Employee Attraction and Retention: The Case of Nursing in Western Australia

PUBLIC POLICY VOLUME NUrv1BEFi 2009 133 Copy provided by the Western Australian Parliamentary Library in accordance with Section 48A of the Copyr...
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PUBLIC POLICY

VOLUME

NUrv1BEFi

2009

133

Copy provided by the Western Australian Parliamentary Library in accordance with Section 48A of the Copyright Act 1968

Employee Attraction and Retention: The Case of Nursing in Western Australia

Marita Naude and Therese Jefferson Curtin Graduate School of Business, Curtin University of Technology Western Australia's population is both growing and ageing rapidly. This has significant implications for the State's health sector, including its capacity to plan for and manage an appropriately skilled workforce. This study reports on employee attraction and retention in three hospitals that have been relatively successful in managing labour attraction and turnover. The study focuses on employees' perspectives about the key factors which encouraged them to seek and remain in employment with their current hospital. The key conclusion is that the factors which first attracted employees to their current employer provide some contrasts with the factors that facilitate their retention. This has important implications for successfully integrating human resource practice into public health policies in a context of increasing demand for health services. Although this study was conducted in the health services, some of the insights and understandings are useful to other sectors and organisations. Skills shortages are a key issue for employers and policy makers in Western Australia (State Training Board 2008; CCIWA 2007) and are particularly concerning for sectors that are constrained in their capacity to pay relatively high wages to attract and retain employees (State Training Board 2008:7). These issues extend to Western Australia's health sector which, as outlined below, is experiencing an ongoing shortage of skilled health professionals. Over half of the health professionals employed in Australia's health service industries are nurses (Productivity Commission 2005:XVI) and policies to address skills shortages in the health sector will require human resources strategies with the capacity to attract and retain skilled nursing staff. Much has been studied and published on the reasons people leave nursing and factors that contribute to the profession's lack of attractiveness as an for school leavers (see for example Blackman, Hall and Darmawan 2007; 1998 ,2000; Health Department of Western Australia 1997; Committee 2002; Dockerey and Barns 2005; McCabe, Nowak and Preston 2001). However, there are many nurses who remain long term job satisfaction. The researchers were analysed motivations for selecting and remaining in appeared relatively satisfied with their choice of career was on the nurses' (and not the organisations' or m"n"rlAnlRn,fs') pel'spec1iye$. This project reports findings from a qualitative employees of three Western Australian hospitals rates, defined as less than 20 per cent per descriptions of the experiences and perceptions

© 2009 Curtin University of Technology ISSN 1833-21

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and remain in employment with their particular hospital. This is of interest to public policy makers, who both regulate and employ the majority of health industry workers. In 2003-04, 9.7 per cent of GDP was spent on health care in Australia, with expenditure on the health care workforce accounting for about two-thirds of that total (Productivity Commission 2005, XVI). Measures which encourage labour retention are significant not only because of the potential cost saving associated with reduced labour turnover but also because of their role in addressing current skill shortages in the nursing labour force.

Background The ongoing shortage of skilled health workers, including registered nurses has been an ongoing policy concern in Australia and internationally for over a decade (Nowak 2005). In common with other jurisdictions, Western Australia is currently experiencing a statewide shortage of registered nurses (Department of Education, Employment and Workplace Relations 200S). There are important reasons to expect that this shortage will continue as demand for health services increases in response to: rising incomes; Australia's ageing demographic profile and an associated change in the mix of health concerns; and retirement and other exits from an ageing health sector workforce (Productivity Commission 2005, XVII). Those charged with formulating health policy and managing service delivery increasingly recognise that current staff shortages are having adverse effects on effective health service delivery (Duckett 2005). Within this context, strategies that both attract employees and retain their services are likely to form an important component of measures to address increasing demands on health service delivery. There is no specific formula that can accurately estimate the direct financial costs of labour turnover across different hospitals. However, some indication of the magnitude of costs can be gained from international studies that suggest turnover in medical centres can represent 5 per cent of total operating budget or as high as 50-60% of the relevant person's annual salary (Hoffman 19S5; Jones 1990; Loveridge 19S5; Wise 1990; Waldman, Kelly, Arora and Smith 2004; Hayhurst, Saylor, and Stuenkel 2005; Middaugh and Hester 2006). If this estimate is applied to Australia, it means that for a registered nurse earning around A$5S,000 per year the loss is around A$29,000 to $34,500 while for a nursing director earning around A$90,000 the loss is around A$45,000 to $54,000. As in all areas of labour turnover, the loss is more than just the direct financial loss and associated costs such as exit interviews, recruitment and selection. Indirect cost include loss of productivity, lower morale, loss of corporate knowledge and experience (Alexander, Bloom and Nuchols 1994; Karsan 2007; Contino 2002; Hay 2002).

