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Turnover Rates due to Burnout in Healthcare

Review of Literature

High turnover rates as a result of nurse burnout are a major issue in healthcare that needs to be resolved. Kelly et al. (2021) established that burnout can be addressed by improving resilience through mental health awareness and mindfulness-based stress reduction to address nurses’ turnover. The article provided high-quality evidence as the conclusions made were definitive and supported by the data provided. The evidence is applicable to the PICOT question as it supports improvement in mental well-being could reduce burnout and turnover. The findings are consistent with those of other studies (Kwon et al., 2021). The major difference was the methodologies used to collect data as Kelly et al. (2021) obtained patient data from health databases while Kwon et al. (2021) used anonymous online surveys. The controversy in the article is that it does rule out the contribution of other factors in improving nurses’ resilience.

In another study, Kwon et al. (2021) associated burnout with turnover intention and suggested that nurses’ turnover intention could be mitigated by improving their mental health. The article provides low-quality evidence as the sample size is insufficient for the study. The findings can be applied to the PICOT question to address nurse turnover. The evidence provided in the article is supported by other studies that associate burnout and nurses’ intention to leave (Chen et al., 2019). The similarities between the studies included the methodology as they were both cross-sectional studies and some of the variables in the studies. The difference identified included the location of the studies as one was conducted in Korea and the other in Taiwan (Chen et al., 2019; Kwon et al., 2021). There was no controversy identified in the study.

However, Tununu and Martin (2020) established that psychiatric nurses did not suffer from burnout because they had low emotional exhaustion. The article provides low-quality evidence that cannot be generalized as it was conducted in one psychiatric hospital, and the evidence varied from that of other studies (Scanlan & Still, 2019). The evidence applies to the PICOT question as it provides an alternative view of the existence of burnout among psychiatric nurses. The similarity between the articles is that they were single-site studies The differences noted include the geographical location and the participants’ response rates since one had 100% and the other 25% response rate (Scanlan & Still, 2019; Tununu & Martin, 2020). The controversy identified is the sufficiency of the sample size yet the findings were inconsistent with those of other studies.

Research indicates that there is an inter-correlation between turnover intention and burnout (Scanlan & Still, 2019). The evidence provided was of high quality as the findings were supported by data from the study. The findings are applicable to the PICOT question to provide a solution to the issue of turnover by developing strategies to reduce burnout. The evidence is similar to the findings of Chen et al. (2019). However, the major difference between the studies was that Chen et al. (2019) investigated burnout as a mediating factor influencing turnover intention among nurses with high patient-nurse ratios. The controversy that exists in the articles is the different measurements of turnover intention (Chen et al., 2019; Scanlan & Still, 2019).

Wei et al. (2022) established that burnout was prevalent among nurses in delivery and peri-operative settings. The article provided high-quality evidence as the conclusions were supported by the results of the study. The evidence is applicable to the PICOT question since the researchers recommended the need to improve burnout symptoms and nurses’ physical and mental health. The findings are consistent with the evidence in other studies that associated work-related stress and increased burnout in nurses (Karimi et al., 2022). The difference noted is the location of the study as Wei et al. (2022) was conducted at a single site and the other in two hospitals (Karimi et al., 2022). No controversy has been identified in the study.

Karimi et al. (2019) found that some elements of burnout influenced turnover intention such as a personal accomplishment. The quality of the evidence provided was affected by the small sample size, which could have influenced the results, but the study was conducted in multiple settings, which improves the generalizability of the findings. However, the evidence is related to the PICOT question as the authors recommended monitoring nurses’ mental health to prevent the effects of burnout such as turnover. Other researchers have also identified burnout as a common problem among nurses during the COVID-19 pandemic (Maunder et al., 2022). The two studies were conducted in multiple settings. The studies were conducted in two different geographical locations. The controversial information in the article is that work position was the highest predictor of the intention to leave.

