A Contemporary Model for Improving RN Job Outcomes

Abstract

The pandemic has highlighted three critical nursing workforce issues: turnover, wellbeing, and equity. A comprehensive framework is needed to understand the interactions between these concepts. This paper proposes a model that allows for more inclusive understanding of professional outcomes for RNs, with attention not just to job outcomes, but also to equity for underrepresented groups in the workforce and individual wellbeing. The model highlights the importance of systems and societal elements, contextual elements, and individual responses to the dynamic conditions of work and life, and can be used to advance research and practice to create effective retention and support strategies.

Introduction

Since the onset of the pandemic, nursing workforce issues such as inequity, burnout, turnover, and attrition from the profession have gained national attention with startling statistics and compelling stories. Organizations, communities, and researchers all have concerns about the sustainability of the workforce and together must determine what steps can and should be taken to care for and retain registered nurses (RNs) at work. Retention strategies should rely on what is already known to be effective, but there are few reports providing meaningful data. While the literature provides detailed description of personal, workplace, and organizational factors influencing RN job decisions or intentions, the absence of robust intervention data or a comprehensive model that considers systems and contextual factors makes it difficult to advance knowledge about effective retention and support practices, particularly for underrepresented nurses. The purpose of this paper is to propose a model that allows for more comprehensive understanding of professional outcomes for RNs and which helps nurse leaders target support and retention strategies at multiple levels.

Background

Turnover and Job Outcomes

Three high stakes issues currently affecting the RN workforce are turnover, wellbeing, and equity. Turnover and retention describe the movement of RNs in and out of jobs. Research in the past few decades explores these job outcomes, often using job satisfaction or intentions to leave or stay in a job as critical outcomes. High turnover has multiple negative impacts on organizations, including finances, productivity and performance, and patient care quality.^1,2 Despite these negative impacts, few published studies from the past decade report on interventions or solutions designed to mitigate turnover, and the limited available data are based on inconsistent definitions and measurements of factors in isolation instead of examining interactions in different contexts.³

Wellbeing

The concepts of turnover and retention represent organization-focused outcomes that do not account for individual RNs’ experiences, nor do they give adequate information about the holistic health of RNs as a population. Wellbeing includes multiple aspects of health in physical, mental, emotional, and professional domains. Even prior to the pandemic, RNs experienced poor physiological health outcomes,^4,5 which continued during the pandemics as RNs and other healthcare workers experienced higher rates of exposure to and infection from COVID-19 compared to non-healthcare workers.⁶ These physical risks, together with high rates of mental health symptoms such as stress and exhaustion, have contributed to increased rates of RNs thinking about or actually leaving their jobs, citing staffing issues and the negative impact of work on their own health as the primary reasons for wanting to leave.⁷ An RN’s wellbeing influences their ability to be present and engaged at work and outside of work, affecting both patient care quality and their own quality of life.^8,9 With the widespread impact of the pandemic on RNs’ health, improving wellbeing must be considered from the perspectives of quality and safety, workforce sustainability, and population health.

Equity

Equity refers to the elimination of preventable differences in outcomes. While attention to equity is needed for many groups of RNs, including those with disabilities, nonbinary gender identities or diverse sexual orientations, this paper uses RNs who identify with historically underrepresented or marginalized racial or ethnic groups as an exemplar of a systems issue (racism) impacting RNs in various contexts. The term BIPOC (Black, Indigenous, and other People of Color) is used with the intention of including all peoples experiencing racial marginalization. To achieve equity within the profession, workforce research must focus on groups of RNs experiencing poorer outcomes, such as the higher rates of stress and burnout and higher intent to leave the profession experienced by BIPOC RNs as compared to their White counterparts.^7,10 While few studies directly address the experiences of marginalized groups, limited available data show that BIPOC RNs experience both microaggressions and overt racism from patients, colleagues, and supervisors, in addition to other influences of systemic racism such as biased hiring, compensation, and promotion processes that favor White RNs.^11,12 While general work focused on supporting RNs in the workplace will help RNs from marginalized groups, specific attention to systems and organizational factors and the inclusion of underrepresented RNs in strategy development and implementation can help ensure a lack of bias in policies and practices affecting RN employment and work. Together, turnover, wellbeing, and equity are critical issues that must be addressed to ensure a healthy nursing workforce in the years to come.

What Do We Already Know?

Understanding available data about RNs requires attention to data sources and pertinent concepts or frameworks. Studies of RN turnover typically describe the problem in terms of individual or organizational characteristics. Fewer than 20% of current studies report results of an intervention, and most of those focused on new RN transition to practice.³ In the nursing literature, data on RN job outcomes comes from studies of inpatient RNs within specific organizations³ or national datasets such as the National Sample Survey of RNs.¹³ However, because the sampling methods and survey foci differ, it is difficult to compare or integrate findings among these sources.

