Sustaining working ability in the nursing profession - investigation of premature departure from work - (NEXT NURSES' EXIT STUDY) | NEXT NURSES EXIT STU | Project | Results | FP5 | CORDIS

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Background: One of the two worldwide most discussed stress models is the effort-reward imbalance (ERI) model by Siegrist (Siegrist J. Adverse health effects of high effort low reward conditions at work. J Occup Health Psychol 1996;1:2743). This model maintains that lack of reciprocity between efforts spent and rewards received (i.e. high cost / low gain conditions) in a core social role, the work role, defines a state of emotional distress in those who are particularly prone to autonomic arousal and neuroendocrine response and related adverse health outcomes. High efforts and insufficient reward are topics high on the agenda within the nursing profession. Here, effort often includes high emotional, physical and quantitative demands and reward comprises aspects such as - Pay (financial reward), - Recognition and respect within a hierarchical system and public image (esteem reward) and - Possibilities for development, career opportunities and job security (status control reward). Many of these aspects are closely related to the ongoing adjustments, which have been taking place since the early 80s to the health care sector turning it into an economic environment focused on management efficiency. Besides the effort component (assessing work demands), the items cover the three reward components as indicated above. In NEXT the instrument was used to investigate: - The degree of perceived effort and reward in the participating countries and in different health care settings, - The impact that effort-reward imbalance has on the nurses with respect to -- Physical health -- Psychological health -- Behaviour intention (intention to leave the nursing profession- ITL). In the analysis we have considered data from 24,328 nurses from seven countries. Results: - Perceived distress in nursing is not a consequence of increased intensity of demanding work but also of a lack of reward. - In nurses effort-reward imbalance is associated with an increased risk of poor physical and psychological health. - Substantial differences exist with respect to effort-reward imbalance (ERI) among nurses in Europe. There are four countries with extremely high ERI: Poland, Slovakia, Germany and Italy. - High effort-reward imbalance among the nursing profession may reflect the national economic transition (Poland and Slovakia) or transition in the health care system (e.g. Germany and Italy). In all instances it should be regarded as a warning signal. - The findings emphasise the need for esteem reward and status control reward in nursing, not only of financial reward. - Nurses with high ERI more often want to leave their profession. - Institutions with low ERI benefit from higher commitment to their institution and to the profession. Dissemination and use potential: - NEXT shows that the ERI model can be used as a valuable indicator in health care: In international benchmarking it identifies nursing professions in a crisis. In national benchmarking it identifies risk groups. The model has shown the potential to identify health care institutions as models of good practice. - The ERI instrument is a self-administered work stress assessment tool, which can be useful in work place health promotion. The instrument supports the implementation of specific intervention activities to reduce the burden of distress among nurses mostly concerned. Appropriate measures include human resources development as well as organisational restructuring based on needs of staff and the population served.

Main National Results of the NEXT study in the Netherlands Beatrice van der Heijden & Esther van der Schoot Some main outcomes of the Dutch part of the NEXT-Study: Based upon a categorization in three types of reasons we have divided the reasons for premature leave that were mentioned by the Dutch respondents as follows: - Individual causes: parental obligations, taking up further studies, moving due to partners job, having found a job abroad as a volunteering nurse, desire to stop working in shifts, personal development plans, physical and psychological health complaints, too much travel time, and overeducated as a health care scientist, - Work-related causes: bad job conditions, lack of participation in decision-making, high workload, having found a new/more challenging job, working climate, team atmosphere, dissatisfaction with job content, too much routine in current job, lack of job satisfaction, bad communication with direct supervisor, work conflict, dissatisfaction with personnel management, too much routine in current job, and - Socio-structural causes: opportunity for early retirement. It is interesting to mention that most reasons for premature leave can be linked to working conditions and work-related factors such as working climate, relationship with supervisors, dissatisfaction with shift work and so on. Our quantitative survey outcomes point out that the Dutch nurses main reasons for termination of the job (N=40) comprised: - Continuing professional development (5%), - Their perceived working conditions (32.5%), - Health reasons (5%), - Other private reasons (22.5%), and - Other professional reasons (35.%). None of the Dutch nurses indicated pay or time needed to take care of a relative as main reasons. Again we can conclude that working conditions and other professional or work-related reasons appear to be high importance in predicting premature leave. Study the impact that premature departure has on the individual Five variables referring to the impact that premature departure has on the individual have been taken into account in the quantitative part of the leavers questionnaire: (1) nurses general health, (2) personal burnout, (3) work ability, (4) sleep, (5) pain and/or disability due to low back pain and neck/shoulder pain. Our Dutch data indicate that nurses do not appear to suffer highly of health-related problems. Most nurses indicate to perceive their general health as good, in most cases they do not experience burnout, have high work ability, sufficient quality of sleep, and a low disability score. Presumably, Dutch nurses do not experience physical or psychological health problems, as a result of premature leave. It might be that for Dutch nurses the situation is the other way around, after having decided to leave, their perception is positively influenced. Possibly, this outcome indicates that people indeed want to have control over their personal life. After having made up their mind, health perceptions are good. Studying the longitudinal data from the NEXT study can provide insight into the direction of the relationships and might answer the important question: Do nurses leave because of a lack of individual well being? versus Do nurses experience a lack of individual well being because of premature departure? Please contact Beatrice van der Heijden (heijden@msm.nl) in case you would like to have more information.

