Peer Reviewed Articles How to Avoid High Turnover
Open Nurs J. 2017; 11: 108–123.
Interventions to Reduce Adult Nursing Turnover: A Systematic Review of Systematic Reviews
Mary Halter
1Kinesthesia of Health, Social Intendance and Education, Kingston University and St George's, Academy of London, London, England
Ferruccio Pelone
2National Guideline Alliance, Imperial Higher of Obstetricians and Gynaecologists, London, England
Olga Boiko
1Faculty of Health, Social Care and Education, Kingston Academy and St George'southward, University of London, London, England
Carole Beighton
1Faculty of Wellness, Social Intendance and Education, Kingston University and St George's, Academy of London, London, England
Ruth Harris
3Nursing & Midwifery, King's College London, England
Julia Gale
iFaculty of Health, Social Intendance and Education, Kingston University and St George's, Academy of London, London, England
Stephen Gourlay
4Faculty of Business organisation & Law, Kingston University, London, England
Vari Drennan
aneFaculty of Health, Social Care and Didactics, Kingston University and St George'south, Academy of London, London, England
Received 2017 Mar 20; Revised 2017 May 22; Accepted 2017 Jun 8.
- Supplementary Materials
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Supplementary material is bachelor on the publisher's website along with the published article.
GUID: CB94B557-15A2-4AF5-8BD8-2CA177BA0430
Abstract
Background:
Nurse turnover is an consequence of business organisation in wellness care systems internationally. Agreement which interventions are effective to reduce turnover rates is of import to managers and health care organisations. Despite a plethora of reviews of such interventions, force of show is hard to determine.
Objective:
We aimed to review literature on interventions to reduce turnover in nurses working in the developed health care services in developed economies.
Method:
We conducted an overview (systematic review of systematic reviews) using the Cochrane Database of Systematic Reviews, MEDLINE, EMBASE, Applied Social Sciences Index and Abstracts, CINAHL plus and SCOPUS and frontward searching. Nosotros included reviews published between 1990 and January 2015 in English. We carried out parallel blinded selection, extraction of data and assessment of bias, using the Assessment of Multiple Systematic Reviews. We carried out a narrative synthesis.
Results:
Despite the big body of published reviews, only 7 reviews met the inclusion criteria. These provide moderate quality review evidence, albeit from poorly controlled master studies. They provide evidence of effect of a minor number of interventions which decrease turnover or increase retentiveness of nurses, these beingness preceptorship of new graduates and leadership for group cohesion.
Conclusion:
Nosotros highlight that a large body of reviews does not equate with a big torso of loftier quality testify. Agreement equally to the measures and terminology to be used together with well-designed, funded principal research to provide robust evidence for nurse and human resource managers to base their nurse retention strategies on is urgently required.
Keywords: Intervention, Nurses, Nursing staff, Personnel turnover, Review, Systematic, Workforce
1. INTRODUCTION
Turnover amongst nurses, that is, nurses leaving their jobs or leaving the profession, has received international attention due to the size of the issue [1] and the consequences of high rates of turnover [2]. Supply need gaps are projected in developed economies such as Australia [3], Canada [4], the United States of America [5] and in the Britain (United kingdom of great britain and northern ireland) [6], as are shortages in many other EU countries [7]. Negative consequences of such shortages for the nursing workforce in less developed economies is well documented [seven]. Nurse turnover is described as having a large number of individual, organisational and societal antecedents or determinants and, although the strength of the prove is not as strong as its size suggests, a number of causal or correlational models from nursing exist and have some overlap with those from the broader human resource direction literature [8]. A pressing issue for nurse and human resource managers in developed economies is to introduce interventions which are effective in addressing those determinants, reducing nurse turnover and increasing nurse memory [9]. A series of policy initiatives (in the Britain National Health Service) were put in identify in the early 2000s [10] just it has been suggested that 'it is unclear how effective the initiatives were in retaining staff and whether they were fully implemented.' [xi,p16] A contempo review aiming to support the growth of nurse numbers concluded that adopting a number of strategies, including some based on evaluated intervention (for example Gess 2008 [12] or Hirschkorn 2010 [thirteen]), although the review did not appraise the quality of these studies [10].
Outside of nursing, the human resources literature on retention management is reported to describe a large number of practices and groups of do that have been shown to be effective in the retention of individuals, although a conceptualisation of them as a whole has non been forthcoming [14]. Reported strategies include operation-based reward systems, long-term career prospects, personal recruitment and socialisation all based on retaining an private although a model for the retention of resources has also been proposed as an alternative way of considering the event of retentiveness [14].
