Nurse Turnover as an Indicator of the Level of Organizational Culture in a Health Care Facility

INTRODUCTION

Human resources are the most important factor in an organization. Every organization needs to employ people with professional knowledge, skills, abilities, and a positive attitude toward work. These employees become a source of the organization’s competitiveness and prosperity (Joniaková et al., 2016). The ability to attract and retain quality employees, develop their potential, and manage their performance belongs among the key activities of nursing managers. Many health care facilities in the Slovak Republic are in a state of organizational “depression.” It manifests itself in an unhealthy atmosphere, indifference, pessimism, increased turnover and absenteeism, and the presence of employees who are burned out, cynical, and frustrated. Organizational culture is declining, employees do not identify with the organization’s goals, and they reject change. Conflicts, errors, complaints increase, and the quality of provided care is insufficient. The causes of organizational depression include inappropriate and insufficient communication in the health care facility, arrogance of top management, insensitivity to employees’ needs, chaotic changes, and threats to jobs and wages (Škrla, Škrlová, 2003).

In Anglo-Saxon literature, the term turnover in a broader sense has become established as turnover and is considered dysfunctional employee behavior. There are many causes of turnover, usually a synthesis of several causes: personal (better prospects, career growth); technical or organizational (dissatisfaction with working conditions, with managers, poor interpersonal relations, e.g. bullying); family (job security, migration, following a partner); financial (low salary) (Tomčíková, Živčák). A certain degree of turnover is in essence a necessary part of the functioning of every company. It is the movement of employees and job candidates in the labor market among individual employers. Employee turnover also brings certain benefits to the company, as new employees bring new ideas and impulses into the organization, thereby preventing stagnation. However, if the departure of employees from the company exceeds a certain threshold, management needs to begin addressing it and deal with the causes of higher turnover. The optimal turnover rate should not exceed 8-9 %.

If the natural turnover rate in an organization is exceeded, the smooth running of work is disrupted, labor productivity decreases, error rates increase, the organization has problems in management, and high costs arise for securing new workers, their training, and preparation (Vargová, 2014). Absenteeism and employee turnover due to dissatisfaction with the job are costly for the organization. The costs of a turning-over employee in organizations range from several thousand EUR to several tens of thousands EUR. These are costs of terminating the employment relationship; costs of acquiring a new employee (costs of recruitment and selection of the employee, invitations, tests, selection interview, costs of adaptation of the new worker, of the mentor) and costs = loss - from lower work performance during the adaptation period (Joniaková et al., 2016). In order to limit unwanted turnover, it is necessary to monitor the factors that cause or influence it and then try to eliminate these factors. The simplest form of turnover analysis in an organization is statistical analysis, which compares arrivals and departures of workers during the year. Another method is the analysis of the reasons for leaving the organization, which are stated either in requests for termination of employment or in an interview with HR at the time of termination of employment.

The most frequently stated reasons are: overall employee dissatisfaction in the organization, unsatisfactory salary conditions, disagreements with a supervisor or coworkers, overly demanding work (Tomčíková, Živčák). In addition to the age and other personal characteristics of employees, the turnover rate is also influenced by the competitive environment, i.e. the possibility of other job offers in the region (Vargová, 2014). The goal of every organization should be to reduce undesirable turnover, especially among those employees in whom the organization has a long-term interest. An employer with turnover problems can be identified based on job advertisements that recur at regular intervals. Managing turnover in an organization is based on facts that influence it: the significance, traditions and prestige of the organization, the level of management, stability and prospects, work regime and working conditions, type and content of work, physical and psychological workload, method of remuneration, the organization’s wage policy, the behavior and demeanor of managers at all levels of management. Remedy must begin with the top management of the organization by replacing some managers, but also employees, critically assessing organizational culture, choosing appropriate communication, and developing strategies to introduce the necessary changes. Further measures consist of implementing measurement of employee satisfaction and other indicators, being interested in employees’ needs, and supporting a positive work atmosphere (Škrla, Škrlová, 2003).

ORGANIZATIONAL CULTURE

Organizational culture is formed by group norms or traditional ways of behavior of a group of people. The term organizational culture has been used in management theory since the beginning of the 1980s. Every organization has its own unique culture and the corresponding specific values. Organizations differ from one another in their atmosphere, way of working, or performance. All aspects of culture are influenced by history, environment, traditions, and technologies.