The Slovakian health care sector is currently under transition. The main goals of the new health care reform are to introduce changes in terms of financial stabilisation of the system, to mobilise resources, to raise the efficiency of the system and to decrease the expectations of citizens. In relation to these efforts, there is an ongoing process of reconstruction of the health care network. Reducing the number of acute care beds, shortening hospital duration for acute patients and increasing the number of long-term care beds will have an impact on the size and need of nursing staff. To select the Slovakian institutions we used the Register of the Slovak Health Department and the Institute of Health Information and Statistics in Bratislava. According to the eight geographic regions and types of institutions, 93 institutions were selected. The study base almost perfectly represents the Slovakian distribution of nursing staff in 2001. Nursing staff working in hospitals comprised 83% of all participants, 13.9% and 2.2% of staff were working in old peoples¿ homes and in home care respectively. Females were on average older than their male colleagues. Of the 3,396 respondents, 5.3% of all nurses had thought about giving up nursing completely weekly or daily. Although female respondents had higher tendency to consider leaving effect size was not relevant. Younger nurses showed a higher intent to leave with maximum levels in the age group of up to 24 years. Nursing staff over 55 years of age considered leaving their profession the least. Institution type, qualification level, health and work ability and Burnout were not associated with the wish to leave the profession. Intent was higher at the beginning of their professional career. Those with less seniority in the institution had thought more about leaving the profession.

In order to represent the diversity of the occupational conditions in the French territory, we selected five different regions to create a partnership for a longitudinal study. These regions are distributed in the north as well as in the south of France. In each area, a sample of the various types of institutions was chosen with the assistance of the governmental agency in charge of hospitalisation (ARH). 55 institutions were selected to provide a sample representing the diversity in proportion to each type of healthcare structure in France. This sample is representative of the repartition between private and public sector, between specialties and representative of the different occupational level of HCWs in France. The national representative sample is made of 5,376 HCWs. For the total French sample of all occupational levels, the main reasons for dissatisfaction or strong dissatisfaction are: psychological support (expressed by 66.1 % of HCWs versus 50.3 % in Europe), Staff handovers when shifts change (53.7 % vs 37.1%), Physical working conditions ( 52 % vs 44.2%), Opportunities to give patients the care they need (49.5%vs 41.3%), Pay in relation to need for income (44% vs 53%), Work prospects (37.4% vs 40%), The way abilities are used (36.4% vs 31.6%). Healthcare workers of the European sample (versus France) declared suffering from the following disorders: - Injury due to an accident 13 % (18%), - Musculoskeletal disorders 52.8 % (56.2%), - Mental disorder 18.9 % (25%), - Skin disorders 27.7% (42.8%). Over half of HCWs in Poland, Slovakia, Belgium and France declared having had no sick leave in the last 12 months. Short sick leaves, 5 days or less, are far more frequent in Great Britain, Norway, The Netherlands and Finland. But more than 16 % of HCWs had more than 15 days of sick leave in France, Finland and Germany and less than 8% in Belgium and Norway. Studies about risk factors where conducted for each of these issues. Risk factors for frequent worries about making mistakes and exposition to violence where also studied. We conclude, that substantial reduction in healthcare errors and violent event will not come until more attention is given to human solutions, such as improving teamwork and communication in healthcare teams. These multivariate analysis conducted to the conclusion that it is necessary to prevent mental and physical disorders by better working conditions. To reduce early exit it is necessary to organise better work prospects and to assure better quality of care by team building and team support. It is important to note that HCWS with serious musculoskeletal disorders cannot find another job. They stay, and have frequent sick leaves. One year after, frequent ITL is still 13.3 % among the respondent to Q12 (higher among specialised nurses 17.1%). HCWs who changed their mind, and no longer intended to leave, described better conditions : worry about making mistakes decreased; Care needed to be done less rapidly; less lifting of patients without aid. HCWs who changed their mind, for ITL described worse conditions: Satisfaction about work prospects; Pride to belong to the institution; Variety of work; Influence on work schedules; Satisfaction with handover shift; Perceived health. Work unevenly distributed so that it piles up was more frequent. HCWs who exit and answered Qex left at normal retirement age (22.2 %) and premature (13.8 %). The bigest group of those who returned this questionnaire, found new employment within health care or were studying for a higher degree in healthcare (43.3 %). However, 12.8 % started a new job outside care and 7.9 % left for other reasons, mostly child care. HCWS having exited from their institution considered that contributed strongly to their decision: Low psychological support, Inadequate personnel numbers, Time pressures, Neduced nursing conditions for patients care, Inadequate occupational development opportunities. These longitudinal results confirm the major influence of mental health among HCWs with ITL and the good mental health among HCWs with intent to stay. Those who changed the institution and those who do not work anymore in care do not declare having bad mental health. Most of Qex have recovered good mental health. These longitudinal results confirm also the negative influence of back pain on ITL. On the other hand, a physician diagnosis of MSD is linked with fewer changes of institution. A project has been proposed to the Health Ministry to implement targeted measures into 28 out of 61 institutions involved in the NEXT study. Four Regions Councils are also discussing a regional implementation plan and we already have an agreement with Rhône-Alps Region. Languedoc-Roussillon Region is using these results through the regional social insurance preventive fund. Assistance Publique-Hôpitaux de Paris included targeted measures resulting from NEXT in its social plan 2005-2009 and its prevention plan.