Our awareness of the existence of some literature focused on nursing retentivity alongside the human resource literature based on many dissimilar task roles and settings, led united states to undertake a preliminary phase of review - making an assessment of potentially relevant literature specific to nursing and its size for review [fifteen] - when nosotros were deputed to carry out a review of the adult nurse turnover literature. Using Medline solitary at this stage we identified a large body of reviews (Table i ) relevant to the study'southward objectives that indicated that nurse and human resource managers would exist faced by a plethora of reviews of interventions to reduce turnover in adult nursing [16, 17], many of which were not conducted according to reviews guidance [15].
Table i
Medline search strategy and number of articles found on 17/01/2015.
| # | Searches | Results |
|---|---|---|
| ane | exp Nursing Staff/ | 34106 |
| two | exp Nursing Intendance/ | 58119 |
| iii | exp Nurses/ | 42050 |
| 4 | (nurse or nurses or nursing).tw. | 176170 |
| five | i or 2 or 3 or 4 | 229957 |
| 6 | exp Personnel Turnover/ | 2974 |
| 7 | ((turnover adj3 (nurse or nurses or nursing)) or ((work or working or workload) adj3 (nurse or nurses or nursing)) or (leaving adj3 (nurse or nurses or nursing)) or (retentiveness adj3 (nurse or nurses or nursing)) or (retain adj3 (nurse or nurses or nursing)) or (stay adj3 (nurse or nurses or nursing))).tw. | 10391 |
| 8 | 6 or 7 | 12673 |
| 9 | Job Satisfaction/ and (turnover* or get out or leaving or retention or retain or stay or staying).tw. | 2220 |
| ten | Exhaustion/ and (turnover* or leave or leaving or retention or retain or stay or staying).tw. | 644 |
| 11 | Personnel Management/ and (turnover* or leave or leaving or retentivity or retain or stay or staying).tw. | 379 |
| 12 | Workload/ and (turnover* or leave or leaving or retentiveness or retain or stay or staying).tw. | 1018 |
| xiii | ((exhaustion or morale or stress) adj5 (turnover* or exit or leaving or retention or retain or stay or staying)).tw. | 949 |
| 14 | ((economic* or fiscal or pay*) adj5 (turnover* or leave or leaving or retention or retain or stay or staying)).tw. | 672 |
| xv | (chore satisfaction adj5 (turnover* or leave or leaving or retentiveness or retain or stay or staying)).tw. | 421 |
| xvi | ((piece of work or working or workload) adj5 (turnover* or get out or leaving or retention or retain or stay or staying)).tw. | 2002 |
| 17 | (organization* adj5 (turnover* or leave or leaving or retentivity or retain or stay or staying)).tw. | 585 |
| eighteen | 9 or 10 or 11 or 12 or 13 or 14 or 15 or 16 or 17 | 6758 |
| 19 | eight or 18 | 17664 |
| twenty | (incentive* or intervention* or strateg*).tw. | 885703 |
| 21 | (meta anal$ or metaanal$).ti,ab,sh. | 77150 |
| 22 | ((methodol$ or systematic$ or quantitativ$) adj3 (review$ or overview$ or survey$)).ti,ab,sh. | 63670 |
| 23 | (medline or embase or index medicus).ti,ab. | 57545 |
| 24 | ((pool$ or combined or combining) adj (data or trials or studies or results)).ti,ab. | 10785 |
| 25 | literature.ti,ab. | 352373 |
| 26 | 21 or 22 or 23 or 24 or 25 | 456788 |
| 27 | 26 and review.pt,sh. | 217357 |
| 28 | v and 19 and 20 and 27 | 176 |
| 29 | limit 28 to english language language | 165 |
Against this background, the aim of this research was to undertake an overview (that is a systematic review of systematic reviews [18]) on interventions to reduce turnover in nurses working in the field of adult health intendance services, that is the largest group of nurses in all countries [19-21]. Our desire to provide a review that might be used by nurses in do informed our conclusion to employ an overview, whose purpose "in identifying and appraising all published reviews is to describe their quality, summarise and compare their conclusions and discuss the strength of these conclusions, so that the best evidence is made bachelor to clinical decision-makers." [22].
ii. Material AND METHODS
The review methods and the reporting of them are based on the guideline from the Preferred Reporting Items for Systematic Review and Meta-analysis Protocols (PRISMA-P) 2015 argument [23] and the guidance within the Cochrane Handbook for Systematic Reviews of Interventions [18, 24].
2.1. Criteria for Inclusion
The inclusion criteria were as follows:
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Published from 1990 onwards
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Population: The review was focused on those delivering adult nursing (i.eastward. licensed or registered) in health services (both in hospital and community) in developed economies (according to the definition of the International Monetary Fund [25])
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Intervention: The review examined any type of service, management or human being resources activeness aimed at reducing rates of adult nurse turnover
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Comparison: Any comparators used within the included reviews
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Outcomes: Whatever outcome examined inside the included reviews
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Review design: Any class of literature review which had been peer-reviewed, contained a statement of review, reported its search strategy and/or inclusion/exclusion criteria, reported either empirical findings or a list of included primary studies and included a methodological quality assessment of its included master studies, that is a review containing fundamental aspects of a well-conducted systematic review
Exclusion criteria were every bit follows: Reports from any types of principal studies; reviews published in linguistic communication other than English language; reviews that did not evaluate adult nursing turnover as described in the inclusion criteria or presented data on nurses working across settings that could include the care of children or in specific mental health settings; reviews that did not report empirical findings; reviews published only in abstract form; whatever course of literature review using breezy and subjective methods to collect and translate show; commentaries and not peer-reviewed reviews; any review in which the majority of included manufactures were not-peer reviewed publications and reviews that did not study an appraisal of the quality of the studies they included.