In their study, Maunder et al. (2022) found that nurses experienced high levels of burnout during the COVID-19 pandemic. The findings were consistent and generalizable and can be applied to the PICOT question to address the problem of nurse turnover due to burnout by helping nurses cope with work-related stressors such as COVID-19. A similar study conducted by Karimi et al. (2019) had similar findings where data was collected through surveys. The differences identified include the setting, and the measures of burnout used. No controversies were identified in the study.

There are some other elements of burnout such as client-based and personal burnout that influence the intention to leave among nurses (Chen et al., 2019). The quality of the evidence was supported by the statistical data and the sample was sufficient. The findings provide important information for answering the PICOT question by reducing burnout to address nurses’ intention to quit their jobs. Similar findings were provided by Kwon et al. (2021). But the difference is that Chen et al. (2019) used a large sample from multiple settings and conducted the study in one setting. No controversial information was identified from the study.

Kowalczuk et al. (2020) associated burnout symptoms with working excessively, which increased nurses’ tendency to frequently take sick leave. The evidence was consistent with the data provided and was correctly interpreted. The sample size was sufficient for generalization and the study was conducted in multiple sites. The evidence can be used to answer the PICOT question since the researchers explained that burnout and excessive work affect employees’ mental health. Therefore, reducing workload could reduce burnout and prevent nurses from leaving. The similarity identified with the other articles include the research design; But differed in the data collection procedure as the authors applied paper-questionnaires Kowalczuk et al. (2020), other than online surveys (Maunder et al., 2022; Wei et al., 2022).

Rudman et al. (2020) associated nurse burnout with various mental health problems such as insomnia, depressive symptoms, and cognitive problems. The article provided high-quality evidence as the sample size was sufficient and the results were consistent and generalizable. The findings apply to the PICOT question since improving nurses’ mental health would prevent them from such problems and could be overwhelmed by the demands of their careers. The evidence is consistent with other studies that identified the association between burnout and mental health issues (Maunder et al., 2022). However, the study involved nursing students while the others mostly focused on nurses and other healthcare professionals (Kowalczuk et al., 2020; Maunder et al., 2022).

PICOT question support

Burnout is a major issue among nurses that should be addressed to prevent nurse turnover. Current research indicates a significant association between burnout and nurses’ intention to quit their jobs to seek other opportunities. Studies have suggested that addressing burnout could help reduce nurses’ intention to leave their careers or positions by improving their resilience (Kelly et al., 2021). Burnout is associated with increased psychological distress (Maunder et al., 2021), and low satisfaction with their jobs (Scanlan & Still, 2019).

It is important to note that the relationship between nurse turnover and burnout can be influenced by other factors such as workload, which may not independently affect nurse turnover. The PICOT question seeks to establish whether improving mental health and well-being could address the problem of nurse turnover. Available evidence indicates the need to create strategies to reduce burnout and improve nurses’ job satisfaction to reduce their intentions to leave (Scanlan & Still, 2019). Strategies to help nurses cope with stressors in the workplace could reduce nurses’ burnout and turnover intentions by enhancing personal accomplishment and reducing emotional exhaustion (Karimi et al., 2019).

Practice Change

To address the problem of the high turnover rate of nurses affected by burnout, implementing a mental health program to reduce burnout can help nurses to cope with job-related stress. Kelly et al. (2021) identified improving employee well-being as essential in preventing nurses from leaving their positions or units. Tununu and Martin (2020) explained that promoting open communication and resources could help reduce burnout among nurses and provide a safe working environment. It is important to identify and prevent factors that lead to nurse burnout to successfully prevent nurses from the intention to leave, especially when faced with critical situations (Karimi et al., 2019).

Objective

The project change aims to reduce the nurse turnover rate caused by burnout by providing nurses with a program that will improve their mental health. When the nurses’ mental health is improved, it would be easy to cope with stressors that arise in the workplace and prevent them from burnout and subsequently intentions to quit. The intervention will protect not only nurses from harm but also patients since burnout is associated with psychological distress which threatens patients’ safety (Maunder et al., 2022). Improving nurses’ mental health would translate to improved patient outcomes.