Concepts and Theory

Studies of RN turnover use theory inconsistently. Current concepts and frameworks for understanding turnover come from the field of organizational behavior, where the substance of turnover research has no frank contradictions with the work done in nursing. However, research in organizational behavior has shifted away from describing static individual or organizational factors toward inclusion of concepts that describe employee decisions in the interactive contexts of work, life outside of work, and individual responses to various experiences.¹⁴ Specific recommendations for conducting turnover research include measuring actual voluntary turnover rather than intentions, designing studies that seek to understand elements of change and time in turnover, and closely analyzing multilevel contextual influences on workplaces and employees.¹⁵ Overall, organizational behavior research provides helpful concepts, theories, and questions that can be adapted to advance work in RN job outcomes.

Limitations of Current Data

RN turnover studies often focus on static factors rather than processes or contexts in which RNs make job decisions.³ Studies revolve around job intentions rather than actual decisions and lack holistic measures that incorporate wellbeing as a professional outcome. A tendency to prioritize the presence of the RN in the job without exploring their engagement with the job means that an RN who stays in a job reluctantly and one who does so enthusiastically are counted as “success” despite data showing important differences in job performance in those situations.¹⁶ Additionally, frameworks often lack the necessary structure to examine systemic elements such as racism, reimbursement, or regulatory requirements like documentation that impact workplace experiences.⁹ Without a more holistic framework that includes context, systemic elements, and decision-making processes, future research may not influence policy and practices that impact RN work outcomes in a meaningful way, particularly in regards to equity as a critical workforce concept.

Proposed Model

The Dynamic Model of RN Job Outcomes (Dynamic Model; Figure 1) builds on findings from several recent systematic reviews within and outside of nursing and focuses on contextual factors that have previously been minimally addressed within nursing.^3,14,17,18 The model is designed to provide structure that accommodates the multiple data sources and concepts that have been used to describe turnover in RNs and the general workforce, assists in moving toward equity, and affords the opportunity for closer examination of RN wellbeing in the context of job decision-making. The name of the model comes from its representation of the dynamic contexts in which RNs live and work, and the term ‘job outcomes’ refers to the dual outcomes of wellbeing and turnover or retention. The model includes antecedents to wellbeing and turnover and how RNs respond to the antecedents within the contexts of work and life. Specific concepts listed in the antecedents, contexts, or responses are not intended to be an exhaustive list, but rather exemplify categories or types of elements that fit into the model.

Figure 1.

The Dynamic Model of RN Job Outcomes

Antecedents

Antecedents are grouped at the level of individual, unit/workgroup, and organization, all of which are located within the current healthcare system. In the model, general categories are used to represent antecedents, for example ‘structures’ at the organization level represents internal policies and practices such as compensation, benefits, or advancement practices which could be further examined and defined. Including the broader healthcare system in this model allows for examination of the impact of regulation, reimbursement, and national/state/local healthcare policy on the various antecedents and the RN directly. The systems level also provides the opportunity to study the impacts of social issues such as systemic racism, other - isms, and large-scale phenomena like the pandemic on RN outcomes.

Context

A key feature of the model is the inclusion of work and personal contexts, with elements including job attitudes, significant experiences in the workplace, and links between work and life such as employers offering education benefits or access to childcare. Context also includes organizational features that affect work structures, and factors at community or systems levels that may change workplace operations and the experience of working.¹⁴ Contextual factors are critical to understanding how RNs’ responses to work experiences differ over time and in different situations. Because the actual work context may be rapidly changing, categorizing these factors as stable or static limits understanding of how they impact an RN at a given point in time. Including work and personal contexts also supports the examination of experiences of underrepresented and marginalized groups (listed in the model as ‘bias versus equity’) as they impact individual RNs at work and outside of work.

RN Responses

The individual RN stands at the center of the model; their innate responses to the changing contexts of work and life are represented in concepts that directly impact their decision to stay or leave as well as their personal and professional wellbeing. Engagement can be defined as one’s feeling of being connected with work,¹⁷ and embeddedness refers to the set of work and life circumstances that connect a worker with their employer¹⁴; decreased levels of either concept are related to increased turnover rates in nursing.¹⁷ Resilience refers to an individual’s ability to adapt and thrive in the face of stressors, and is an individual response that can change with time, situation, or targeted intervention.¹⁹

The circular arrow in this model represents time as an important concept for RN responses and decision-making. Understanding cycles of change in RN responses and even the frequency of RNs’ job decision processes can help leaders develop targeted strategies for supporting RNs and to identify additional potential resources to deploy at critical moments. Likewise, understanding which processes are common among RNs provides opportunities to mitigate turnover by increasing other supports. For example, if RNs are likely to respond to a manager leaving by quitting their jobs, organizations can collaborate with them to identify needed resources prior to a manager’s departure.