2.ii. Search Methods for Identification of Studies
We searched the Cochrane Database of Systematic Reviews, MEDLINE (Ovid), EMBASE (Ovid), Applied Social Sciences Index and Abstracts ASSIA, CINAHL plus (EBSCO) and SCOPUS Five.iv (Elsevier) from 1990 to 2015 (searches conducted Jan 2015). Search strategies were guided past a systematic approach to the research questions [26] and a Medline search strategy was developed (Table 1 ) and converted or modified to run on other databases (Supplementary file 1). We identified boosted studies by searching on PubMed past using the "related citations" algorithm and screening the reference lists of included studies on for other reviews [27].
two.3. Pick of Studies
The results of the electronic search were downloaded into an Excel spreadsheet Subsequently removing duplicate articles, relevant reviews were selected according to eligibility criteria using a two-step screening process:
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Championship and abstract screening: Two authors (FP and MH) reviewed in parallel the titles and abstracts of all the articles resulted to define their eligibility for full text retrieval. Disagreements were resolved by peer give-and-take and a tertiary view from the project lead (VMD) if required.
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Full-text screening: Two reviewers (FP and CB) read in parallel all the selected full-text manufactures to analyse whether they met the inclusion/exclusion criteria. Any discrepancies between the ii reviewers were resolved in discussion with the third reviewer (MH).
ii.4. Information Extraction
Information were extracted to excel spreadsheets (FP and CB) using a predefined extraction form and spreadsheet on: full general characteristics of the review e.g. author(due south), year, geographical scope, research area, and authors' aims/ research question(s); descriptive characteristics due east.thousand. type of review (design), option criteria to include primary studies, number and study designs of articles incorporated in the reviews and outcome measures; results- effectiveness of all interventions reported in the included reviews, the management of findings against the outcome measure and the references for the principal studies; main conclusions, using the review authors' words and limitations, as noted past the review authors. Discrepancies were resolved through discussion amid the information extractors.
The chief studies included in each review were also listed and compared beyond the reviews to assess the degree of overlap in the reviews we included.
2.5. Cess of Methodological Quality
The eleven-betoken Assessment of Multiple Systematic Reviews (AMSTAR) checklist [28] was used to assess the quality of each included review. This tool has been widely used in previous similar overview of reviews and it is considered to exist a valid and reliable instrument [29]. Using the AMSTAR scale ii authors appraised each included paper. Any review that scored viii or higher was considered at low chance of bias, between five and seven at moderate take a chance of bias and four or less at high risk of bias.
2.6. Data Analysis
Because of the heterogeneous nature of the focus, inclusion criteria and outcome measures of the included studies data were analysed thematically. Following the detailed reading involved for data extraction, the resultant spreadsheet was examined and a thematic index of interventions developed. The thematic index (supplementary data file 2) was applied to each data extraction and four main groupings of interventions (individual, leadership, group and organisational levels) were used to analyse across reviews, using Microsoft Excel 2010 to record the decisions applied for all reviews considered. A narrative business relationship of the findings from the reviews containing an cess of the methodological quality of included primary studies has been structured using the take chances of bias in the review as the primary group level and the thematic content analysis as the second level, likewise drawing on the number and quality of the included primary studies. In this style nosotros aim to describe the findings by 'weight of evidence'. [xxx]
The systematic review protocol was registered with PROSPERO 2015: CRD42015017535 [31].
3. RESULTS: REVIEW Option, STUDY CHARACTERISTICS AND QUALITY ASSESSMENT
3.i. Review Selection
The flow chart representing study selection, including reasons for exclusion, is summarised in Fig. ( one ). A total of seven reviews met the inclusion criteria and were included in the review. Supplementary File three provides a listing of citations for the excluded studies in the final stage of the choice process.
3.2. Study Characteristics
Details of the 7 included reviews are provided in Tables ( 2 , three and 4 ). The included reviews were conducted between 2008 and 2014. All were published in English language and originated from Canada [32-35], the United States [36, 37] and Taiwan [38]. Five reviews focused on the effectiveness of retentivity strategies targeted at registered nurses [33, 38] or newly graduated nurses [34-36]. One review aimed to examine the relationship between managers' leadership practices and staff nurses' intent to stay in their current position [32], and another focused on a single intervention: sabbaticals as strategy to enhance nursing retentiveness and revitalisation to generate positive outcomes [37].