Problem

The problem of nurse turnover resulting from burnout is common among nurses working in busy and understaffed units. There is a relationship between a high workload and increased burnout, which is a predictor of high turnover (Chen et al., 2019). Nurses are more likely to be overwhelmed when they ate overworked Therefore, there is a need to improve nurses’ ability to cope with the stress that arises due to high workloads and help them to be more resilient. Nursing is a challenging profession that is faced with many challenges such as staffing shortages and nurses are bound to find themselves in difficult situations; thus, have to be mentally strong.

Current state of problem

Since the emergence of the COVID-19 pandemic, nurses have been faced with relentless pressure to care for many patients. The pro of the problem is the increasing demand for nurses as the opportunities for front-line workers have increased as more nurses leave the profession to seek other opportunities. However, the negative part of the problem is that many healthcare institutions still need to hire more nurses as they still struggle to properly compensate the existing workforce putting more pressure on the remaining workforce. Hospitals have been faced with the challenge of managing their costs and providing quality care (Chen et al., 2019).

Strengths and weaknesses of review of literature

The major strength of Kelly et al. (2021) was a sufficient sample size and consistent results, while the limitation was the fixed times of data collection. In Kwon et al. (2021), the main strength was the relevance of the article to the PICOT question, while the weakness was that it was a single-site study, which limited its generalizability. The main strength of Tununu and Martin (2020) was a sufficient sample size but was conducted in a single hospital. In Scanlan and Still (2019), the main strength was the consistency of the findings but lacked a random sample. Wei et al. (2022) provided consistent findings from a sufficient sample size but only focused on peri-operative units of one hospital.

Karimi et al. (2019) provided consistent findings, but the sample size was small and relied on self-reported data, which can be biased. The main strength of Maunder et al. (2022) was the study design that allowed for follow-up, but there was a high drop-out, which created an opportunity for bias. Chen et al. (2019) had a sufficient sample size for the study, but the model may not be used with other mediators. In Kowalczuk et al. (2020), the main strength was that the hypothesis was confirmed, and the major weakness was the cross-sectional study design and self-reported data, which can be biased. Lastly, Rudman et al. (2020) had a sufficient sample size from different settings, and the major weakness was the over-reliance on self-reported data.

References

Chen, Y. C., Guo, Y. L. L., Chin, W. S., Cheng, N. Y., Ho, J. J., & Shiao, J. S. C. (2019). Patient–nurse ratio is related to nurses’ intention to leave their job through mediating factors of burnout and job dissatisfaction. International journal of environmental research and public health, 16(23), 4801. https://doi.org/10.3390/ijerph16234801

Karimi, L., Raei, M., & Parandeh, A. (2022). Association between dimensions of professional burnout and turnover intention among nurses working in hospitals during coronavirus disease (COVID-19) pandemic in Iran based on structural model. Frontiers in public health, 10. https://doi.org/10.3389/fpubh.2022.86026

Kelly, L. A., Gee, P. M., & Butler, R. J. (2021). Impact of nurse burnout on organizational and position turnover. Nursing outlook, 69(1), 96-102. https://doi.org/10.1016/j.outlook.2020.06.008.

Kowalczuk, K., Krajewska-Kułak, E., & Sobolewski, M. (2020). Working excessively and burnout among nurses in the context of sick leaves. Frontiers in psychology, 11, 285. https://doi.org/10.3389/fpsyg.2020.00285

Kwon, C. Y., Lee, B., Kwon, O. J., Kim, M. S., Sim, K. L., & Choi, Y. H. (2021). Emotional labor, burnout, medical error, and turnover intention among South Korean nursing staff in a University Hospital setting. International journal of environmental research and public health, 18(19), 10111. https://doi.org/10.3390/ijerph181910111

Maunder, R. G., Heeney, N. D., Hunter, J. J., Strudwick, G., Jeffs, L. P., Ginty, L., … & Wiesenfeld, L. A. (2022). Trends in burnout and psychological distress in hospital staff over 12 months of the COVID-19 pandemic: a prospective longitudinal survey. Journal of Occupational Medicine and Toxicology, 17(1), 1-11. https://doi.org/10.1186/s12995-022-00352-4

