ORIGINAL ARTICLES

Management impact of staff turnover in the view of nurses: an exploratory study

Nayara Mizuno Tironi¹, Larissa Gutierrez de Carvalho Silva², Mara Solange Gomes Dellaroza², Maria do Carmo Lourenço Haddad², Marli Terezinha Oliveira Vannuchi²

¹Federal University of Paraná
²State University of Londrina

ABSTRACT
The staff turnover affects the work of the nurse, so how do the nurses manage staff turnover in their team?
Aim: To identify the perceptions of nurses of the management of the turnover of nursing staff in their operational units.
Method: A descriptive exploratory study with a qualitative approach, conducted with nurses working in the inpatient units of a university hospital.
Results: The testimonies indicate a concern with the quality of care provided, work overload, developed skills and staff management.
Discussion: Changes in personnel show to the managers new points to note in their work process, as a more active supervision to the newly admitted workers and service training, which results in a work overload. The findings suggest that job turnover affects the work process, and these changes are experienced and managed in different ways, according to each nurse.
Descriptors: Nursing Staff; Nursing, Supervisory; Organizational Innovation; Job Market; Labor Force.

INTRODUCTION

We call turnover the number of workers hired by an establishment to replace those who have left in a given period of time⁽¹⁾, and the ratio of this number to the number of employed workers. It can be measured by the number of employed workers who remain in their work departments or areas at the company in a given period⁽²⁾.

The causes of turnover are multifactorial, but the situation of supply and demand of human resources in the market is a main reason, as well as the country's economic situation regarding employment opportunities, wage and benefit policy of companies, physical - environmental and labor – conditions, organization culture, involvement in decision making and flexibility of the organization's policies, among others^(3-5).

The internal or external transfer or rotations are also related to worker satisfaction and job stress; the more the workers feel professionally satisfied, the lower the probability of their exit^(2,6,7).

A study on the turnover in the Brazilian formal market from 2003 to 2008 showed that the turnover rate increased: the average length of stay in employment is 5.1 years. This index dropped in 2009 due to the crisis in the labor market due to the problems in the economy⁽³⁾.

With regard to the health care area, a survey conducted in the city of Belo Horizonte showed that, within one year, the turnover rate was considered acceptable and the professional category that had the highest turnover rate was the laboratory technicians auxiliary workers, followed by doctors and nurses⁽³⁾.

In nursing, the excessive rotation of human resources causes imbalances in the composition of the workforce, and incurs costs and undesirable effects both in quality and productivity of nursing care. Also, the process of recruitment, selection and training of a new professional demands time and financial resources, which certainly requires from nurses the use of management strategies to maintain the team’s productivity and harmony⁽⁶⁾.

The idea for this study arose due to the experience of the authors in the inpatient departments of a university hospital, when many nurse professionals were dismissed, due to a temporary service contract, based on the Brazilian Labor Law code (CLT) and the concomitant inclusion of new workers employed by the Government regime. This situation made the authors reflect about the implications for the management team, raising the question: how do nurses manage the turnover of nursing professionals on their team?

Given the above, the objective of this research is to identify the perceptions of nurses of the administration of turnover of nursing staff in their operational units.
This study may provide a basis for new strategies to be made for the management of human resources in nursing, especially facing internal transfer of workers, considering permanent and continuous training and job satisfaction as important requirements for the quality of nursing care service.

METHOD

This is an exploratory descriptive research, with a qualitative approach and performed in adult medical-surgical inpatient units of a public university hospital which has 316 beds, is located in the city of Paraná, and maintained exclusively with funds from the Brazilian Public Health System (SUS).

The adult inpatient units were the department chosen, since they represent 48.7% of the institution's beds and are the areas with greater turnover rates. The inpatient sectors comprise four units – the male, phthisiology, female and communicable diseases units - with 19 nurses during the morning, afternoon and evening shifts.

The participants were eight nurses working in the inpatient units and who met the following criteria: accepting to participate in research, having a statutory (Government career) contract with the institution, having been working in the area for at least 36 months and who are not on vacation or any license.