The term organizational culture is dominated by opinions, traditions and values that are applied in the management style, in the way employees are motivated, and in public presentation. It is the way work is carried out and the way people are communicated with. Organizational culture significantly influences the long-term success of an organization. On the one hand, it can be a carrier of competitive advantage and a source of strength, and on the other hand, it can also be a brake on the development of the organization and even a source of its destruction. Organizational culture represents a system of assumptions, ideas, values, and norms that have been adopted and developed in the organization and have a major influence on the behavior, thinking, and conduct of employees. Outwardly, it manifests itself as a form of social interaction among employees, in common habits, customs, clothing, material equipment. Basic patterns of behavior become a model for new employees. Through its unwritten laws, it positively or negatively affects employee behavior and motivation. Organizational culture also consists of experiences that are reflected in the thinking, feelings, and behavior of employees, and determines people’s behavior in the organization, as well as their behavior toward the organization’s external environment. The main parameters that determine its function within the organization are the strength and content of organizational culture. The content of the organization’s culture consists of basic assumptions, values, and norms of behavior that are shared in the organization and externally manifested through artifacts and behavior (Vaverčáková, Hromková, 2018).

Kachňáková (in Joniaková et al., 2016, p. 439) defines the culture of a company, organization as “a system of assumptions, ideas, values and norms that have been adopted and developed in the organization and have a major influence on the behavior, thinking and conduct of employees. Outwardly, it manifests itself as a form of social interaction among employees, in common habits, customs, clothing, material equipment, etc. Basic patterns of behavior become a model for new employees.” The management of a health care facility must realize the importance of a healthy organizational culture for the development and future of the organization. A healthy organizational culture, together with the values and vision of the hospital management and a healthy financial background, are factors that influence the success of the entire health care facility. Organizational culture reflects the values of the organization as presented by top management. It represents patterns of management behavior toward people and the behavior of employees among themselves. Every health care facility, indeed every department, has its own specific organizational culture (Škrla, Škrlová, 2003). The culture of the organization influences the success of the organization and is a set of values, attitudes, norms, and patterns of employee behavior. Every employee is both a creator and a product of culture. They bring into the organization’s culture their experiences from previous jobs and their own ideals. Organizational culture is a tool for leading and motivating employees. A strong organizational culture means that the rules of behavior are clearly defined, employees know what is valued and what is sanctioned. Within a health care facility we assess the overall organizational culture, but it should be noted that each department also has its own specific organizational culture (Plevová, 2012). A strong organizational culture strengthens employee motivation and their identification with the organization. The state of organizational culture is also influenced by the organization’s vision and size (Kilíková, 2018).

“Organizational culture is the way work is done in a health care facility, in a department; it is a set of beliefs and values that shape the behavior of nurses. It represents specific ways of behaving by members of the organization, communication, dress code, gestures, taboos, traditions, rituals and the way goals are achieved” (Škrla, Škrlová, 2003, p. 316). Organizational culture significantly influences employee behavior, and thus becomes an important source of competitive advantage. It influences all activities and processes taking place in the organization. It strengthens employees’ relationship to work, shapes relationships among employees, and influences their engagement and activity. The nursing manager together with HR specialists decide which nurses are hired into the health care facility and subsequently, during their time in the health care facility, can most significantly influence their behavior. It is necessary to set the recruitment and selection processes for nurses so that the incoming nurses are “compatible” with the culture of the health care facility, have a similar value orientation, are able to adapt to the ways of behavior and identify with them. During the selection process, the manager must verify through appropriately asked questions whether the nurse will contribute to the desired culture of the organization, consider her attitudes and patterns of thinking. The extent to which the incoming nurse identifies with the culture of the organization must also be considered by the nurse, since her own expectations are in line with the organization’s expectations, because this will significantly affect her job satisfaction. Alignment of mutual expectations is a prerequisite for employee stability in the organization.