Tabular array 2
General characteristics of the included systematic reviews.
| First Author year | Aim(s) Enquiry question(due south) | Selection criteria used to include primary studies (PICOS) | Scope 1. Geography ii. Time limit 3. Linguistic communication |
|---|---|---|---|
| Chen 2014a | To examine current information and clinical applications of mentorship programmes to attain a superior understanding of the implementation and effectiveness of such programmes for recently registered nurses. | P Recently RN I 1:ane Mentorship program C No comparison groups O Retentiveness; Turnover; Price S Experimental or a quasi-experimental peer-reviewed primary studies | 1 USA, ASIA ii 1999-2011 iii Not stated |
| Cowden 2011b | To examine the human relationship between managers leadership practices and staff nurses intent to stay in their current position. | P Staff nurses I leadership practices C No comparison groups O Intention to stay Due south Peer-reviewed qualitative or quantitative studies | 1 International (past Canada) 2 1985 - 2010 3 English |
| Larty 2014c | To study the effectiveness of strategies for retaining experienced RNs. | P Experienced RN's (newly qualified excluded) I Any intervention aimed to increase the memory of experienced RNs C No comparison groups O Retentivity/ turnover S Quantitative research studies | 1 By and large USA 2 No limits three No limits |
| Park 2010d | To nowadays an integrative review of the research that was conducted to explore the furnishings of orientation programs for newly graduated nurses on their confidence, competency, and retention. | P Infirmary based, NGNs I Orientation programs in nursing literature (included internships, residencies, and structured orientation programs) C No comparison groups O Retentivity S Not stated | ane USA 2 1990-2007 iii English |
| Rush 2013e | The purpose of the written report was to review existing research literature to identify best practices of formal new graduate nurse transition programs. | P NGNs inside one twelvemonth of graduation (acute intendance settings) I transition programs or orientation programs C No comparing groups O Memory; Turnover Cost-benefit S Any empirical study | 1 Mostly USA two 2000-2011 3 English language |
| Salt 2008f | To conduct a systematic review of published research to determine the effectiveness of retention strategies targeted at NGNs. | P NGNs I A retention strategy was identified equally a style to engage NGNs to continue service within a unit of measurement, hospital, or organization C No comparison groups O Memory S Only published and peer-reviewed primary studies | one United states 2 No limits 3 No limits |
| Swenty 2011g | To review and examine the literature supporting a professional sabbatical, a potentially viable and innovative change strategy that could renew, revitalize, and retain nursing staff practicing in the acute care setting. What is the bear witness related to professional sabbaticals in nursing? | P Nursing, business organization & education I Clinical practice sabbatical C No comparison groups O Retention; Turnover S Not stated | 1 United states of america 2 1999 - 2010 3 English |
a [38], b [32], c [33], d [36], e [34], f [35], g [37],
Table 3
Summary of reviews presenting interventions with multiple strands.
| Intervention type | Effect Review authors' summary of findings | Supporting show | ||
|---|---|---|---|---|
| Type, number, and quality of included studies as reported by the review author(s) | Review quality score | Review reference Beginning Author Yr | ||
| - Nursing practice models - Teamwork approach - Leadership practice - Organisational strategies - Individual strategies. | Near studies reported improved retention as a result of the intervention. Squad piece of work and individually targeted strategies including mentoring, leadership interest and in depth orientation increased chore satisfaction and produced higher retention results. Retentivity was highest when multiple interventions were used. | Total number 12 Quantitative 12 Experimental (quasi) two Observational x- Quality Quality cess tool adapted from Estabrooks et al (2003)a "All included studies were rated equally medium or high in the quality cess." b, folio 1030 | Moderate (vi/11) | Larty 2014b |
| - Preceptor programme - Needs-based orientation plan - Residency plan - New graduate internship programme - Externship before graduation from a basic RN programme | Based on the strongest evidence, the highest retentivity rates were associated with retentiveness strategies that used a preceptor program model that focused on the NGN also every bit a programme length of 3 to half dozen months. | Total number 16 Quantitative sixteen^^ ^^Blazon of quantitative studies included not discussed Quality Quality assessment tool adjusted from several existing frameworks (Cummings and Estabrooks 2003c, Estabrooks et al 2001d); "Eleven studies in the review were considered moderate, 3 were high, and ii were weak."east, folio 288 | Moderate (7/11) | Salt 2008e |
a [53], b [33], c [54], d [55], east [35]
Table 4
Articles most frequently included in the reviews assessed.