Background: In almost all European countries there is a big concern about the negative consequences implied by the nursing shortage on the quality of care provision. The NEXT-Study started in 2001 and ran until June 2005. In Italy, the investigation was carried out by means of pre-validated questionnaires on a longitudinal basis. The assessment of reasons and possible consequences of premature departure from nursing was based on the NEXT-Study conceptual model, depicting "push" and "pull" factors related to retention and recruitment of nurses into the healthcare system. Sample: Nurses from public and private hospitals, long-term and home care services were sampled according to their distribution in the north, the centre and the south areas of the national territory. Out of a total of 7447 nurses approached in 2003, 5641 filled-in the baseline questionnaire. In 2004, 4088 nurses who remained in their institution also filled-in the follow-up questionnaire. Of the 466 nurses who left the institution, 139 answered the exit and 131 the follow-up exit questionnaire. The study was conducted in the course of profound changes in the Italian healthcare system, during an unstable political situation and an important phase of severe economical recession. However, significant measures were taken to ameliorate the professional profile of nurses through higher education, autonomy and managerial career opportunities. The Italian sample was characterized by: an high percentage of male nurses (25,9%) due to preceding unemployment rates in the south area and the impact of laws facilitating the entry of males into nursing; a low percentage of young nurses (9,1% <30y), since nursing was considered as not rewarding and with a poor social image; low percentage of old nurses (12% >50y) as a result of massive early retirement policies which were launched until recent years. Furthermore, Italian nurses were employed mainly in hospitals (86,3%), as transition to the territory was only partially accomplished. Finally, the Italian sample consisted of a low percentage of ward sister and nurse managers, since steps of vertical or horizontal career were still lacking or not yet well organized inside the healthcare institutions. Results: Nurses reported high intent to leave nursing (20,7%) and even higher intent to change institution. Among nurses who remained, intent to leave the profession was elicited mainly by higher emotional demands only in the younger, while in both the younger and the older by lower career perspectives and higher work/home conflict. Out of the 101 nurses who left the institution and also responded to the exit questionnaire after the baseline, 71 continued to work inside nursing (70,3%), 6 outside (5,9%), while 24 didnt answer the question. One year after exiting previous institution, nurses declared to be more satisfied mainly in relation to their health and private life. These 71 institution leavers were characterized by higher intent to change compared to stayers, higher uncertainty concerning treatment, worry about making mistakes and work/home conflict, more understaffing and wish to change work schedule. Compared to stayers, nurses <45 yrs old who left their job (N=210) reported more job demands and work-home conflict, were born outside the region of employment, were without children or without support for childcare and more willing to change work schedules. Nurses over 50y with higher perceived health status reported better working conditions and effort/rewards balance. A protected physical work environment and the possibility to share and discuss problems among colleagues and other medical and administrative staff sustained nurses work ability. Conclusions: In Italy, the major problems were related to fewer people entering nursing and to the high internal mobility among the younger. Different social parts involved in confrontation on these results proposed the following: providing nurses with the possibility to certificate patients care needs as a way to improve their professional image towards the public and the institutions, better territorial distribution of nursing education posts or establishment of grants and housing facilities for sustaining nursing students internal mobility, more selective criteria to nursing applicants in order to avoid subsequent loss of students not bearing a real vocation for nursing, mentoring for the young and valorisation of older nurses expertise, assigning adequate time to care provision within hospitals and/or creating continuity of care between hospitals and home care services, more institutional support for a better matching between healthcare staff planning and staff private life obligations, providing more time for handovers, providing more sustainable nurse to patient ratios and more worker-oriented flexibility and mobility, renegotiating nurses institutional spaces of autonomy to match up their tasks and engagements with their professional skills.

In NEXT, it was observed that nursing turnover was not uniform across hospitals. In the Belgian sample, figures varied from 0.6% to 13.1% during the NEXT investigation period. We compared low-turnover hospitals, defined as attractive, and high-turnover hospitals, defined as conventional. To interpret variations in turnover, we explored the antecedents of commitment, job satisfaction and retention, i.e. managerial practices and work environment attributes, which are relevant characteristics to examine. To define attractive and conventional institutions, we proceeded as follows : between September 2002 and September 2003, the number of nurses who had been present at Q0 and who had then voluntarily left the institution were recorded in the 16 hospitals recorded. An annual turnover rate could thus be computed. The institutions were then classified into four quartiles according to their turnover rate: (1) 0.6% to 3.1% (attractive hospitals); (2) 3.7% to 5.0%; (3) 6.3% to 7.4% and (4) 11.8% to 13.1% (conventional hospitals). We contrasted structural and organisational features of hospitals belonging to first and fourth quartiles. Significant differences were obtained for the following dimensions (p<0.05). In attractive institutions, nurses reported a higher satisfaction regarding the value of their work, in terms of better fit between work content and their professional nursing ideal, better fit between nurses, personal and professional values and the philosophy of care advocated by the nursing department, and patient centeredness. Attractive institutions had a higher score with regard to nurse autonomy defined as independent clinical decision-making in the best interest of the patient. Relationships between staff nurses and the hierarchical levels (from the head nurse to the chief nurse executive) were perceived as better in attractive institutions. In attractive institutions, nurses felt their workload to be more acceptable than in conventional institutions. Nurses reported that they were less frequently confronted with emotional demands and difficult and troublesome physician relationships. The burnout level was lower than in conventional hospitals. Finally, nurses in attractive institutions reported fewer work-family conflicts, due to a good balance between work demands at hospital (foreseeable and flexible work schedules) and personal life. As a whole, these features are typical of common variance sources: - Transformational leadership, associated with strong supervisor support, individual consideration, and impetus for improved nursing practice; - A high degree of organizational support associated with feelings of recognition and reward; - Fairness and justice in human resources management practices, resulting in feelings of meaningful and valued work; - Open and timely communication allied with some degree of formalization; - Good relationships between colleagues, between physicians and nurses, resulting in a good overall organizational climate, favouring trust and respect, and leading to a higher commitment. Dissemination of such NEXT results and further research should help hospital managers to identify the managerial practices and work environment attributes that lead to both a high level of quality of care and a good nursing staff attraction and retention. Acting on these attributes and creating a workplace that fosters retention might prevent the lower productivity caused by high turnover rates and help institutions in their human resources management. We can consider that such results and relevant management theory can lead our team into the development of a European model of attractive healthcare organizations.

