Maximising the experiences of our scarce nursing resource

It is widely acknowledged, and has been for a long time, that the number of nurses worldwide is insufficient to meet the ever-increasing need for their unique combination of knowledge, skills and expertise. In a world where both nursing and financial resources are likely to become scarcer, it is incumbent on nurse managers to provide working environments in which nurses feel valued, respected and satisfied in their work. Our first two papers in this issue consider the cost of nursing turnover, from both a financial perspective and the effect on staffing practice and patient outcomes. Li & Jones (pp. 405-418) (USA), in a literature review, found inconsistency in both conceptualisation and measurement of turnover, concluding that more work still needs to be done in order to present a true picture of overall costs. However, in a study from New Zealand, North et al. (pp. 419-428) found that ‘the cost per registered nurse turnover represents half an average salary’ with highest costs related to temporary cover and productivity loss – and both associated with adverse patient events. They conclude that ‘a culture of turnover was found that is inconsistent with nursing as a knowledge workforce’. High rates of nursing turnover create unstable working environments, with loss of experience and expertise, increased usage of temporary staff, and lack of commitment to teamwork. As a result, quality of care may be reduced, and patient outcomes suffer. Both studies conclude that nurse managers require more information regarding turnover at a local level to enable strategies to be developed to reduce it and prevent the adverse effects associated with it. Nursing turnover, and factors associated with it, concerns a high number of the papers submitted to the Journal of Nursing Management, and clearer pictures are beginning to emerge of the relationships between elements of nurses’ working lives and environments. Indeed, sophisticated work is emerging globally that is enabling predictions of attributes in the working environment that result in enabling nurse managers to improve working conditions. The next nine papers explore various elements of this working environment. Choi et al. (pp. 429-439), from Hong Kong, identified professionalism, management and ward practice as significant factors in predicting turnover and intention to leave, and staffing and resources as an additional factor in predicting job satisfaction. Li et al. (pp. 440-448), from Taiwan, report on the mediating effects of structural empowerment on job satisfaction; whilst Johansson et al. (pp. 449-458) from Sweden explore role-stress. In a systematic review, Brown et al. (pp. 459-472) draw together factors which influence intention to stay and retention of nurse managers (defined in this study as front-line managers). They acknowledge that this group, as a sub-group of all nurses, are under-represented in the literature. However, job satisfaction, organisational commitment, organisational culture and values, feelings of being valued, and lack of time to complete tasks leading to work-life imbalance were identified as key issues. This is unsurprising, as these issues have been reported in the Journal over at least the last decade. Tourangeau et al. (pp. 473-482) (Canada) explore generation-specific incentives, with Gaki et al. (pp. 483-490) considering predictors of motivation for nurses in Greece. Blando et al. (pp. 491-498) (USA) consider the impact of hospital security programmes and workplace aggression on nurse perceptions of safety. Asah (pp. 499-510) looks at access to computers in nurses in rural health-care in South Africa; whilst the last paper in this grouping explores factors influencing migration in nursing (Dywill et al. pp. 511-520). The diversity of country of origin of these papers is testament to the significance of these issues to nurse managers world-wide as we all attempt to create workplace environments that will result in a stable and contented workforce. Ultimately, there will always be turnover, and of course working environments benefit from new ideas, constant challenge and practice development. What is needed is more conclusive evidence of healthy levels of turnover, often resulting from stimulating environments which encourage staff development. We need to know where potentially positive factors become toxic and stressful, resulting in low motivation, commitment and resultant constantly changing staffing. The increasing numbers of both systematic and integrative reviews submitted to the journal demonstrate the growing research database now available, and whilst these are useful in drawing to together the evidence, they emphasise that the data itself is in existence for nursing management practice to draw on. It is to be hoped that in future, papers evaluating strategies to tackle these issues will be more prominent. Similarly, there is growing evidence relating to the influence of leadership styles on the working environment. Zampieron et al. (pp. 521-528) (Italy) add to the literature on nurses preferred and perceived leadership styles, reinforcing messages from others’ work about differing perceptions and preferences between leaders and subordinates. There is now a wealth of research evidence from across the world on this topic, which would be worthy of an integrative or systematic review. The next two papers from Bamford et al. (pp. 529-540), and Laschinger et al. (pp. 541-552) in Canada address the effects of authentic leadership. The latter conclude that ‘the authentic behaviour of nursing leaders was important to nurses’ perceptions of structurally empowering conditions in their work environments …. and ultimately contributed to lower levels of emotional exhaustion’. Bamford et al. (pp. 529-540) found that ‘nurses who work for managers demonstrating higher levels of authentic leadership report a greater overall person-job match in the six areas of work life and work engagement’. Both studies suggest that greater emphasis on training for authentic leadership attributes, such as self-awareness, relational transparency, ethics and balanced processing, will help develop empowering work environments. These findings are reinforced in the next paper, by Hutchinson & Hurley (pp. 553-562) (Australia), considering leadership capability and emotional intelligence as moderators of workplace bullying. They argue that both factors ‘offer real potential to mitigate bullying behaviour’ but acknowledge disparity between clinical and managerial nurses in preferred styles, and that there is a ‘need to understand the expression, experience and management of emotions in the workplace’. In a second paper, Hutchinson (pp. 563-571) presents four forms of bullying as workgroup manipulation, suggesting that recognising these as ‘processes and patterns of victimisation and contagion….provides a deeper understanding of bullying and illustrates the place of intervention strategies which foster the emotional intelligence climate in nursing teams’. In a similar vein, Jackson et al. present three forms of avoidant leadership behaviours – placating, equivocal and hostile – which can influence nursing culture and experience at work. This focus on nurses in groups, as opposed to individual factors, emphasising the influence of peer-pressure in the working environment is reflected in the final two papers. Bularzik et al. (pp. 581-590) (USA) explore links between nurses’ perceptions of their group goal attainment capability and professional autonomy; whilst Gaudine et al. (pp. 591-602) (Canada) consider the effects of absenteeism feedback and goal-setting interventions in relation to their work colleagues. The papers in this issue present a fascinating snapshot of nurses’ experiences in the workplace as well as showing how managers are tackling some of those which impact negatively. There will always be jobs for nurses to fill, and managers do well to remember that our workforce has a choice. Nurses have the ability to be mobile, but, as a predominantly female workforce, they are often constrained in that mobility by other life responsibilities and relationships which limit the scope of that choice. We need to retain our skilled workforce rather than assume there will be an endless supply to replace those who leave. The nurses we need might not be in the right place at the right time. Moreover, with costs of turnover so high, we have a moral responsibility to reduce unnecessary expenditure on turnover. We need to find more effective and innovative ways of using the wealth of information now available on nursing management factors to improve the working environment to ensure nursing talent and experience is not lost, and encourage every nurse to grow in their knowledge and skill in contributing to patient care.

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