| Manufactures | Salt | Park | Cowden | Swenty | Lartey | Blitz | Chen | |
|---|---|---|---|---|---|---|---|---|
| 2008 a [35] | 2010 b [36] | 2011 c [32] | 2011 d [37] | 2013 e [33] | 2013 f [34] | 2014 g [38] | ||
| Owens h [61] | 2001 | ten | x | |||||
| Beecroft i [62] | 2001 | x | ten | |||||
| Squires j [63] | 2002 | ten | x | |||||
| Crimlisk thousand [64] | 2002 | x | x | |||||
| Roche 50 [65] | 2004 | x | x | |||||
| Almada m [39] | 2004 | x | ten | 10 | ||||
| Blanzola northward [66] | 2004 | ten | x | |||||
| Marcum o [twoscore] | 2004 | 10 | ten | x | ||||
| Altier p [41] | 2006 | x | 10 | x | ||||
| Herdrich q [67] | 2006 | x | ten | |||||
| Keller r [68] | 2006 | x | 10 | |||||
| Krugman due south [42] | 2006 | x | x | ten | ||||
| Lee t [69] | 2009 | x | x | |||||
| Komaratat u [70] | 2009 | x | x | |||||
a [35], b [36], c [32], d [37], e [33], f [34], thou [38], h [61], i [62], j [63], grand [64], fifty [65], thousand [39], n [66], o [40], p [41], q [67], r [68], due south [42], t [69], u [lxx].
3.iii. Quality Cess of Included Reviews
The AMSTAR scores for the reviews ranged from three to 7. Of the reviews, six [32-36, 38] were judged of moderate quality and ane [37] of low quality. The cess of each review against the AMSTAR criteria is presented in Fig. ( 2 ).
Graph of the methodological quality of the included reviews, according to AMSTAR quality items.
All reviews noted that the methods of the included studies were different, and that overall quality of the primary report ranged from loftier to low. The tools used to assess the quality of included papers in the included studies are shown in Tabular array three .
The majority of the reviews limited their searches to the English linguistic communication, with the exception of two reviews [33, 36]. The number of included principal studies in each review ranged from v to 40-seven Table ( 3 ). 3 systematic reviews included quasi-experimental study designs [33, 34, 38]; however, observational study designs dominated, and no review reported any randomised controlled trials. But 2 reviews included qualitative or mix-methods main studies [32, 34]. Of the 164 principal studies in the seven included reviews, 14 were included in at least two reviews, and of these simply four papers of primary studies [39-42] were included in iii reviews Tabular array ( 4 ).
3.4. Findings on Interventions to Reduce Turnover in Adult Nursing
The evidence from the included reviews is presented here narratively past thematic analysis of interventions, grouped into four content categories: individual, job-related, interpersonal, and organisational interventions; unless otherwise stated, the reviews were of moderate quality. In addition Tables ( 3 and iv ) split the presentation of the supporting detail of these reviews by the type of interventions reviewed.
iii.5. Interventions at the Individual Level
At the private level, interventions were heavily but not exclusively focused on newly qualified/graduated nurses (NGNs), and on supportive programmes of transition or development. Preceptorship - 1-to-one guidance through clinical experience - was a component of the bulk, alongside a range of plan components (for instance, classroom learning or grouping discussion) and support systems (for example, the program director or clinical educator). These programmes were variously named, including the terms residency, internship and orientation as well as mentoring and preceptorship itself.
Residency received positive support in iv reviews [34-36, 38] reporting several studies, with some overlapping reviews. 1 of these reviews did not provide the description of the written report designs, although the authors noted that the excluded studies appraised to be of low quality [36], and some other described its three included studies as i pre test-postal service test and 2 experimental case study designs [35]. The included studies measure the turnover outcome in the experimental group and compare information technology to general pre-published reports locally or nationally.
Internships also received some emphasis as positive for retention, supported in 2 reviews [35, 36], drawing on half-dozen studies of variable design but including ane with a controlled pre test-post test design. Orientation focus programmes for transition were highlighted in 3 reviews [34-36] every bit positively impacting on turnover in iv primary studies.
One to one mentorship programmes of three months' duration were reported as essential to retaining newly registered nurses, reducing turnover in two quasi experimental pretest-posttest studies (from the U.s. and Taiwan) in one review [38]. For preceptorship itself at that place was bear witness in one review [35], from ten studies from the USA, all of which were experimental in blueprint, although six were ane group case studies, two were ane group pretest-posttest and only two included a control grouping (nonrandomised) pretest-posttest design. Half of these studies were besides reported in the review to have included a focus on supporting RNs to work in the preceptor chapters through educational training and/or monetary incentives [35].
Evidence for the positive affect of externships (preceptored and employment experiences of the student nurse the twelvemonth before graduation from a basic RN education program) was express to one study reported in ane review [35]. Needs-based training or specialty training programmes (designed to develop skills for specific clinical areas and including classroom instruction, observational experience, journaling, instance study, coaching, and figurer-based training) was also reported to increment retention, although only ane of the chief studies (where the design was conspicuously reported by the review authors [35]) was robust, with a control arm.