Research method Our understandings of the factors that motivate nurses to remain in employment and more particularly, remain with a particular employer are relatively under researched. The need for more detailed understandings of factors that motivate nurses to remain in employment prompted researchers on this project to utilise a qualitative descriptive and contextual approach to identifying and analysing nurses' decisions to select and remain in employment with their particular hospital. The research objectives for the project were twofold:

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1. To explore and describe the factors that attract nurses to a specific hospital; and 2. To explore and describe the factors which motivate these nurses to remain working at that specific hospital. According to Jabri (2006) understanding the culture of an organisation (and the reasons why employees select the organization and remain working in the organisation) is largely dependent on understanding the narratives from the employees on how they experience their workplace. Narratives provide knowledge on the environment and context of the employee and are essential knowledge to provide policies and practices responsive to the needs of the employees. As the researchers wanted to understand the approach to recruitment and retirement from the view of the employees, narratives were the suitable method for data collection. We were motivated by Fuimano's recommendation that researchers focus on what is working: The answer doesn't lie in finding new nurses, but in identifying what's good about nursing, perfecting that, and then creating support structures to fill the void between what you have and what you desire. (Fuimano 2003: 52) Reflecting a narrative approach, a major section of the survey contained open ended questions. This was supplemented by questions seeking biographical data that could contextualise the qualitative findings. Data were collected through a survey consisting of three sections. Section A focused on biographical data and career development opportunities which have previously been identified as important to the retention of nursing staff (Fuimano 2003; Numerof, Abrams and Ott 2004; Pieper 2003; Vaughn 2003). Section B was an open ended question focusing on the reasons nurses chose for selecting their specific hospital when initially searching for employment. Participants were asked to describe in their own words the reasons (personal, professional, social, economic etc) that lead to their employment decision. Section C was an ended question focusing on the factors that motivated participants to remain hospital. Participants were asked to describe in their own words the motivating them to remain working at that specific hospital.

Data collection and analysis Consistent with Jabri's (2006) approach were sought from employees in selected hO:3piJals r6th8,dF,6h In order to identify hospitals that might to attract and retain nursing staff, the r",c:",,,,,'rh,,rc: seled:$d •

A hospital with a nursing turnover



Nurses with a length of employee

Three hospitals in Western Australia's necessary criterion for labour turnover Each hospital was approached and agreed. Each hospital was responsible distributed by a hospital employee were not part of the selection process project, namely, that participants have