Scanlan, J. N., & Still, M. (2019). Relationships between burnout, turnover intention, job satisfaction, job demands and job resources for mental health personnel in an Australian mental health service. BMC health services research, 19(1), 1-11. https://doi.org/10.1186/s12913-018-3841-z

Tununu, A. F., & Martin, P. (2020). Prevalence of burnout among nurses working at a psychiatric hospital in the Western Cape. Curationis, 43(1), 1-7. https://doi.org/10.4102/curationis.v43i1.2117

Wei, H., Aucoin, J., Kuntapay, G. R., Justice, A., Jones, A., Zhang, C., … & Hall, L. A. (2022). The prevalence of nurse burnout and its association with telomere length pre and during the COVID-19 pandemic. Plos one, 17(3), e0263603. https://doi.org/10.1371/journal.pone.0263603

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High nurse turnover is one of the major issues that nurse leaders and hospital management face. High nurse turnover has a significant negative impact on nurse leaders, hospital managers, nurses, patients, doctors, and the entire healthcare system (Bae, 2022). (i) There are several reasons for high nurse turnover rates among which is burnout which causes physical and mental strain on nurses forcing them to leave their jobs. Nurse turnover forces hospitals to spend more resources hiring and training new nurses and affects the overall morale of nurses and increases the burden of heavy workload as the remaining nurses have to cover the gap left by others (Bae, 2022). The purpose of this paper is to examine the impact of high nurse turnover on nurses’ mental health and how a ten-week mental health program implemented based on Orem’s self-care theory can reduce the rate of this turnover.

The rate of turnover for registered nurses is approximately 26.8 % in the U.S. and the rate of turnover for new graduate nurses is 18.1% with 17.1% of new nurses leaving their jobs within the first year of employment (Zhao et al., 2018). High turnover rate caused by burnout is a major nursing issue that negatively affects nurse motivation and mental health and therefore should be properly addressed (Bae, 2022). The purpose of the ten-week mental program is to reduce the impact of turnover rates caused by burnout on nurses' mental health, therefore, reducing the rate of turnover. (f) The program will address nurses’ mental health wellness and help them cope with work-related stress which causes burnout.

Turnover Rates due to Burnout in Healthcare

PICOT question

The PICOT question evaluates whether a mental health program can help reduce the nurse turnover rate in comparison to the rate of turnover before the program. The intervention aims to address high nurse turnover caused by burnout. The population in this intervention is the critical care nursing staff, the intervention is implementing a mental health program, the comparison is the rate of turnover before the program, the outcome is a reduced nurse turnover rate and the time is ten weeks.

Population

The vulnerable populations to high nurse turnover rate due to burnout are critical care nurses as they are exposed to high stress work. The heavy workloads of critical care nurses as a result of the high nurse-patient ratio affects nurses mentally and physically. Due to the high turnover rate, nurses' performance level reduces increasing the risk of medical errors because they are overworked and their commitment and motivation are adversely affected forcing them to consider leaving their jobs (Kaddourah et al., 2018). Various risk factors increase turnover rates such as unfavorable work environment, job dissatisfaction, salaries and compensations, communication barriers, and high nurse-patient ratio.

According to Kim and Kim (2021), a high nurse-to-patient ratio is one of the major causes of burnout that directly leads to a high turnover. When there is a high turnover rate, nurses have to take additional shifts and take up heavy workloads to cover the gap left by other nurses. A high nurse-patient ratio impacts patient safety adversely and leads to low-quality services as nurses are often exhausted mentally affecting their well-being. According to Dewanto and Wardhani (2021), an unfavorable work environment causes approximately 10% of the turnover rate. When nurses work in a stressful environment with limited resources to perform their duties, they are more inclined to leave their jobs to pursue better options leading to a high turnover rate.