Data collection occurred from August to October 2011 after approval by the Research Ethics Committee of the State University of Londrina (UEL), under opinion ID 088/2011 registered at the National Research Ethics System (SISNEP) under Register Nr. 0065.0.268.268-11. The selection of participants was made randomly, contemplating the three work shifts - morning, noon and night. The respondent nurses were mostly female, with a mean age of 45 years. Most of them worked on the night shift.

Data collection was conducted through individual interviews, recorded in audio, in a private room of the institution during the working hours of the participants, using the guiding question: “What are your perceptions regarding the management of nursing workers turnover in the sector in which you work?” In appropriate situations, we applied auxiliary issues to contribute to the quality of the evidence: “Are there any managerial changes for you with this employee turnover? How do you feel about the turnover in this area?”

Before starting data collection, we opted to carry out a pilot test in a hospital sector similar to the field of study. This procedure contributed to the improvement of the guiding and auxiliary questions in relation to the objective of the study.

After gathering the information, we performed the full transcription of the speeches, which later were read carefully to identify the units of meaning (UM) relevant to the purpose of the study, allowing them to be analyzed according to Content Analysis proposed by Bardin⁽⁸⁾. This way, some steps were followed, starting with successive readings of the material, marking parts of interest. Highlighted excerpts were grouped according to their similarities forming thematic categories which were interpreted with inferences.

In order to preserve the identity of respondents and differentiate them, they were identified with the letter E followed by Arabic numerals corresponding to the order of the interviews.

RESULTS

By analyzing the statements, the thematic category called “Managerial impact of staff turnover in the personal view of nurses” emerged and was subdivided into subcategories entitled “Detachment from participation in decisions about the turnover”; “Feelings of incompetence”; “Contributing to the adaptability in the work”; “Human Resource Management” and “Concerns regarding the quality of care”.

Detachment from participation in decisions about the turnover
In the hospital context, it is important that decisions are shared with all the personnel involved, including the resolutions related to the admission and demission of professionals. The work must be carried out in an integrated way, to make sure that everyone analyzes the proposals presented and reflects together on the consequences of each choice. However, this is not seen in the following testimonies:
We have to change, it comes from up... We have to change the shifts and that’s it (E1).

We get disappointed because no one informed me, no one told me. We are personnel in charge of that worker, and we take too much pressure because of it. (E5).

It is treated hierarchically, i.e., the change is made and the team accepts and of course, like us, they (the nursing staff) know about the turnover, and sooner or later it happens (E6).

The nurses' dissatisfaction about the non-participation in the change process, as they are communicated with only after the decision, is noticeable. But this perception in relation to turnover differs from that previously observed when there is a notice.

Because when you make a planned turnover it’s a different situation, it is quieter and easier, you plan the exit, you plan the entry, you plan the training, you plan actions that you will require, you plan with your team a whole series of programs. (E5)

Feelings of incompetence
The demission of a team member brings impacts on staff dimensioning, (for example, there’s the adaptation to the service without the co-worker), but it can generate concerns in the managers regarding their competence.
] Now when the turnover is imposed and takes you by surprise, then you begin to think, “I wonder what's going on? Why is he leaving?” (E5)

] I try to deal with it as a supporter: if it's his will we question why, when he quits it’s because something is wrong, then we have that feeling of, like, “Why? Is my administration wrong? Are my actions wrong?” (E5)

Contributing to the adaptability in the work
In addition to the uncertainties generated by the worker's demission when there is the insertion of a new member in the group it may be stressing for the nurses.
It’s no good. You train that employee and then he is suddenly out, then comes another, and then to train them again is too stressful. (E3)

] it will cause a little more trouble to prepare them for our service here. (E3)

We don’t know who is coming, so we have to train who comes, teach all the routines in the area, do the training with him, then we don’t know what to expect. It's a new thing coming. (E5)

The admission of a worker into the unit stimulates the rescue of the role of the nurse educator, which requires commitment and dedication of this professional to ensure the maintenance of staff competence to the provision of care. However, when faced with the unknown and confirming the inexperience of the new worker to the details of the area, the nurses must be creative and use their experiences.
] And suddenly the person arrives and has no experience, you have to work, you have to put into practice the knowledge you acquired, what you have. (E5)