EMPLOYEE ATTFiACTiON AND FiETENTION iN NUfiSING

the preceding 2 years. Data was collected during the latter part of 2003 and the first part of 2004 and data analysis was finalised in 2005. An information sheet outlining the project was provided to each participant along with the survey. All participants provided signed informed consent and the project was approved under Curtin University of Technology's research ethics processes. A follow up letter was distributed in early 2004 reminding employees of the opportunity to participate in the study. Four hundred (400) surveys were distributed throughout the three hospitals and 153 (38.25%) were returned. In 14 of these surveys, sections Band C were not completed and therefore could not be used, leaving 139 (34.75%) completed surveys which form the basis of our discussion. Data from section A (biographical data) were analysed through basic descriptive quantitative methods and reflected in tables and figures. A summary of the demographic characteristics of those who responded to our survey is provided in Appendix A Data from sections Band C were analysed using qualitative analysis methods and coded into categories. The researchers read through the responses and identified and coded the main themes. The identification and coding of themes involved active decisions by the researchers. For example, a comment about good salary would be grouped within "good conditions of employment". Similarly, a comment regarding availability of parking would alsobe grouped within "good conditions of employment". So while the comments pertain to quite different factors, within the context of the project, these factors are both conditions of employment. This has some important implications which are common to much qualitative research. Firstly, comments by one participant regarding two different factors ("good salary" and "availabilityof parking") may actually be grouped into the same category ("conditions of employment"). Secondly, no data were categorised twice. N*Vivo software was used to assist with data management. In the following discussion a list of categories and their relevant code is provided for the study's two focus areas: selecting a hospital and staying with a hospital. Each category has been listed with a number in brackets which gives an indication of its ranking in terms of the frequency with which comments arose, for example, "Close to home (1 indicates that this category had the highest number of comments. In terms of analysis, no significance can be given to the number of comments that are relevant to each category. It is of interest, however, because the categories that are ranked more highly have a richer and more diverse array of supporting data on which to base discussion.

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In the following discussion we have grouped categories of data into broad themes, shown in the left hand columns of Tables 1 and 2. The grouping of categories under these broader themes facilitates discussion of participants' diverse comments and also assists with identifying a shift in emphasis between comments about selection compared with those about staying. One of the aims of this research is to "bring in the voice of participants" (Creswell 1998). Verbatim quotations from participants are used to support the following discussion.

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Selecting a hospital As noted above, participants were asked to respond to an open ended, exploratory request for their views:

"Please describe in your own words the reasons (personal, professional, social, economic etc) why you selected the specific hospital to work at." The categories of data that were formed by analysing participants responses are listed in Table 1, grouped according to the themes identified in the left hand column. Table 1: Reason for selecting a hospital - List of data categories. Close to home (1)

Necessity and convenience

Right job, at the right time, Full time job, First hospital to give me a job (2) Needed the money (18) Able to transfer from previous job; no break in service (20) Good reputation (3) Good physical environment and adequate equipment (4)

First impressions

Personal, friendly, welcoming atmosphere (12) Good teamwork; Multi-disciplinary approach (14) Recommended by a friend/friend who works at the hospital (19) Available undergraduate/graduate/refresher program (5) Good staff development (8) Huge variety of clinical conditions; Job variety (13)

Ongoing professional development

Promotion opportunities; Opportunities for career advancement (15) Good research opportunities (21) Previous experience valUed and acknowledged (24)

Employment conditions

Key criteria

Management and organisational practices

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Necessity and convenience The job search process implies that a potential employee has decided that they either need or want employment. It is perhaps not surprising therefore, that issues relevant to the necessity for employment and practical matters associated with convenience are remembered as important factors in selecting a particular hospital as a future employer. Issues of location and timing were common issues of comment. In general terms, some of these responses suggested that potential employees had a number of job search criteria which contributed to their initial search and selection process.

i. Close to home The response most frequently given as a reason for initially choosing to work at a specific hospital was that it was "close to home". As described by the statements below, a preference for working close to home was often expressed in economic terms, as well as reasons of convenience: "Economic - close to home. Less travel time and petrol cost." "Close proximity to my home. "

ii. Right job at the right time An interesting factor to note is that selection of the hospital was regarded as the "right job at the right time". As responses were grouped into categories, the motivators relating to this particularfactor vary slightly. For example, some participants indicated it was a job when they needed one, for others the job enabled the work type and/or hours most suitablefor them: "I saw the ad in the paper and it was the right job at the right time." "It was the only hospital which was able to offer me full time employment. "

iii. Needed the money Some of the participants expressed the necessity of their employment situation in fairly direct terms: because they needed the money: "Badly needed the money."

iv. Able to transfer from previous job, no break in service This was mentioned by just four participants but is the key category within the necessity/convenience theme that is closely influenced by the personnel practices of a particular hospital. While location, timing and need are likely to be strongly influenced by the context and perceptions of the potential employee, continuity of employment can potentially be the subject of specific policy and practices of individual hospitals.