These reviews vary in how actual turnover rates are reported, making comparison or synthesis hard. For instance, while the rates of turnover compare favourably with boilerplate ranges for turnover or retention of new graduates, "few studies had designs with the degree of control necessary to dominion out competing explanations"[34]. With the same caveats most strength of evidence, longer transition programmes (up to one year) appeared to achieve amend results regarding turnover [34, 35].
Other interventions identified at the individual level in the moderate quality reviews were bicultural training which was positively associated with turnover in one study in one review [35], and caste of fit to the job/lower work abilities which was negatively associated with turnover in i written report in some other review [33].
In add-on, 1 review of poor quality/high risk of bias [37], suggested that a clinical practice sabbatical (a go out of absence for an identified purpose) for nurses in acute care settings was a feasible option as a strategy to increase retentiveness. Descriptions of the nineteen included articles in this review are unclear, but it appears that only 5 addressed nursing sabbaticals and retentiveness and all were at best descriptive studies and at worst anecdotal accounts; the review authors conclude that the evidence is limited.
3.6. Interventions at the Leadership Level
Two reviews addressed interventions at the leadership level. Direction training in leadership behaviour featured in i study in 1 review [33], and supervision support in seven primary studies in another review [32], every bit significantly related to intent to stay.
3.7. Interventions at the Organisational Level
Two reviews considered interventions at the group or organisational level. I of these reviews [32] discussed nine primary studies where group cohesion was reported as significantly associated with intention to stay. However, no item was given about the nature of the interventions and variation in the reliability and validity of the measurement tools used was highlighted. Another review also described 2 studies demonstrating a positive impact of one year squad oriented interventions (1 of team discussion groups, the other undefined) on turnover [33]. Nursing exercise models, for case nurse-managed units and unit of measurement-level cocky-management widely used by hospitals with Magnet accreditation in N America [43-45] were reported to have mixed evidence of effect [33].
three.8. Summary of Interventions and Their Effectiveness
Tables ( 3 and 4 ) present the interventions reported in the reviews, alongside a summary of evidence of effectiveness. In summary, the tables highlight that the specific or multiple interventions reviewed that may have an effect on retentivity or intention to stay are orientation programmes (including preceptorship, internships, residencies, and structured orientation programmes [34, 36] and mentorship [38]) for new graduates; transformational or relational leadership [32, 33]; and team work. [33] Retention is reported as highest when multiple interventions are used [33]. Clinical sabbaticals received some support although the review quality was low [37].
four. DISCUSSION
iv.1. Summary of Findings From and Limitations of the Included Reviews
Seven reviews of interventions to reduce nurse turnover were institute which had undertaken a quality appraisal of their included studies. These reviews provided consistent and important messages about what might work to increase retention or at to the lowest degree intention to stay. Firstly, they reported positive affect of transition programmes for newly qualified nurses. [34-36, 38]. These programmes were variously named, including the terms residency, internship and orientation likewise as mentoring and preceptorship itself. Questions nonetheless remain as to the effectiveness, efficiency, and costs of different methods, frequency and elapsing of preceptorship programmes for newly qualified nurses who are in different types of clinical specialities and are themselves at a unlike life stages.
Secondly, the reviews likewise offered bear witness of the positive impact of nurse managing director leadership styles that were perceived as 'transformative' or encouragment of work grouping cohesion in reducing turnover or increasing retention (used interchangeably in this review) [32, 33]. Questions remain equally to the extent these types of nurse leadership or management styles influence nurse turnover rates in different types of clinical services and in different types of organisational and job market place contexts. In addition at that place are questions as to the effective (including judgements of cost) mechanisms for developing, maintaining and enacting these nurse leadership styles as judged by the primary outcome (rates of nurse turnover) and secondary outcomes such every bit described above.
Reviews of multiple interventions advise that this approach is more effective than single interventions [33].
In that location was footling overlap in the included primary studies in the reviews we analysed, due to their different foci, apart from two reviews of supportive programmes for newly graduated nurses [35, 36]. This finding highlights the importance of providing a summary of show from more than i systematic review on an important topic [19], equally the separate reviews focus on different interventions or unlike sub-populations of developed nurses.
The quality of the reviews was in the AMSTAR category of moderate, although half of them were borderline with being classified equally stiff reviews. These included the quality appraisal of their included primary studies in weighting their give-and-take and drawing conclusions [32, 34, 35].
The reviews' primary studies variously measured the intention to get out, turnover and retention, and the original reviews' authors commented on the reduction in the strength of conclusions they could infer due to the weak study designs and variable validity and reliability of the measurement of these outcomes [32, 33]. Examples of weak designs commented on were the absenteeism of control data in many of the primary studies [34, 36]. Other limitations noted by the original reviews' authors included a predominantly North American focus [33, 35, 38], and a lack of focus on the retention of experienced nurses [33]. The absenteeism of meta analysis in each review due to heterogeneity of studies was also a limitation [32].