Introduction. The financial situation in the Polish health care system is very difficult, and many entities including large hospitals - are threatened with bankruptcy. This situation has impact on perceived employment possibilities among nurses, which are much lower in Poland than in any other country participating in the NEXT-study. The above factors seem to explain why intent to leave nursing in Poland was rather low. Results. The risk of premature departure from the nursing profession was estimated on the basis of the question, How often during the last year have you thought of leaving the nursing profession? Among the 4354 Polish nurses, a majority (64.4%) claimed they did not consider such decision at all; less than one-fourth (24.6%)- thought less frequently than a few times during the year; and about one in ten persons (11%) - a few times during the year, or more frequently. The will to leave the profession was tied to age. It turned out that the persons from the two youngest groups (>30 and 31-40) think of leaving most frequently once a month or more often (15% and 11.6%, respectively)than those aged 41-50 (9.4%), and those who are above 50 years old (6.1%)- the least frequently. The only factor tied to professional differentiation and clearly influencing the will to leave work was the type of the workplace. Most frequently, thoughts on leaving were seen among persons working in intensive care wards (15%) and medical wards (12,2%), as well as in the day clinics/outpatient clinics (12.4%). This intention was the least frequent among nurses working in pediatric wards (6.6%) and nursing homes (6.4%). Identification of persons who left the nursing profession prematurely was made on the basis of Qex questionnaire, which covered those persons who in mid-2004 - that is, 12 months from the date of the first research (questionnaire Q0) - did not work for the same employer. In Poland, the Qexe was completed by 122 persons (98% of them were women). Among them, the most frequent formal reasons for leaving were: obtaining the retirement or disability entitlement (63.6%) and individual decision on leaving work (19.8%). Other formal reasons were: being fired by the employer (5.8%), terminating work due to other obligations (5%), expiry of the employment contract without the possibility of extending it (4.1%), or without the will to extend it (1.7%). Among 77 persons who retired, only a small percentage (7.8% of all retiring) reached the statutory retirement age which is 60 years in the case of women. Most of them have obtained earlier retirement pensions (36.4%), or the so-called bridge pre-retirement benefits (54.5%). Only 1 person left for a disability pension. The analysis of premature leaving the nursing profession covered two categories of persons. The first category comprised nurses who left on retirement and on other forms of benefits before reaching the retirement age. There were 71 such persons, and their average age was 53 years. Those persons, asked for the three main reasons for earlier retirement, named most frequently: job uncertainty (21%), the workplace being closed down (20%), personal financial problems resulting from financial problems of the workplace (17%), and health problems (15%). The analyses have shown that among the persons leaving work there are no significant differences in the reasons for leaving between the persons who stay in the nursing profession and those who start new work outside that profession. It turned out that financial reasons play the most important role in the decision to leave. Other significant reasons also included the low prestige of the nursing profession, and lack of promotion opportunities as well as the lack of opportunities for professional development. Shortage of personnel was another important cause for leaving. In the social relations sphere, the most frequent reason for the decision to leave are problems with the direct supervisor. Reasons connected with the content of work are also of great importance. First of all the sense that the work offers insufficient professional challenges. Among reasons linked to the general atmosphere of work, particularly important is the belief in high turnover of nurses. The Polish part of the NEXT-study was the first large-scale research of nursing community in Poland. Thus, the results aroused great interest among representatives of nursing profession. The results were disseminated in several ways: publications in nursing journals, in scientific journals and conferences.

Work Ability Index (WAI) was developed in the early 80ies by researchers from the Finnish Institute of Occupational Health to evaluate the congruency between individual's feelings of personal resources and the perceived requests of his/her work environment. Perceived work ability is explained by two interacting factors: - The individuals' perceived resources and - The self-evaluation of one's own working conditions. The first factor includes functional capacities (mental, physical and social resources) as well as the workers' health, competences, attitudes and values. The second factor includes characteristics of work that may sustain the individuals' work ability, namely physical and psychological work demands, work environment, work community as well as work management and leadership. Within the NEXT-Study, the Work Ability Index was used to provide empirical evidence of the relationship between work ability, age and intention to leave nursing. This relationship was evaluated in a representative sample of 25.976 qualified nurses in ten European countries, to contribute to the implementation of initiatives aimed at sustaining the work ability of nurses over time and prevent premature exit from their profession. In all ten European countries scores on the Work Ability Index were significantly lower in the older (>45, age range 19-71) than in the younger nurses. Furthermore, in all countries there was a significant association between low Work Ability Index scores and 'intention to leave nursing' (Odds ratios between 1.98 and 21.46), especially among the younger nurses, since these are offered more employment opportunities to improve their work and personal conditions. In some countries work ability differed between the younger and the older nurses to a larger extent, due to differences in sample composition, retirement age, policies addressing recruitment and retention, aging support systems and labour market. Poor leadership and staff's social relationships were the major working conditions impacting on the decrease of perceived work ability of nurses across Europe. Indeed, workload and the availability of good information to accomplish work tasks heavily depend on such factors. The NEXT was the first study to use the Work Ability Index from a cross-cultural perspective. This instrument proved to be sensitive, in all countries, in predicting intent to leave nursing, which can turn into real exit if employment opportunities allow for it. Thus, work ability is an important organizational resource. Human resources managers should recognize examples of good practices and promote work conditions effective in supporting work ability to avoid depletion of resources, which manifested as intent to leave, burnout, disability or other bad health outcomes.