] So it makes the leaders, the nurses have to develop new strategies, it creates stress, it generates stress due to this situation, but it’s part of our job. (E6)

Human Resource Management
In public hospitals, it is common that the professional staff is not replaced immediately, causing a lack of these in the units.
] The bad thing that you have got here is knowing that there are no people to work here and no one knows when they’ll come. (E5)

] And then you have to restructure all your staff again so that all service demand is met, because we know that the demand does not decrease, it is imposed on us and we have to make sure this demand is satisfied in the best way. (E6)

You are losing an employee and don’t have anyone to replace him and you will have do some management to make it work ... you have to cover his shift... (E8)

We observed in the subjects a dissatisfaction regarding the lack of planning about staff turnover and the need for adequacy of workers so that all patients are treated properly.

Concerns regarding the quality of care
The change in professional staff in hospitals promotes a restructuring of the work process and nursing supervision.
Our change happens in the greater attention we must provide to that segment which has something new. (E6)

We have the changes and then the nurses’ alert feeling gets higher again. (E3)

Besides the more accurate supervision of new workers, the nurses realize that the quality of care provided in general decreases.
] When there is too much turnover, it prejudices us. So I get unhappy because [the quality of] my work and the work of the team falls. (E5)

] This turnover falls on quality, [we] always try to keep a team with greater uniformity in functions (E6)

DISCUSSION

From the testimonies we perceive the need for a participatory management, because the best work environments are those in which nurses are involved in decision making, especially on staff turnover⁽⁹⁾. In addition, participatory management is an approach in evidence in organizations seeking to decentralize decisions and do them in consensus, allowing all the work team members to participate with shared responsibility and balanced power. The nurse, in this scenario, is an important player for the resolution to be shared by all. This professional is able to achieve the collective participation in providing quality care to patients, leading the team that will be affected by the change and observing the consequences that a decision will have on the nursing work process⁽¹⁰⁾.

When there is prior notice of the change, the nurses can plan their actions with the team. The planning helps in determining nurses' actions using a working method to achieve a goal, and is also a way that enables the exercise of communication, decision making and leadership⁽¹¹⁾.

Considering that the study site is a public hospital, the hiring process is performed by tender, which does not allow for the participation of employees in the selection process. It should be noted that this process of admission of workers is performed dynamically, and there is no way to predict the time of entry of a new worker; it depends on the consent of the state government and all the procedures involving the admission of a worker in a government department, i.e., the weakness in planning is part of the recruitment and selection process of a public institution.

With this, the dissatisfaction of nurses in relation to the lack of anticipated information on the decisions taken at a higher level and the non-participation of all involved, is known. Although they question institutional norms, these workers are aware of the institution dynamics and the fact that they can not change it.

Thus, despite the weaknesses, the service may seek a way to improve the responsiveness of these changes in the sectors with a reception program sponsored by a continuing education for explanation of the mission, vision, values and philosophy of the institution. This way the impact of turnover will be reduced.

It should be noted that the nurses interviewed did not indicate possibilities like that quoted above to reduce the negative impact of the unpredictability of the admission of new workers, only demonstrating their dissatisfaction against this process.

As the team leader, it is essential that the nurse seeks management strategies to deal with real situations and to be aware of its governance (or lack of) before some situations, such as the hiring of public servants.

The interviewees verbalized that the demission/quitting of the worker generates negative feelings about their performance with the team, giving rise to questions about possible failures or omissions of the group.

This thought about the employee's reasons for leaving is a reflection of a worker’s tendency to remember the negative factors of their experiences with more intensity⁽¹²⁾. In this scenario, the nurses associate the worker’s leaving with job dissatisfaction and, consequently, failures in management.

These alleged errors can be associated with their way of leading the team, since, according to the leadership and the support provided to the employee, there is an improvement in the work environment and consequent satisfaction and less turnover(5). However, dissatisfaction is not due only to the management, since several causes are involved in a worker’s leaving process, such as the relationship between co-workers, payment, inflexible shifts and recognition at work⁽⁵⁾.