The second important process is the adaptation of the new nurse. During the adaptation period, new employees adopt common values, attitudes, norms, and patterns of behavior. Failed adaptation is a reason for nurses leaving during the probationary period, which increases the employer’s costs. Managed adaptation contributes to the socialization of the new employee and the building of the desired culture. Even within the activities of education and career development of nurses, there is room for strengthening aspects of the organization’s culture. If the employee does not identify with the cultural standards and required ways of behavior and work, this negatively affects their performance (Joniaková et al., 2016). Only an organization with a functioning system and a good organizational culture can move toward long-term prosperity. An organizational culture audit is used for the objective evaluation of the existing organizational culture. It helps managers orient themselves in work and human relations within the organization as well as in relation to its external environment. Every organization has specific features that determine the requirements for organizational culture. In general, however, we can define the basic requirements of a “healthy” organizational culture. These are the strength of organizational culture, the influence of organizational culture on strategy, and the influence of organizational culture on organizational performance. A strong organizational culture, unlike a weak one, exerts a strong influence on employee behavior and actions. The benefits of a strong organizational culture from the perspective of the organization and its performance can be considered primarily the acceptance of common values and goals, the alignment of employees’ perception and thinking, and the direction of people’s behavior. It significantly increases employee satisfaction through the use of common norms and patterns of behavior. It serves as an element of organizational cohesion and of the development of the organization’s internal and external potential (Smerek, 2017). To evaluate organizational culture, management can use the services of professional auditing and personnel companies, interviews with employees or patients. A healthy culture cannot be enforced or dictated; it is manifested in employee loyalty, their high productivity, creativity, engagement, joy in work, and the development of their potential. An unhealthy organizational culture can negatively affect quality and productivity (Škrla, Škrlová, 2003).

Managers influence the culture of the organization through their managerial activity and behavior, either positively or negatively. By adhering to corporate rules, directives, and, for example, dress code, they emphasize the importance of organizational culture. The well-known “the fish rots from the head” aptly captures this (Joniaková et al., 2016). Organizational culture can be built by management or can develop spontaneously. Strong, charismatic individuals can change culture through their demeanor and behavior, both positively and negatively (Škrla, Škrlová, 2003).

AIM

To assess the impact of factors of organizational culture and the level of organizational culture of a health care facility on nurse turnover.

SAMPLE AND METHODOLOGY

The sample consisted of 136 respondents. 67 % of the nurses were aged up to 29 years and 77 % had first-cycle university education. Data collection was carried out from September to November 2022 using a self-constructed questionnaire. Categorical data were processed using contingency tables with the chi-square test. In the case of cardinal data, we present basic statistics in the form of the number of respondents, arithmetic mean, standard deviation, median, minimum and maximum value. Given the nature of the data, we used the nonparametric Kruskal-Wallis test as a nonparametric analysis of variance. If the p-value of the test criterion of the statistical test was less than the numerical value of 0.05, we considered the observed differences to be non-random and causally related to the monitored parameter. Calculations were performed using InStat® software, version 3.02, GraphPad Software, Inc., USA and Statistica®12 software, StatSoft, USA.

RESULTS AND DISCUSSION

In our study, we focused on the influence of the level of organizational culture on nurse turnover in health care facilities. We found that nurse turnover is related to organizational culture. 36.7 % of respondents declared satisfaction with the organizational culture of the health care facility in which they are currently employed, but as many as 43.4 % of respondents were unable to assess the level of organizational culture of the health care facility. 56.6 % of nurses assessed the level of turnover in the health care facility as adequate and only 23.5 % of nurses as excessive. 40.4 % of nurses stated that they have a loyal relationship with the organization - their employer, however, in the control item, up to 97 % of respondents considered themselves loyal employees. Table 1 contains the results of the statistical comparison of the relationship between respondents’ satisfaction with organizational culture and their perception of the turnover rate. Based on the statistical processing of the data, we state that the observed frequencies differ statistically significantly from the expected ones (p<0.001). The subjective perception of turnover in the workplace by respondents is not random from the perspective of their satisfaction with organizational culture and may be influenced by culture. In respondents who are not satisfied with organizational culture, there is an evident increased perception of excessive turnover (n=12) compared with the expected frequency (n=5). In the case of nurses who declared complete satisfaction (answer “yes”) with organizational culture, on the contrary, an increased number of answers in the sense of low turnover (n=16) is observed compared with the expected (n=10). In the case of partial satisfaction with organizational culture, a greater representation of answers in the sense of average turnover (n=41) is observed compared with the expected counts assumed in the case of independence of the monitored parameters (n=35). In the indicated category of perception of satisfaction with organizational culture, the reduction of both boundary possibilities of turnover assessment is interesting (low: 6 observed vs. 12 expected; excessive: no change).