Background: The demographic change in Europe is causing challenges and problems for the nursing profession. Currently the nursing profession is facing a lack of nurses. Where possible, nurses are leaving their profession prematurely. However, NEXT data indicates that, when there are no or only few job alternatives nurses are forced to remain in their profession. As a consequence the ageing of the nursing profession can be observed, such as in Germany. Many employers as well as the public are prejudiced with respect to the work ability of older workers. In nursing, these prejudices predominantly concern reduced physical capacity, less flexibility and more sickness absence. On the other hand, social capabilities are commonly expected to be better. Nursing is a highly demanding profession with respect to both emotional and physical demands. Furthermore, the nursing profession is known to be at higher risk of adverse psychological health than other professions. As a consequence a central question for assuring future health care provision is: Is nursing at older age possible? NEXT has provided the opportunity to assess this question. Summary of results: For the sake of homogeneity of results we have limited this report to registered nurses working in hospitals. The data from 25,321 nurses from ten countries has been included. The NEXT basic assessment was used for this analysis. We defined the older age group of nurses to be 50 years or older. More details and results can be found in the NEXT Scientific Report (www.next-study.net). - There were profound differences with respect to the proportion of older nurses in hospitals between the NEXT countries; the highest proportion was in Finland (25.5%) and in Norway (19.6%). The lowest proportion was in Belgium (9.6%) and in Poland (7.4%). - Older nurses worked the same number of hours per week as younger nurses. - Older and younger nurses did not differ with respect to absence from work when considering the two causes sickness and family duties together. - In most countries older nurses reported better working conditions than younger ones: e.g. less emotional and quantitative demands and more influence at work. Moreover, their work involved less lifting and bending . - Younger nurses were generally healthier than their older colleagues but tended to suffer more from burnout. - In some countries (e.g. England, Norway), older nurses reported distinctly better working conditions than their colleagues in other countries (e.g. Belgium, Germany, Finland). - In Finland, the older nurses reported a higher work load than older colleagues in other countries. (This is logical since the proportion of older nurses in Finland is high.) Still, commitment, job satisfaction and physical health were considerably better. - The Norwegian example shows that older nurses can have both low work load and positive health and attitudinal outcomes. - Countries with a high proportion of older nurses show the most positive health and attitudinal outcomes. This cannot only be attributed to the healthy worker effect (=sick nurses leave the profession earlier) because the two countries with the highest proportion of older nurses (Finland and Norway) show the most positive health and attitudinal outcomes. Discussion: The NEXT findings indicate rather pronounced age related differences in the work situation of older nurses. Older nurses tend to report better working conditions. Here, the healthy worker effect must be taken into account which describes the observation that especially in physically demanding jobs - older professionals remaining in a profession constitute a positive selection of healthy and high-performance individuals. However, the two countries with the largest proportion of older nurses show the most positive health and attitudinal outcomes. This speaks for the fact that a successful integration of older nurses in the nursing work force is possible. Conclusions: - Health policy makers should recognise that the nursing work force is ageing and will continue to age. - Health policy makers should learn from good examples with respect to older nursing work forces (e.g. Finland, Norway, Great Britain). - Health care institutions should recognise that older nurses often can be a resource with better expertise, more commitment and better psychological health. - However, the lower physical exposure and lower general health should be acknowledged and preventive measures taken at early stages. - Health care institutions should prevent age discrimination among nurses (see low perceived social support) and assure high mutual support in the work groups. - All stakeholders should accept their responsibility in reducing age discrimination in the nursing work force.

In Belgium, there were 174,010 nurses and midwives in 2000, for 10 millions people. About 60% of them were working in hospitals, 25% in long-term care, the remaining 15% in home care services. The main professional categories were registered nurses and certificate nurses, i.e. 74% of the active work force. Despite these figures, health care settings have difficulties to employ qualified registered nurses and are sometimes obliged to recruit less qualified personnel. This problem is mainly due to the low activity rates in both male and female nurses. Recruitment difficulties are exacerbated by part-time nurses (45% in hospitals), pregnancy, maternity leaves and the breast-feeding period, and government initiatives to reduce working hours prior to retirement. Another problem related to the nurses employment and career is the turnover rate, ranging from 0.6% to 22.6% during the one-year follow up of the Belgian sample. Sample. 37 institutions were involved in the survey (hospitals, nursing homes and home care settings). 4257 of 6947 nurses approached (61.3%) returned the Q0. The response rate was 65% (range 20.7% to 100%). Q12 was sent to 5953 stayers, while during the follow up, 597 leavers received Qex. 257 leavers sent back the filled-in questionnaire. Results. In Q0, 9.3% of 3973 respondents who answered the "intent-to-leave" (ITL) question thought of giving up nursing completely monthly or more often. Those thinking of this "several times per month or more" were compared to those considering it less often or never. Age was clearly associated with ITL in a curvilinear way. ITL was at a maximum in 30-to-34 years nurses. ITL was less prevalent in younger nurses and nurses over 50. In the analysis, job dissatisfaction was considered as the single most important factor affecting nurse turnover and premature departure from the profession. Women job satisfaction was found to be significantly higher (m=6.9; n=3142), compared with men (m=6.6; n=324; p<0.005). Satisfaction with use of abilities was lower for men (m=5.4 versus m=5.8; p<0.001), which can reflect unease with the traditional image of nurses or a clash between what men do as nurses and what they think they should do to progress in their career. Job satisfaction appeared to vary with work setting: it was higher in home care (m=7.2) than in nursing homes and in hospitals (m=6.6) (p<0.0001). This could be explained by the characteristics of home care (higher autonomy, rewarding relation with chronic patients). Job satisfaction increased with hierarchical level: head nurses were the most satisfied nurses (m=7.1), and staff nurses the least satisfied (m=6.8). This can be attributed to more decision latitude, a valued position within nursing hierarchy, and more professional and social recognition. Satisfaction was lower among specialized nurses (m=6.7) than among registered nurses (m=6.9; p<0.001). As suggested by Price and Mueller (1981), a higher level of training may lead to dissatisfaction if organisational constraints hinder the use or the development of knowledge and abilities, while these nurses have higher expectations towards management. Job satisfaction and professional commitment were negatively correlated with ITL, (r = -.38 and r = -.33) as well as work ability (r = -.35). The ratio between the prevalence of nurses with poor work ability index (WAI) and high ITL and with good WAI and high ITL was 2.79 (CI 95%: 2.56-3.05). The relationship between WAI and burnout was negative (r = -.55). The correlation between burnout and ITL was r = .36. Job satisfaction itself was highly correlated with all other variables, the association was higher with burnout (r = -.45) than with WAI (r = .42) or with professional commitment (r = .20). All these associations were significant at p<.001. Among the sample of leavers, 80% had a new job when they voluntarily left their previous job and 13% were searching for a new job. 87% who prematurely left their job obtained a new job in the nursing sector, with hopingly better work conditions but with an identical hierarchical position. Those 13% who left nursing care remained in the social or health sector. In the Belgian hospitals NEXT sample, nursing turnover varied from 0.6% to 13.1%. We compared low-turnover hospitals, defined as attractive, and high-turnover hospitals, defined as conventional. Findings show that factors related to the workplace are predictors of nurses ITL. Many of these variables are under the control of institution. In the future, the fit between nurses supply and increasing demand in various settings will be more difficult to ensure. Consequently, institutions need to address several basic issues to keep competent, motivated and happy nurses. Management must listen to nurses concerns and provide flexible scheduling, adequate staffing levels, and appropriate rewards and recognition. Managers have also to create dynamic teams in which nurses have autonomy and accountability.