Outcomes

The first outcome in the model is turnover or retention, with a focus on actual phenomena rather than intention. Focusing on the actual outcome allows us to correctly identify precursors to turnover and assess the effect of targeted intervention. The outcome of turnover includes voluntary and involuntary turnover, allowing for examination of outcomes such as layoff due to systems or organizational changes versus individual decisions to leave. Including outcomes of both staying and leaving better allows for integration of research on turnover and retention.¹⁴

The second outcome identified in the model is wellbeing, which includes multiple domains of health and wellness that impact an RN. In addition to personal health outcomes, RNs’ wellbeing affects their work experiences and job decisions, for example when struggles to attend to the needs of their families make it difficult to remain in the workforce. Including wellbeing as a job outcome allows for a richer understanding of the RN and supports ongoing assessment of the impacts on RN health via personal and work-related demands and exposures.

Wellbeing and turnover are represented in close relationship with one another. Wellness domains are frequently viewed as antecedents of turnover, and data suggest that decreased wellbeing (e.g. burnout) is associated with increased intentions to leave a job and actual turnover.^20,21 However, placing individual wellness only as a precursor to a job decision emphasizes an organizational point of view, namely that the most important outcome is an RN staying in a specific job. Including wellness as an outcome conveys the importance of RN wellbeing from a population health perspective. The link between the two outcomes reflects the possibility that wellbeing and workforce retention are intertwined, and facilitates further examination of concepts such as ‘presenteeism’, when RNs come to work unwell and perpetuate their own burnout as well as affecting patient care outcomes.²²

While this model primarily focuses on the factors leading to an RN’s job outcomes, some secondary effects are listed to underscore the ramifications of those outcomes. In addition to patient care quality, organizational impacts such as the cost of replacing RNs, decreased productivity, and unit functionality can be considered along with quality metrics like length of stay or infection rates.

Discussion

The Dynamic Model combines evidence and theory from nursing and organizational behavior for a contextualized and situated understanding of factors driving RN job outcomes. The model pulls together key concepts in an RN-centric model that provides multiple opportunities to explore changes to work environments that increase an RN’s engagement with their work and mitigate burnout.²³ The model also brings attention to the wellbeing of a population of workers who share similar experiences and exposures.

The Dynamic Model is useful in providing structure to investigate and understand the effects of the current global pandemic on RNs. The pandemic has led to prolonged exposure to disease and stress among RNs around the world as initial experiences of high exposure and infection led to prolonged stress and increased workload.²⁴ Evaluating the ongoing impact of those stressors requires longitudinal work using a comprehensive framework such as the Dynamic Model.

Several recent publications reinforce the structure and concepts presented in the model. The Systems Model of Clinician Well-Being relied on an extensive review of the multidisciplinary literature on clinician outcomes to create a model useful for guiding work to prevent burnout and promote well-being.⁹ The model parallels the Dynamic Model in its inclusion of context, individual mediating factors that impact clinician wellbeing, and systems level antecedents that highlight the impact of the healthcare industry, regulation, and societal values on clinician outcomes.⁹ Also recently released, the Future of Nursing 2020–2030 report identifies the need for evidence-based strategies to attend to nurse wellbeing and addressing differences in compensation and barriers to practice that potentially impact an RN’s response to specific work contexts.²⁵ Both the Clinician Well-Being and the Future of Nursing reports strengthen the timeliness, underlying tenets, and applicability of the proposed model.

The model can also serve as a foundation for planning intervention studies. One example of a study using the model would be the development of an organization-wide ‘training team’ that deployed to units experiencing high turnover (‘unit’ and ‘work context’ categories). The team would help train incoming staff, decreasing the training burden on the RNs remaining on the unit. Outcome measures would be RN’s perceptions of their workload and support as well as measures of wellbeing (stress or burnout) and unit retention rates (collective turnover).

Limitations

While this model and similar evidence-based frameworks share key features and provide space to explore different concepts and contexts, there is much within the Dynamic Model needing evaluation or confirmation. It is difficult to capture the nuances affecting a person’s life, health, and job decisions, particularly when examining the influences of racism and other societal biases. As with any new model, this one provides questions and opportunities to refine knowledge rather than providing answers. Finally, while the model can provide information about factors influencing RNs, the urgent needs of the RN workforce necessitate intervention-focused research to help RNs remain engaged, well, and working. The model can help provide direction for such research, and results should be examined within the model to identify or confirm relationships between antecedents, contexts, responses, and outcomes.

Conclusion

Research on nursing job outcomes needs an updated and comprehensive model to advance knowledge of how to support and sustain a healthy nursing workforce. The proposed model weaves current turnover theory and recommendations from organizational behavior with findings from nursing research, and its structure provides opportunities for exploring and understanding conceptual relationships more deeply. Nurse leaders can use the model to plan interventions that improve outcomes for patients, organizations, underrepresented groups, and individual RNs, with the goal of sustaining a healthy and diverse nursing workforce.

Key Points.

• Understanding retention means examining work and life contexts that may influence nurses’ feelings and decisions about their jobs

• Wellbeing needs to be considered in relationship with retention as important individual and workforce outcomes

• Promoting equity in the workforce requires examination of systemic issues like racism and their impacts on the work and life contexts of nurses