Nursing research

According to Lockhart (2020), improving the nurse-to-patient ratio is an effective intervention that reduces turnover rates caused by burnout. The research conducted by American Medical Association shows that hospitals with a low nurse-to-patient ratio (4:1) have a high nurse retention rate compared to those with a high nurse-to-patient ratio (8:1) (Lockhart, 2020). Reducing the 8:1 nurse-to-patient ratio by half reduces the rate of turnover due burnouts by approximately 25% (Lockhart, 2020). According to Lockhart (2020), over four patients per nurse increases nurse burnout by 23% affecting the mental health of nurses with heavy workloads. This intervention requires a hospital to incur additional expenses to hire more nursing staff.

According to Luo et al. (2019), one effective strategy for reducing the high turnover rate caused by burnout is implementing support groups where nurses can voice their concerns and gain emotional and mental support. These support groups help nurses cope with the pressure that comes with their demanding nursing practice. Nursing support groups are important as they teach better scheduling, discuss well-being and overall nurses' health and provide safe respite areas for nursing staff. According to Luo et al. (2019), support groups help nurses find self-care techniques that improve their mental health and prevent or reduce burnout therefore indirectly reducing the turnout rate.

Proposal

Implementing a mental health program can reduce the turnover rate caused by burnout among critical care nurses. When implementing this program, there are numerous resources required. The intervention would allow nurses to examine their mental well-being and take care of their health. It also gives nurses insight into how to deal with the pressures and challenges of the nursing profession. When implemented effectively, this intervention has the potential to reduce nurse burnout because it addresses all stakeholders involved and who work with nurses such as doctors, nurse leaders, and other clinicians.

Resources

These resources include a printed guide to help nurses cope with burnout, online support forums, training courses, a venue, therapy platforms, a computer, a tablet or a projector, and a thought record diary among others (Lockhart, 2020). (i) The individuals that would be involved in implementing this intervention are hospital managers, nurse leaders, nurses, and other physicians such as doctors and psychiatrists. (ii) Nurse can play an advanced role in ensuring that this intervention is implemented effectively to reduce the rate of turnover that leads to nursing staff shortages. Nurses with advanced skills are able to provide leadership, and use their critical thinking skills to solve problems that may arise during the program. (iii) The program is expected to run for ten weeks upon implementation where the rate of turnover after the mental health program will be compared to the turnover rate before the implementation of this intervention to determine its effectiveness.

Orem’s self-care theory

Orem’s self-care theory is the ideal nursing theory that one cause use as a foundation when implementing this intervention. According to Dorothea Orem, the founder of Orem’s self-care theory nurses should be responsible for their care, be self-reliant and provide quality care to patients who need their services (Khademian et al., 2020). This theory is best-suited in dealing with burnout which causes a high turnover rate as nurses have to be responsible for their care including mental well-being first before they can offer their best to their patients. this theory requires nurses to maintain autonomy, benevolence, nonmaleficence, and justice on themselves before they can do the same for their patients. self-care in form of mental health program helps nurses cope with burnout and therefore reduces the turnover rate.

High turnover rate negatively impacts patient care, therefore, affecting patients' quality of life. It also adversely affects the cost of care as patients are forced to spend a long time in hospitals. High nurse turnover also affects hospital managers who have to spend a significant amount of time screening new nurses who have high qualifications and skills that suit the hospital's needs (Zhao et al., 2018). A high nurse turnover rate is also costly to patients and hospitals as the former incur additional medical costs due to low-quality patient care and prolonged hospital stay while the latter spends more on training new nurses, hiring additional nursing staff, and providing incentives to retain experienced nurses.

References

Bae, S. H. (2022). Noneconomic and economic impacts of nurse turnover in hospitals: A systematic review.  International Nursing Review,  69(3), 392-404. https://doi.org/10.1111/inr.12769

Dewanto, A., Febrina, S. S., & Wardhani, V. (2020). The importance of nurses’ cognitive and emotional engagement in developing hospital quality culture.  Enfermería Clínica,  30, 97-101.