Introduction: In Germany, the need for nurses has changed during the NEXT investigation. Until 2002, there was a lack of qualified nurses. Thereafter, additional financial constraints (mainly because of a DRG based reimbursement system) have resulted in the substantial reduction of hospital staff, mainly nursing staff. At the same time, national unemployment has increased considerably, making it more difficult for nurses to find alternative occupations. This is reflected by NEXT figures: In the basic assessment 2002/3 18.4% of all participants in Germany intended to leave the profession (which is high in relation to most other participating countries), one year later this figure decreased to 17.7%. At the same time the proportion of participants fearing to become unemployed increased from 9.4% to 20.2%. Consequently, the number of participants having left the profession was lower than could have been expected in the beginning of the study. Instead, the target of attention shifted towards those who would like to leave their job and cannot do so. This group of people is likely to increase substantially in Germany. Results: In the German Basic assessment (2002/3) 6,484 caring staff working in 75 health care institutions (hospitals, nursing homes and home care services) were approached and 3,565 returned the questionnaires (response rate 55%), one year later 6,115 people were approached of which 2,538 carers responded (41.5%). Between the two assessments, 529 carers have left their institution (Leavers) and received a leavers questionnaire, 213 people responded (40.3%). - Results of the leavers assessment. Of the 213 leavers, only 31 nurses have left the profession and continued working in another profession; 27 nurses stopped working, e.g. for family reasons; 17 nurses retired; 111 have left the institution and continued to work in health care. The differentiated analysis shows that in Germany the main reason for leaving nursing (and continuing in other area) was dissatisfaction with the working conditions. This was followed by dissatisfaction with the social work environment, a perceived lack of challenge in work demands, and, finally, financial reasons. In contrast, those changing to another health care institution did so rather because of financial reasons, while the work content played a much lesser role. - Results of the analysis of the nurses intention to leave the profession, ITL. In Germany, the proportion of nurses intending leaving the profession was comparably high (18.4% in the basic assessment = ranking third after UK and Italy). There, risk factors for intending to leave the nursing profession were age (young nurses, maximum 25-30 years of age), - higher nursing qualification, - working in hospitals, - low professional seniority (max in 2nd professional year), - low health and low work ability. By means of multiple logistic regression analysis, a substantial proportion of the variance of ITL could be explained (29%, selection: registered nurses in hospitals). The main factors leading to the nurses wish to the leave nursing were: - Lack of professional alternatives (10.4%, lack of professional promotion prospects, dissatisfaction with work prospects), - Health reasons (9.6%, esp. psychological health), - Work organisational factors (8,9%, low possibilities for development, low influence at work, too many tasks not belonging to nursing, receiving conflicting orders, time pressure), - Private conditions (8.0%, work home conflict, living alone, being single parent, number of weekly working hours), - Work Content (6.1%, high quantitative demands, confrontation with troublesome patients, physical risk factors), - Social work environment (4.7%, and relation to nursing administration or physicians, low quality of leadership. Less influential were - Individual opportunities (2.7%, afraid to get job / to become unable to work) and - Objective opportunities (1.8%, open caring jobs in region, recent job offer from outside health care). Dissemination and use potential: The analysis of ITL (in Germany) shows that ITL may be a highly relevant indicator for health care on general level (national and international) but possibly to the same degree when comparing health care institutions. With respect to the national level, we have delivered new detailed knowledge concerning the underlying factors for the nurses wish to leave the profession. This knowledge shall be included in the (necessary) long term planning of the nursing work force in Germany. The results have been and will be presented to the stakeholders, which show a deep interest. Furthermore, our results show that ITL has the potential to identify attractive institutions, which then may be characterised by other institutional factors (see results above). The results from the German assessment have received great national attention. Dissemination has been very active and will continue on all levels.