Nurses should be concerned about an ethical training in the relationship with their employees and show respect and sensitivity to the employee's problems, with fairness, impartiality and praise of the work done. But this is no guarantee of job satisfaction, as it is virtually impossible to satisfy all the needs of subordinates⁽¹³⁾. Therefore, the feeling of incompetence raised from the leaving of a worker will permeate their everyday work; however they should be aware that they did everything that they could to provide satisfaction to that professional in their workplace. Even so, their attitudes alone can not guarantee that a worker will stay at the unit.

With the arrival of new employees in the sector, it is necessary for nurses to insert them in the team and in the work process through training and resources that promote the adaptation of new professionals in the institution, in order to reduce the variability in the form of provision of care⁽¹⁴⁾.

In Intensive Care Units (ICU), the training for the newly admitted employees has an average duration of one month and is performed by nurses, focusing on a review of techniques and routines. In inpatient units, this activity is similar to that experienced as a stress for nurses who must perform one more task in the sector⁽¹²⁾. The training at the units is done during the provision of care to patients, so it is not possible to carry out the practice period without assistance.

That is why the burden of nurses is experienced, since it is necessary to conduct the training and at the same time assist and manage the aid to the patient. But despite this excess of functions, nurses demonstrate awareness that this is their role as the technical personnel in charge, who must ensure the quality of services through guidance and supervision. For these reasons, for the new worker the training to ensure the quality of care is essential.

The new employee adaptation is experienced many times, in an unexpected way and with the need of improvisation, which takes time that could be spent on other activities, generating feelings of anxiety, irritability and stress in the nurses.

On the other hand, the adaptation allows the nurses to be creative, which is a key to finding solutions and it leverages the intelligence of human beings, who will think in new ways and explore new paths. In this context, nurses will have to reinvent the work process in the best way possible⁽¹⁵⁾. In addition, although not desired, nurses will accumulate knowledge to deal with an adverse situation and change their behavior, contributing to their work in the institution⁽¹⁶⁾.

The restructuring in the team caused by the service demand increases the workload, and therefore can raise workers' absenteeism, disrupting the service, reducing the performance, increasing fatigue and medication errors. These factors affect the safety and quality of care^{(7, 17)}.

The long period for replacement of human resource staff (in the hospital, the admission process of an employee by public tender ranges from 10 to 11 months, including disclosure of the applicant's request proposal, interest, admission exams and availability to perform the function) makes the nurses of the units use management strategies. Overtime requests, changes in the work process and routines of the entire sector are tactics used to meet the service demand without burdening employees too much, to ensure a satisfactory nursing care.

With staff turnover, the supervision of nurses must be more careful. In the statements it is clear that the “alert state” is constant and with the new event in the area there’s an increase of this attention. In this way, it is inferred that nurses must be aware every day in their work, looking for a safe and good quality provision of care through appropriate supervision of the work done with the use of management strategies such as effective communication and continuous feedback.

Considering that health professionals, especially in nursing areas, may make mistakes, especially when technical and organizational processes are complex, the supervision of nurses is essential for the workers, those newly admitted above all others, to feel safe and able to perform their activities with autonomy and quality⁽¹⁸⁾.

This supervision is carried out privately by a nurse because he is in charge of the organization, planning, coordination and evaluation of nursing care services, in addition to prevention and systematic control of damage that may be caused during the provision of care⁽¹⁹⁾.

The decline in the quality of nursing care has consequences for the institution and society, such as not achieving the goals established and the dissatisfaction of patients and professionals. However, the leader must provide conditions for the work to take place safely and with quality through their management actions⁽²⁰⁾.

Even if there is dissatisfaction at work, it is important that the critical and reflective view of the unit by nurses is maintained and that the quality of services is minimally guaranteed.

Thus, changes in the context of human resources management in nursing areas raise important points to note in their work process, like the need of closer supervision in the change location to ensure quality care.

