to leave are influenced by many factors which can be categorized into two types, namely, individual and management. Individual factors are mainly career aspirations, advancement and motivation. Management factors consist of poor relationship with nurses, unfriendly work environment and motivation issues. Therefore, management should maintain smooth relationship with employees, provide career paths and motivate nurses to increase the retention rate of nurses.
Footnotes
Interview Questions for Nurses