In view of the critique of systematic reviews in terms of the ease of conducting poor quality ones that are given loftier esteem in publication and read by many who cannot easily differentiate their quality [46], we propose that this summary has an important part to play in highlighting what is already known alongside where a lack of inquiry studies exit space for uncertainty in the field of retention strategies for developed nursing.
four.ii. Limitations and Strengths of Our Overview
Our overview is limited by design. Systematic reviews themselves are open to criticism as subversive of 'reading, writing, thinking, interpreting, arguing and justifying [47]. As an overview (systematic review of systematic reviews) we have also relied upon the review authors' reporting and interpretation of the master studies and take made some assumptions about quality based on descriptions of research pattern if critical appraisal of each master written report was not clearly described in the reviews. We suggest that this limitation is mitigated by simply including reviews that have reported a quality appraisal of their included studies. We have too assessed the quality of the included reviews using a widely recognised tool for this chore [28]. We accept therefore provided an business relationship of what should be the highest quality reviews available although we notation that there are no reviews which offer stiff bear witness, and the AMSTAR tool authors themselves promote farther testing of the tool [28]. We accept accustomed review authors' descriptions of heterogeneity every bit limiting opportunities for meta assay without carrying out any formal analysis to consider whether the diversity has implications for the interpretation of findings. We accept also treated the terms turnover and retention as direct opposites noting that the included reviews do not comment on their differences, although there are some authors who argue that though interrelated, they are conceptually different and the reduction of one does non necessarily atomic number 82 to savings in the other in economic terms at to the lowest degree [48].
4.3. Our Findings in the Context of Other Literature
We initiated our investigation of the evidence on interventions to reduce adult nurse turnover following our early reading and subsequent interlinked systematic overview of the determinants of consequences of such turnover [8]. The finding we written report at that place of a myriad of determinants of turnover, albeit a body of literature widely open to critique of its quality, which might suggest a myriad of linked interventions have been studied. In dissimilarity, when nosotros applied criteria based upon guidance for the skillful conduct of systematic reviews [15] we have found a adequately narrow range of interventions tested and reported. Moreover, interventions were tested with a narrow range of nurses, in studies which the reviews' authors consider to lack rigour, particularly in the measurement of the primary result of involvement, that is, the charge per unit of turnover. In the context of the ongoing international miracle of nursing turnover and projected supply-demand concerns [6] this is a somewhat surprising finding.
Information technology was as well a surprising finding that otherwise well conducted reviews conflated evidence from self-reported determinants of turnover (i.eastward. what reports groups of nurses say are the causes of their intent or action to get out) with the review authors' opinions as to strategies to subtract turnover (including in a very contempo overview [49]). While the reviews we overviewed make information technology clear that at that place remains much to exist done to amend the strength of prove, for case there are no controlled trials and very few attempts to control observational studies, we argue such misapplied conflation has restricted the development of truthful intervention studies. In this nosotros hateful studies based on an intervention hypothesis for testing and framed by questions of interest to nurse and human resource managers which have the primary outcome of reduction of turnover rates (effectiveness) rates but secondary outcomes linked to accepted quality dimension criteria [l] such as of acceptability, patient condom and experience, staff well-being and cost consequences.
These findings are particularly pertinent when strategic guidance exists on good practice in staff retention [10, 51]. A comparison of the bachelor guidance on memory of nursing in England and the show from our literature review [52] suggests there is some evidence that the electric current guidance offered to retain adult nurses is supported in office by the research literature regarding the determinants of turnover, [8] inside the limitations of this evidence being of moderate strength. The guidance is supported in part by the inquiry evidence on interventions with regard to developing nurse leaders and line managers, investing in the workforce and developing and standing staff engagement [51] when nosotros depict on the findings of two reviews [32, 33]. The strategy'due south focus on newly qualified nurses is supported more than widely supported past the evidence. [32, 33, 35, 36, 38] Information technology would appear therefore that this is the nearly likely intervention to accept a positive touch on retentivity. Notwithstanding this argument needs to be seen in the context that nigh of these studies were not truthful intervention studies and nosotros are unable therefore to conclude that the strategies in the guidance would have the desired bear on on turnover, according to the available research evidence.
Conclusion
The current evidence on the effectiveness of interventions to reduce turnover in nursing workforces has a number of important limitations. However, it is of import to note that a body of moderately high quality review evidence does be giving a film of a number of interventions – preceptorship of new graduates and leadership for grouping cohesion - that are evidenced to decrease turnover or increase retention. A management manner by nurse managers that pays attending to a positive work environment and the nurse as an individual within that is also supported past the literature. However, large gaps remain in loftier quality evidence for interventions addressing the plethora of determinants of nurse turnover. While this is disappointing, the ongoing problems with retention and shortages of nurses in many countries mean that more research attention is required to build on the work reported here. Nosotros suggest that nurses and enquiry funders should develop and test the interventions that were shown to be constructive in observational or quasi-experimental studies in controlled studies, powered to let for interrelated concepts on causal pathways to turnover, particularly with groups other than new graduate nurses, and designed with consistent primary and secondary outcome measures.