First impressions The data categories in this theme are relatively more complex than those above. In some cases it appears that participants are recalling their early days of employment with the hospital, implying that comments might be related to a period after their selection of a particular hospital. In other cases, however, the comments specifically refer to a knowledge of the hospital that precedes the participant's period of employment. We have not distinguished between these apparent differences. Rather, we have relied on participants' own perception that these issues were of a particular hospital. Given the relatively large number of about previous graduate

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training experiences within participants' selected hospitals (discussed below), it seems likely that many nurses had a reasonable knowledge of the hospital prior to their current period of employment.

i. Good reputation Comments pertaining to the hospital having a good reputation and being well regarded in the community were relatively common and suggest this was an important factor for some participants: "Felt it was a well recognized and reputable hospital. Well regarded in the community." "I choose this hospital because it has a good reputation. n

ii. Recommended by a friend While this category of data has some similarities with reputation, it generally implied that the employee felt they had special knowledge about the hospital from a close friend. This contrasts with comments from less well known acquaintances or more general notions of high regard within the community. Comments in this category were generally of the following nature: "A good friend of mine also works at

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iii. Good physical environment and adequate equipment A good physical environment and the fact that there is adequate equipment available in the hospital generated a number of comments linking these factors to reasons for selecting a hospital in which to work: "The environmental aspects of the hospital ie cleanliness also affected my decision to work here." "My workplace is well equipped with the latest equipment and at no time are we short of anything to use."

iv. Personal, friendly, welcoming

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Eleven statements were made indicating they regarded it as Ilaving a friendly, recruitment phase: "At the interview was welcomed I was doing them a great favour "Found staff to be welcoming and

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v. Good teamwork; Multi-disciplinary

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Good teamwork was also stated as a the precise basis of participants' hospital. It is possible that these statements a hospitals' reputation. None the less, pel'cepti()r1S number of participants: "Equity among team members is promotec! "Team work is obvious and supoonec: In comparison with factors of necessity show considerably closer links with

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hospitals. While issues of reputation might require long periods of time to establish, other issues, such as the physical environment and welcoming recruitment and orientation processes might be actively addressed through management policy and practices. Ongoing professional development i. Available undergraduate/graduate/refresher program This was a widely cited reason for hospital selection, with twenty six comments made by participants who had taken part in their hospital's graduate program. This experience had prompted them to select this hospital for employment: "I selected to work at this hospital to attend a graduate nurse support program. " "I chose this hospital's Graduate Program as it had a 2 week orientation which was extremely beneficial. It gave the opportunity to do 3 rotations through different wards with a preceptor based in all the wards. "

ii. Good staff development Graduate programs were not the only important form of professional development cited by participants. A wide range of comments indicated that some participants selected their specific hospital because of the opportunities for ongoing staff education and training programs. Some of the participants mentioned they were attracted by the fact that their hospital offered a career path and not just a job: "Good educational system in place. " "Provides educational opportunities. "

iii. Huge variety of clinical conditions; Job variety Another factor that attracted participants to the hospital was a large number of clinical areas available to work in: "The ward that I work on has a huge variety of clinical conditions which enables one to keep updated with many medical and surgical conditions and treatments. " "Large operating department so I will be able to develop a variety of skills and become confident in this area."

iv. Promotion opportunities; Opportunities for career advancement In addition to ongoing training and education programs, participants viewed career opportunities very favourably: "Many opportunities for promotion available."

v. Good research opportunities vi. Previous experience valued and acknowledged vii. Offers specialist work area These three categories have been grouped together due to the relatively few data that specifically discussed these reasons for hospital selection. Despite their small number however, they are important in the context of a relatively large number of comments under the theme of 'ongoing professional development'. Many of the participants clearly gave the issue of professional development a high selection of hospital not only in their initial graduate program experience but as an working lives. It was clear

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that some participants took their career and professional development seriously and thought about the long term prospects offered by particular hospitals. While nursing might be viewed as a profession with relativelyhigh turnover, it is clear that the nurses responding to this study commenced employment with long term, professional careers in mind.