Table 1 Assessment of turnover depending on satisfaction with organizational culture

Authors of several foreign studies reached similar conclusions. The aim of the study by Pedrosa et al. (2020) was to identify scientific evidence on organizational culture factors associated with nurse turnover. In the period from January 2014 to December 2018, the authors conducted a systematic literature review, which shows that nurse turnover affects productivity and the quality of care provided in health care facilities. Negative aspects of organizational culture increase the rate of nurse turnover. NJSNA (2020) reports in its report that in the years 2016-2020, up to 83 % of nurses were replaced in the average hospital in the USA. The highest nurse turnover was recorded in hospitals with 200 to 350 beds (23 %). The report also provides evidence that nurse turnover depends on specialization and the work placement of nurses. High nurse turnover is long-term in acute and intensive care departments. About 24 % of nurses from the total turnover rate are nurses working in their first year in the profession. Lockhart (2020) also states that 18 % of nurses change jobs or even professions within the first year after graduation, one third of nurses within two years. The nurse turnover rate at the national level averages 19.1 % and is expected to increase, while the vacancy rate for nursing positions is 8 %. Hospitals try to retain both experienced and beginning nurses. Nurse turnover is extremely costly for organizations. According to the 2019 National Healthcare Retention & RN Staffing Report, the turnover of one clinical nurse costs from USD 40,300 to 64,000, while the average hospital loses USD 4.4 million to 6.9 million annually. According to the author, the three main reasons for nurse turnover are: relationships, including relationships among colleagues on the ward and the relationship with head nurses; staffing and shift length. These findings are also consistent with our results.

The authors further state that 59 % of nurses terminated employment after less than one year and 74.7 % after less than two years of employment. The 2022 NSI National Health Care Retention & RN Staffing Report contains outputs from 272 hospitals in 32 US states on registered nurse turnover, vacancies, recruitment and staffing strategies. It was found that the average cost of turnover for one nurse increased by 15 % from 2020 to 2021 to USD 46,100. In 2021, the nurse turnover rate increased by 8.4 %, resulting in a nationwide average of 27.1 %. The average cost of turnover for one nurse is USD 46,100, with a range averaging USD 33,900 to 58,300. The vacancy rate for nursing positions in hospitals is 15 %, while it takes an average of 87 days to fill a vacant nursing position. Intensive care units replace the entire nursing staff approximately every five years (Gamble, 2022).

The aim of the study by Bae (2022) was to examine the non-economic and economic impacts of nurse turnover in hospitals. The nurse turnover rate is high worldwide and ranges from 15.1 % in Australia, 27.65 % in the USA, 23 % in Israel, and 12.4 % in South Korea. Nurse turnover is costly and threatens the quality of care. High turnover worsens already poor working conditions, which may threaten the quality of patient care and patient safety. Poor quality of care can lead to further nurse turnover. According to Lindquist (2023), a high nurse turnover rate creates a vicious circle, because overworked nurses who remain with health care providers eventually leave for other employers or leave the profession altogether, either by changing industry or retiring. High nurse turnover means high costs for health care facilities, whether direct or indirect. Direct costs include recruitment, selection, adaptation, courses. Indirect costs are reflected in reduced productivity and employee morale. According to the author, the turnover rate of new nurses reaches up to 30 % in the first year due to unexpectedly high workload and poor communication with team members. It is not surprising that satisfaction scores of nurses in the first year of work are also low, averaging 5.5 out of 10. The average hospital in the USA loses USD 5.2 to 9 million annually due to costs associated with nurse turnover. Nurse turnover costs include severance pay, wages, vacations, and unemployment insurance claims, as well as the costs of removing employees from internal systems and directories (Lindquist, 2023).

The purpose of the study by San, Hyun (2009) was to examine whether and how different types of organizational culture influence job satisfaction and turnover among nurses in Korea. The sample consisted of 527 nurses. The impact of nurse turnover on organizational efficiency is significant. High nurse turnover negatively affects the organization’s ability to meet patients’ needs and provide them with quality care, and the productivity of nurses who remain in care provision. Organizational culture influences employee job satisfaction and turnover intention.