Table v
Summary of reviews presenting specific interventions.
| Intervention blazon | Issue Review authors' summary of findings | Supporting bear witness | ||
|---|---|---|---|---|
| Type, number, and quality of included studies as reported by the review' author(s) | Review quality score | Review reference Start Writer Year | ||
| Orientation programs | Orientation programmes (included internships, residencies, and structured orientation programmes) may encourage new graduates to stay in their current position | Total number 17^ ^ Type of studies included not discussed Quality Quality assessment tool adapted from Beck (2001) a No details available | Moderate (6/11) | Park 2010 b |
| The presence of a formal new graduate transition programme (or orientation plan) resulted in expert retention of NGN and improved competency. | Total number 47 Quantitative xv Experimental (quasi) 8 Observational 7 Qualitative 5 Other* 27 * descriptive studies Quality Quality index with 3 criteria developed by Beck (2001)a and later modified past Park and Jones (2010) b "Bear witness was variable, and overall of low quality, limiting all-time practices recommendations." c | Moderate (5/11) | Blitz 2013 c | |
| Mentorship Programmes | Mentorship programmes are a beneficial procedure for mentors and recently registered nurses. Results accept shown that mentorship programmes improve competence, job satisfaction and reduce the turnover charge per unit among recently registered nurses. | Full number 5 Quantitative 5 Experimental (quasi) 5 Quality Newman and Roberts (2002) d "significant reliability" e page 468 | Moderate (7/11) | Chen 2014 e |
| Leadership Practices | Managers' leadership practices, Transformational or relational leadership approaches resulted in greater intentions to stay in their current positions. Other factors including perceived managing director power, supervisor support, empowerment, involving them in decision making, and promotion of group cohesion all showed a significant positive correlation affecting the staff nurses intent to stay. | Total number 23 Quantitative 22 Experimental (quasi) - Observational 22 Qualitative - Mix-Methods 1 Other - Quality Quality assessment tool adapted from several existing frameworks (Cummings and Estabrooks 2003 f, Wong and Cummings 2007 g, Lee and Cummings 2008 h); "..All studies were rated as moderate or strong" i page 468. | Moderate (6/11) | Cowden 2011 i |
| Clinical do sabbatical | The authors identified a nursing sabbatical equally a feasible option, which can heighten nursing retention and revitalization to generate positive outcomes. | Total number 19 Quantitative 2 Experimental (quasi) - Observational ii Qualitative 3 Mix-Methods - Other 14** **opinion/ consensus papers Quality Stillwell, Fineout-Overholt, Melnyk and Williamson (2010) j Weak evidenceyard page 157 | Moderate (3/11) | Swenty 2011k |
a [56], b [36], c [34], d [57], eastward [38], f [54], g [58], h [59], i [32], j [sixty], m [37], a [35], b [36], c [32], d [37], e [33], f [34], 1000 [38], h [61], i [62], j [63], k [64], 50 [65], m [39], due north [66], o [40], p [41], q [67], r [68], s [42], t [69], u [seventy],
SUPPLEMENTARY MATERIAL
Supplementary material is bachelor on the publisher's website forth with the published article.
ACKNOWLEDGEMENTS
This review was independent research funded by Wellness Education England South London, part of the National Health Service (NHS). The views expressed herein are those of the authors and not the funding trunk, the NHS or the Department of Wellness.
VMD, MH, RH and JG conceived the review and obtained funding; MH, FP, RH, JG, SG and VMD designed the study; FP and MH carried out the searches; MH, OB, FP and CB refined the study design, selected studies and extracted data; OB and MH conducted the thematic analysis; MH led the writing of the manuscript with OB and FP. All authors read, provided critical input and approved the final manuscript.
Listing OF ABBREVIATIONS
| AMSTAR | = Assessment of Multiple Systematic Reviews |
| PICOS | = Population, Intervention, Comparing, Outcomes, Report design; P: Population; I: Intervention; C: Comparison; O: Outcome; S: Report design |
| PRISMA-P | = Preferred Reporting Items for Systematic review and Meta-analysis Protocols |
| NGN | = Newly Graduated Nurses; |
| RN | = Registered Nurse |
Ethics APPROVAL AND CONSENT TO PARTICIPATE
Not applicable.
Human AND ANIMAL RIGHTS
No Animals/Humans were used for studies that are base of operations of this research.
CONSENT FOR PUBLICATION
Not applicative.
Disharmonize OF INTEREST
The authors declare no conflict of involvement, fiscal or otherwise.
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