Employment conditions Employment conditions are closely tied to the notion of "necessity", discussed above. However, this category of responses focuses on the diverse but specific conditions of employment that were important to participants in their decision to work at a particular hospital.

i. Good conditions of employment Statements that were grouped into the category of "good conditions of employment" were reasonably varied and included aspects such as salary packaging, study leave, leave and parking facilities. The availability of safe parking was a definite issue. Indicative comments included: "Salary Sacrifice." "Parking for staff is provided with safety measures .... n

ii. Flexible work hours/limited night duty Comments about working hours were relatively common and several participants indicated flexible working and scheduling hours were key issues in their hospital selection as this allowed them to balance their work with the needs of their families. Some participants highly valued the limited night duty hours expected at their particular hospital: "Very flexible rostering. verv eccommcdeilnq "We have very flexible rostering commitments, study commitments, etc.

iii. Job Security iv. Set night shifts (these pay the These two data categories included for particular participants. The H''''Uc>'V' , important point that while some emploVeEls others require predictable and stable arrian~lerrlerlg

Key criteria This theme groups together some important to some characteristics.

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i. Values, ethics and philosophy The importance of a hospital's ItJIIlJIULJ0 affiliation values, ethics and philosophy was a "I feel comfortable in a Christian "I liked the Christian based ethos

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ii. Private hospital Some participants preferred to work at a Private Hospital as indicated by 14 comments. With one exception, participants did not expand explicitly on their reasons for preferring a private hospital. However, one participant linked private hospitals with better staffing levels: "The fact that it is a private hospital. " "My perception was that a private hospital would have better staffing levels and may not be as busy or as heavy nursing as in the public sector. "

iii. Offered sponsorship There were only two comments in this data category. However, in contrast to the other data categories in this theme, it is a criterion that is relatively amenable to consideration under hospital management and personnel practices. Management and organisational practices i. Excellent support (managers and staff) As with the above theme of "first impressions", these categories are interesting when considered as factors for selecting a hospital. Again these comments suggest the possible importance of reputation and/or the training/education experiences of employees prior to commencing employment: "I find the Management for the most part to be supportive, approachable and easy going at most times. " "Supportive staff members who work well as a team."

ii. Effective management Six comments were made that the specific hospital was selected because the management seemed to be effective. The following statements support this aspect: "Because of the nursing leadership that ---- provides. "

iii. Sufficient staff; good staff to patient ratio To be able to provide adequate nursing care to the patients requires adequate staff. This aspect was commented on a number of times and reflects the importance some participants place on a hospital having strong patient focus and valuing the provision of quality nursing care. This is evident from the following quotations: "They seem to be really customer focused to deliver good quality patient care." "I feel that I could give the quality of nursing care that I want."

Selecting a hospital: Summary Data about hospital selection includes issues that might be taken as "given" for a particular hospital. These include issue such as hospital ethics and philosophy (particularly when related to a specific religion) and private However, there is a range of issues that are relatively amenable to and implementation. These relatively 'manageable' factors are welcoming recruitment and orientation processes to ongoing career opportunities. As the discussion shifts to factors that motivate their current hospital, 'manageable' issues receive even greater

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Staying with a hospital This section is based on an open ended, exploratory and descriptive question in which participants were asked to answer the following question: "Please describe in your own words the factors (aspects, things) that are motivating you to remain working at that hospital. n

The categories of data that were formed by analysing participants' responses are listed in Table 2. Table 2: Reason for staying with a hospital - List of data categories Friendly and supportive staff (1) Colleagues

Good relationships, equity and respect among all health professionals (11) Good teamwork; Multi-disciplinary approach (13) Supportive and effective management (2) Provide quality care (16) Recognition/rewards for hard work (17)

Management and organisational practices

Great autonomy within a team (20) No "them and us" attitude (24) Good orderly assistance (25) Fairly flat hierarchy (26) Good physical environment and adequate equipment (3) Job satisfaction and content (4) Huge variety of clinical conditions; Job variety (9)

Favourable experiences

Opportunity for new challenges (10) Additional

Employment conditions

Necessity and convenience

Ongoing professional development Key criteria

Inertia/perceived barriers to changing employment/hospital Feel

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