Introduction: Five years ago the National Health Service Plan presented a raft of initiatives to improve standards of health care in the UK. Lack of human resources was recognised as the most pressing problem, especially in nursing. Consequently, there are now more strategies to attract and retain nurses in the UK than elsewhere, with important lessons that can be shared with policy-makers in other countries. The aim of this study was to examine the contribution of senior nurses responsible for retention and recruitment (RRNSs). Methods: Data were collected by telephone. Interview transcripts were transcribed and analysed by content. Sample: 92 (59%) of the trusts (N=156) employed a member of staff responsible for nursing recruitment and retention. In 36 (39%) trusts this was an RRNS, 29 agreed to participate. The employing trusts provided acute services in rural, urban and inner city areas across England. Findings: The RRNSs were all clinically experienced nurses who still worked regularly on the wards to maintain clinical competence. Most had been appointed on the basis of their good local knowledge of the trust and their interpersonal skills. As international recruitment declined, RRNSs were implementing strategies to recruit and retain staff locally. Their work appeared to be highly labour intensive, but avoided advertisements in the national press which were regarded as expensive and unnecessary except for posts requiring very senior or highly specialized nurse. Healthcare assistants: Recruitment strategies were designed to reach people who might not have considered working in the health care sector. RRNSs had developed and maintained a wide network of contacts in touch with eligible applicants and went into schools and colleges of further education to discuss career opportunities in the NHS. Potential recruits were guided through the application and interview process and given information about training. Work experience was sometimes arranged and discussions were held on parents evenings in schools. Student nurses: The same types of approach were used to inform potential student nurses, their parents and careers advisors about careers in nursing. RRNSs liaised with university staff to encourage their students to seek employment in nearby trusts. Many visited students during timetabled classroom hours to discuss employment issues and career planning. During the final year students were invited to visit the trust so they could see what it had to offer. Informal talks were held to provide information about the different clinical areas where suitable vacancies were expected and to discover which would be of interest to particular individuals. Formal input included help completing satisfactory curriculum vitae, filling in application forms and performing successfully at interview. By the time they registered, most RRNSs felt they knew potential recruits well enough to conduct a fast-track system of recruitment. The process was kept as brief as practical with streamlining to reduce the length of time between application and interview. It was usual for large numbers of interviews to be conducted on the same day. These initiatives were reported as successful. RRNSs in different parts of the country claimed they no longer had vacancies for newly qualified D grade nurses. Newly qualified nurses: RRNSS operated an open door policy with newly qualified nurses intended to identify and tackle problems as they arose. Opportunities for continuing professional education featured heavily in retention strategies for these staff, with emphasis on fairness and equity. RRNSs frequently mentioned experiencing inequity during their own early nursing careers and wanted to avoid this problem for the newly qualified nurses they hoped to retain. RRNSs focused on work-based learning for new registrants. This avoided the problem of covering the clinical areas when staff were attending courses and was deemed most appropriate for individuals whose student preparation was considered to have emphasised academic achievement at the expense of practical skills: In all trusts D grade (the most junior) nurses were required to demonstrate competency in fundamental clinical skills. Most postholders arranged formal study programmes for newly qualified recruits. They enabled new nurses to develop peer support groups and had set up preceptorship schemes. Many RRNSs also organised schemes allowing new registrants to rotate through different clinical areas. There was little evidence of collaboration with university staff when organising continuing professional education for new registrants. Experienced nurses: Attracting and retaining experienced E grade nurses was challenging. A range of approaches was used, including holding open days and placing advertisements in local newspapers. Most RRNSs scrutinised exit questionnaires completed by nurses leaving the trust to identify reasons for departure.

In 2001, there were 120,000 employees working in the nursing professions in Finland. The availability of nurses has, so far, generally been good, but recruitment problems have arisen in some regions, and particularly regarding substitutes. The "image" of the field as a rewarding sector of work has declined, and it is becoming increasingly unclear whether the field will be sufficiently attractive in the future to recruit enough well-trained staff. In Finland, 65 organizations were involved in the NEXT survey. 3970 nurses answered the basic questionnaire (response rate 77%), and the follow-up questionnaire was returned by 2941 respondents (66 %). Of 722 nurses who left their institution, 402 responded to the leavers' questionnaire (56 %), and 309 returned the leavers' follow-up questionnaire. Results: In the first questionnaire, 20 % of the respondents considered leaving the organization and 15 % leaving the profession. Intent to leave was most common among the young, the temporarily hired, those who had stayed less than a year in the institution, and those perceiving their economic situation to be strained as well as those who had experience of burnout. In addition, thoughts about leaving the organisation were more common among the better trained nurses, and thoughts about leaving the profession among male nurses and nurses with reduced work ability. Weak organizational commitment reported in the basic questionnaire was strongly associated with the follow-up intention to leave the organization (OR 3.41, p<.001, adjusted for many individual and organisational factors), as was also weak professional commitment with the intent to leave the profession (OR 4.44, p<.001). Several work-related factors correlated with decreased commitment. The association was strongest with the feeling that own work is not meaningful or important, dissatisfaction with the way one's own abilities were put to use, dissatisfaction with the opportunities to give patients the care they needed, small possibilities for development, low level of influence, experience of bad atmosphere at work, low quality of leadership and poor promotion prospects. Of the respondents who returned the leavers' questionnaire, 40 % left of their own free will, while 16 % left because their contract was not renewed by the employer. Nearly one fifth left temporarily because of maternity leave and 12 % retired; these respondents are not considered as leavers. Weak organizational and professional commitment as well as the intent to leave was strongly associated with voluntary leaving (p<.001). Those who left were younger and their working contract was more often limited than those who stayed (Chi², p<.001). Age, working contract and commitment independently predicted leaving the institution. The present situation of the leavers was investigated about a year after they had left the institution. Of them, 40 % had returned to the same institution, 48 % worked in another institution, and 12 % were not in work at that moment. Only a few nurses had given up their profession, so it was not possible to compare their situation with that of the others. Nurses who changed institution were younger than those who returned to the institution that they had left (mean age 37.6 and 43.0 years, respectively) (p<.01). Regardless of age, those who had changed institution reported less experience of burnout (p<.05), higher work ability scores (p<.01), and less worry about being unable to work (p<.05) than those who had left and returned to their previous institution. Thus, a year after taking the step of leaving, the wellbeing of those who changed to another institution, seemed to be better. Those who worked in a new institution were more satisfied with their work prospects (p<.01), the physical working conditions (p<.05), and their job as a whole (p<.05), and they also experienced less work-family conflict (p<.05) than those who had returned to the same place. As regards satisfaction with the salary, the groups did not differ. The results indicate that several work-related factors were associated with work commitment. It is possible to strengthen the nurses' commitment to working in their present institution as well as to continue working in the health care sector by improving the organization of work. Additional attention should be paid to arranging the work so that nurses can use their abilities at work in an optimal way, and have good possibilities to develop further. It is important to ensure opportunities for continuous professional training, and to increase the possibilities to influence the work schedules. Special attention should be paid to the physical work environment of the older nurses. Young nurses' thoughts about leaving the profession should be reduced by ensuring as permanent work contracts as possible, and by defining their tasks so that they correspond to their professional education. Especially the health centre wards should be made more attractive for the nurses.