CONCLUSION

The results of this study suggest that the turnover directly affects the work process of the facility manager - the nurse. These changes are experienced in different ways and their impacts are dealt with and overcome according to the uniqueness of each manager.

Considering the field of study and its particularities, the hiring schedule of new employees is unclear, making difficult the planning of insertion of this new employee in the unit. Aware of this reality, nurses seek to deal with it according to their management, aiming at the quality of care provided.

Questions concerning the competence and reassessment of decision making will always be perceived more clearly when there is any change, whether personal or in the structure of the worker’s workplace; but it is essential that this analysis allows a deep thinking in relation to the processes experienced, in order to improve the work dynamics.

Workers’ changes in the unit often are not related to the nurses’ will; but at every scenario change, their health educator ability is stimulated, which plays an important role in this educational process and in the evaluation of nursing care.

In addition, turnover causes difficulties in the management of human resources in nursing and nurses are in charge of people management. It is a constant concern of health organizations, because it interferes in the quality of care and staff productivity.

REFERENCES

1. Battistelli A, Portoghese I, Galletta M, Pohl S. Beyond the tradition: test of an integrative conceptual model on nurse turnover. Internacional Nursing Review. 2013:103-11.

2. Medeiros CRG, Junqueira ÁGW, Schwingel G, Carreno I, Jungles LAP, Saldanha OMdFL. A rotatividade de enfermeiros e médicos: um impasse na implementação da Estratégia de Saúde da Família. Ciênc. saúde colet. [ internet ] 2010 [ cited 2013 jan 10 ]15(Suppl1). Disponível: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1413-81232010000700064. doi: http://dx.doi.org/10.1590/S1413-81232010000700064

3. Sancho LG, Carmo JMd, Sancho RG, Bahia L. Rotatividade na força de trabalho da rede municipal de saúde de Belo Horizonte, Minas Gerais: um estudo de caso. Trab. educ. saúde [ internet ] 2011 [ cited 2013 jan 12 ]9(3). Available from: http://www.scielo.br/scielo.php?pid=S1981-77462011000300005&script=sci_arttext. doi: http://dx.doi.org/10.1590/S1981-77462011000300005

4. Temple A, Dobbs D, Andel R. Exploring correlates of turnover among nursing assistants in the National Nursing Home Survey. The Journal of nursing administration (JONA). 2011;41:34-42.

6. Stancato K, Zilli PT. Fatores geradores da rotatividade dos profissionais de saúde: uma revisão de literatura. RAS. 2010;12(47):87-99.

7. Sung K, Seo Y, Kim JH. Relationships between compassion fatigue, burnout, and turnover intention in korean hospital nurses. J Korean Acad Nurs. [ internet ] 2012 [ cited 2013 Feb 18 ]42(7). Available from: http://synapse.koreamed.org/Synapse/Data/PDFData/0006JKAN/jkan-42-1087.pdf. doi: http://dx.doi.org/10.4040/jkan.2012.42.7.1087 

8. Bardin L. Análise de conteúdo. Lisboa:Edições 70;2011.

9. Aiken LH, Cimiotti JP, Sloane DM, Smith HL, Flynn L, Neff DF. Effects of nurse staffing and nurse education on patient deaths in hospitals with different nurse work environments. Med Care. [ internet ] 2011 [ cited 2013 mai 09 ]49(12). Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3217062/?report=classic doi: 10.1097/MLR.0b013e3182330b6e

10. Bernardes A, Cummings G, Evora YDM, Gabriel CS. Framing the difficulties resulting from implementing a Participatory Management Model in a public hospital. Rev. Latino - Am. Enfermagem. [ internet ]  2012 [ cited 2013 jun 3 ]20(6). Available from: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0104-11692012000600017&lng=en&nrm=iso&tlng=en&ORIGINALLANG=en. doi: http://dx.doi.org/10.1590/S0104-11692012000600017

11. Kleba ME, Krauser IM, Vendruscolo C. O planejamento estratégico situacional no ensino da gestão em saúde da família. Texto Contexto Enferm. [ internet ] 2011 [ cited 2013 fev 05 ]20(1). Available from: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0104-07072011000100022&lang=pt. doi: http://dx.doi.org/10.1590/S0104-07072011000100022