Kaddourah, B., Abu-Shaheen, A. K., & Al-Tannir, M. (2018). Quality of nursing work life and turnover intention among nurses of tertiary care hospitals in Riyadh: A cross-sectional survey.  BMC Nursing,  17(1), 1-7. https://doi.org/10.1186/s12912-018-0312-0

Khademian, Z., Ara, F. K., & Gholamzadeh, S. (2020). The effect of self-care education based on orem’s nursing theory on quality of life and self-efficacy in patients with hypertension: a quasi-experimental study.  International Journal of Community-Based Nursing and Midwifery,  8(2), 140. https://doi.org/ 10.30476/IJCBNM.2020.81690.0

Kim, H., & Kim, E. G. (2021). A meta‐analysis on predictors of turnover intention of hospital nurses in South Korea (2000–2020).  Nursing Open,  8(5), 2406-2418. https://doi.org/10.1002/nop2.872

Lockhart, L. (2020). Strategies to reduce nursing turnover.  Nursing Made Incredibly Easy,  18(2), 56. https://doi.org/10.1097/01.NME.0000653196.16629.2e

Luo, Y. H., Li, H., Plummer, V., Cross, W. M., Lam, L., Guo, Y. F., … & Zhang, J. P. (2019). An evaluation of a positive psychological intervention to reduce burnout among nurses.  Archives of Psychiatric Nursing,  33(6), 186-191. https://doi.org/10.1016/j.apnu.2019.08.004

Zhao, Y., Russell, D. J., Guthridge, S., Ramjan, M., Jones, M. P., Humphreys, J. S., & Wakerman, J. (2018). Cost impact of high staff turnover on primary care in remote Australia.  Australian Health Review,  43(6), 689-695. https://doi.org/10.1071/AH17262

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Sexually transmitted diseases are infections that are spread from one individual to another through sexual activities (Rhodes et al., 2021). Examples include syphilis, human papillomavirus, gonorrhea, and genital herpes. Due to poor testing knowledge, speaking openly about sexual things, and young girls' susceptibility to STDs, adolescents and teenagers are more likely to develop STDs.Even though STDs can affect any population, adolescents and young adults are at increased risk of having STDs. STDs have undeniable effects on individuals, communities, and healthcare sectors. Adolescents and teenagers need to be educated on STDs, especially on how to prevent the spread and the importance of treatment. Teenage STD infection rates are rising globally, and gonorrhea and chlamydia are the most frequent STDs among teens in the United States. In the 2016 STD study, teenagers aged 15 to 19 had a male prevalence of 15.3% and a female prevalence of 4.1% for chlamydia (Shannon & Klausner, 2018). STDs among adolescents are a problem because increased rates of infections increase the health burden of a state. This paper focuses on the impact a 2-month program can have on the knowledge and understanding of adolescents aged 14-17 years about STDs.

Sexually Transmitted Diseases in Adolescents

PICOT question

Can the implementation of a 2-month program on sexually transmitted diseases in adolescents aged 14 to 17 years improve their knowledge about the prevention of sexually transmitted diseases compared to their knowledge before the program's implementation?

The population of focus is adolescents aged 14-17 who are vied to be at increased risk of having STDs because of insufficient knowledge (Shannon & Klausner, 2018). A 2-month program on STDs is seen as the fit intervention for this population. The comparison intervention is the knowledge of this population before having the intervention. After the assessment, the outcome is expected that this population will show increased knowledge in understanding the topic of STDs. The program timing is two months, which is considered reliable and enough time for the education program.

Vulnerable populations

Some of the social determinants for STD among adolescents include age, ethnicity, and family background. School characteristics and neighborhood factors are also considered important in the acquisition of STDs by adolescents. The risk factors of STDs among adolescents include practicing sexual relations at an early age or practicing unprotected sex, being shy to take about one's sex life, having a history of STDs or HIV, and lack of regular STD tests for those who engage in sexual relations (Ayerdi Aguirrebengoa et al., 2020). Also, misuse of drugs can lead someone to engage in improper sexual behaviors that increase the risks of having STDs.

Ayerdi Aguirrebengoa et al. (2020) assessed the risk factors associated with STDs/HIV among adolescents in Madrid. The authors found that the prevalence of STD/HIV was high among adolescents, and the leading risk factors in their study were to having sexual relations at an early age and having a history of STD. Rusley et al. (2022) assessed the trends in risk b

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