The supply of nurses varies between countries and between different health care areas. In Sweden geriatric health care has problems recruiting nurses, and the status of geriatric health care as a professional arena is relatively low compared to other sectors in health care. The main challenge in Sweden is to promote retention of nurses in geriatric health care. Voluntary turnover signifies active decisions on the part of nurses and is influenced by various factors (Lum et al. 1998; Morrell 2004). Identifying factors that influence turn over can hopefully help the organisations to increase their attractiveness and keep their nurses. In the NEXT-questionnaire we investigated work conditions contributing to registered nurses and assistant nurses decision to leave their workplace. Literature reviews and turnover models identify poor job satisfaction as a significant contributor to turnover among nurses (Hayes, L., Duffield, et al. Nurse turnover: A literature review. International Journal of Nursing Studies, in press). Various studies have used various measures and scales to identify many sources of job satisfaction for nurses (Hong, L., E. W. Alison and L. Barriball. Job satisfaction among nurses: a literature review. International Journal of Nursing Studies 2005;42:211 227.), sources that include physical work conditions, relationships with co-workers and managers, pay, possibilities for advancement, job security, responsibility, management recognition, and hours of work. The Swedish participating in the NEXT-study is a part of the longitudinal Swedish cohort study of sustainable health for working in the public sector (The HAKuL-study). The HAKuL-study started two years before the NEXT-study. The questionnaire to the leavers was the same as used in the NEXT-study but the baseline data were collected in another way. The study base consisted of registered nurses and assistant nurses employed at least three months during November 1999/2000 to 2003, in totally 3879 persons. Temporary nurses paid on hourly basis were not included. During 2000-2003 data on retirement pensions and leave from the employment was recorded by means of continuous contact with the work units and the superiors. All leavers received a NEXT-questionnaire focused on reasons for leaving. During a three year period 18% of the nurses left their employment contract. A higher rate of leavers was observed in elderly care compared to other sectors, among nurses younger than 50 years with nurses 50 years of age and older and among registered nurses compared to assistant nurses. Ending their employment did not imply that the nurses left health care, most of them remained in nursing but changed institution. Of the registered nurses who left their workplace, 86% changed nursing institution but remained in the nursing, among assistant nurses 68% remained in nursing. Unsatisfactory salary contributed most to both registered nurses and assistant nurses decision to leave the workplace. The factor consisted of four items describing salary in relation to work performance, educational level, pay opportunities at other workplaces, and salary trends. Lack of professional opportunities emerged as another important factor influencing the decision to leave. The factor contained items concerning promotion prospects and development opportunities, desire for change and unfulfilled professional expectations. For assistant nurses in geriatric health care the patient oriented workload; to much to do, to high emotional demands, physical strain, time pressure and inadequate number of nursing personnel, contributed to a larger extent to their decision to leave compared with assistant nurses in other health care sectors. Reasonable pay and possibilities for development are core parts of sufficient rewards for balance the nurses efforts. For assistant nurses the trend of wages has been less positive and the wage differentials between organisations are less significant. A registered nurse can often increase her salary by mean of changing job in the health care sector, for assistant nurses the possibilities are more limited. Interventions required for retaining personnel in elderly care need to be addressed both at the political level giving more resources to geriatric health care, and at the organisational level to create possibilities for professional development. "There was no flight from the nursing profession and consequently the turnover of nurses mainly represents circulation between institutions. Turnover imposes costs, puts pressure on remaining nurses, and makes it difficult to maintain the knowledge base and care quality. On the other hand, a contributing factor for leaving was a desire for professional development and certain level of nurse circulation among organisations and institutions represents development and flexibility. The positive and negative consequences of turnover, for both nurses and the quality of care, need to be examined.

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Sustaining working ability in the nursing profession - investigation of premature departure from work - (NEXT NURSES' EXIT STUDY)

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