12. Camelo SHH. Professional competences of nurse to work in Intensive Care Units: an integrative review. Rev. Latino - Am. Enfermagem. [ internet ]  2012 [ cited 2013 mar 25 ]20(1). Available from: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0104-11692012000100025&lng=en&nrm=iso&tlng=en. doi: http://dx.doi.org/10.1590/S0104-11692012000100025

13. Yañez-Gallardo R, Valenzuela-Suazo S. Critical incidents of trust erosion in leadership of head nurses. Revista Latino - Am Enfermagem  [ internet ] 2012 [ cited 2013 jan 17 ]20(1). Available from: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0104-11692012000100019&lang=pt. doi: http://dx.doi.org/10.1590/S0104-11692012000100019

14. Bucchi SM, Mira VL. Redesigning the nurse admission training process at the Intensive Care Unit. Rev Esc Enferm USP. [ internet ] 2010 [ cited 2013 jan 22 ]44(4). Available from: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0080-62342010000400021&lng=en&nrm=iso.  doi:http://dx.doi.org/10.1590/S0080-62342010000400021.

16. Mira VL, Follador NN, Ferrari CRS, Oliveira LFMN, Silva JAM, Santos PT. Avaliação da eficácia de um treinamento de profissionais de enfermagem: estudo correlacional. Online braz j nurs. [ internet ] 2012 [ cited 2013 mai 2 ] ;11(3) Available from: http://www.objnursing.uff.br/index.php/nursing/article/view/3652/html

17. Sancinetti TR, Soares AVN, Lima AFC, Santos NC, Melleiro MM, Fugulin FMT, et al. Nursing staff absenteeism rates as a personnel management indicator. Rev Esc Enferm USP [ internet ] 2011 [ cited 2013 mar 28 ]45(4). Available from: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0080-62342011000400031&lng=en&nrm=iso. doi: http://dx.doi.org/10.1590/S0080-62342011000400031

18. Silva AEBdC. Patient’ safety: challenges for nursing research and practice Rev. Eletr. Enf. [ internet ] 2010 [ cited 2013 mai 05 ]12(3). Available from:  http://www.fen.ufg.br/revista/v12/n3/v12n3a01-en.htm. doi: 10.5216/ree.v12i3.11885

19. Brail. Lei n. 7.498, de 25 de junho de 1986. Dispõe sobre a Regulamentação do Exercício da Enfermagem e dá outras providências. Diário Oficial da República Federativa do Brasil, Brasília, 26 jun. 1986. Seção 1;1.

20. Manzo BF, Ribeiro HCTC, Brito MJM, Alves M. Nursing in the hospital accreditation process: practice and implications in the work quotidian. Rev. Latino - Am Enfermagem [ internet ] 2012 [ cited 2013 mai 05 ]20(1). Available from: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0104-11692012000100020&lng=en&nrm=iso. doi: http://dx.doi.org/10.1590/S0104-11692012000100020.

All authors participated in the phases of this publication in one or more of the following steps, in According to the recommendations of the International Committee of Medical Journal Editors (ICMJE, 2013): (a) substantial involvement in the planning or preparation of the manuscript or in the collection, analysis or interpretation of data; (b) preparation of the manuscript or conducting critical revision of intellectual content; (c) approval of the versión submitted of this manuscript. All authors declare for the appropriate purposes that the responsibilities related to all aspects of the manuscript submitted to OBJN are yours. They ensure that issues related to the accuracy or integrity of any part of the article were properly investigated and resolved. Therefore, they exempt the OBJN of any participation whatsoever in any imbroglios concerning the content under consideration. All authors declare that they have no conflict of interest of financial or personal nature concerning this manuscript which may influence the writing and/or interpretation of the findings. This statement has been digitally signed by all authors as recommended by the ICMJE, whose model is available in http://www.objnursing.uff.br/normas/DUDE_eng_13-06-2013.pdf

Received: 06/09/2013
Revised: 11/06/2014
Approved: 11/06/2014