For the data presented in Table 1, we attempted to maximize the yield of information, therefore we did not reduce the categories, e.g. to a 2x2 table, which would have been evaluated by McNemar’s test for dependent variables, which would have been the correct solution in our case, but at the cost of reducing the number of categories. Therefore, we decided on the implemented solution of statistical processing, in which we assume subjective perception of satisfaction with organizational culture in relation to the observed (i.e. not subjective) rate of turnover in the workplace, with the awareness of the need for a moderate interpretation of our findings.

In our study, 63.2 % of respondents considered technical or organizational reasons to be the most common cause of turnover in the health care facility in which they are currently employed (dissatisfaction with working conditions, conflicts with superiors or managers, poor relations in the workplace, possible mobbing) - Table 2. In addition, the nurses’ decision to terminate the employment relationship would be influenced by the work team (43.4 %), psychological burden (28 %) and relations with superiors (21 %). Table 2 shows the statistical significance of the results, but at the cost of the borderline (non-)fulfilment of the frequency requirement for nonparametric tests (n˃5). However, with moderate interpretation, we can state that among organizational factors we find the highest average values and medians precisely in the areas of technical and organizational impulses for turnover (A) and financial reasons (B). Other reasons are marginal in this respect, and the results from processing five respondents probably contributed to the overall statistical borderline significance. The above data indicate that it will be necessary to increase the number of respondents for this group in the future as well, but that will not eliminate its internal diversity, which may, even with a larger number, complicate the interpretation of results obtained even with a larger number of respondents.

By a specified item in the questionnaire we examined what respondents value most in the organizational culture of a health care facility with ordinal scaling of responses from 1 - I value most to 6 - I value least. The order of responses by significance showed the following ranking of the monitored factors: interpersonal relationships; working conditions; communication in the workplace; salary remuneration; motivation; management style.

Table 2 Influence of organizational factors on nurse turnover

The cross-sectional study by Choi et al. (2022) involved 698 nurses with the aim of measuring the perceived domains of the specific competence of their managers and the level of their job satisfaction and turnover intention. The overall perceived level of nurse manager competence was x̄ =3.15 out of 5 (sd = 0.859). The average level of job satisfaction was x̄ =2.85 out of 5 (sd = 0.875) and the average level of turnover intention was x̄ =3.16 out of 5 (sd = 0.817). The findings showed that 34.3 % of nurses were dissatisfied with their current job and 36.3 % of nurses were considering leaving their current workplace. Bolton (2018) wanted to find out whether there is a correlation between organizational culture, manager behavior and employee job satisfaction.

The results showed that organizational culture had an effect on job satisfaction and employee engagement. If employee values are aligned with the organizational culture, it will affect their decision to remain in the organization. Organizations should strive to align the values of potential employees with the organization’s culture in order to increase job satisfaction and employee retention, which can help reduce costs associated with employee turnover. Organizational culture is crucial in whether an employee stays or leaves the workplace. Haroková, Gurková (2012) examined factors of job satisfaction among Czech nurses in their study. Job satisfaction of nurses is an important indicator of the culture of a health care facility, it has an impact on performance and reduces nurse turnover. They confirmed that interpersonal relationships in the workplace determine job well-being, and thus nurses’ satisfaction. They found a dependence between the type of workplace and nurses’ satisfaction. The lowest level of satisfaction was found in the area of social benefits. The authors recommend that management of health care facilities improve social benefits as one of the strategies for reducing nurse turnover.

CONCLUSION

From the perspective of sustainability of human resources in nursing, it is essential that nursing managers incorporate into strategies to mitigate nurse turnover also aspects related to the organizational culture of the facility, improvement of working conditions, mentoring and adaptation programs.

Research limitations

The main limitation of the conducted research, which affects the possibilities of interpreting the results, is the size of the sample and the associated representativeness of the findings and their applicability in a global context. Given the low number of respondents, the results serve to create a comprehensive picture of the studied issue in practice. The findings supplemented the literature sources by providing empirical support. The study had a subjective character, based on the subjective perception of nurses, and no validated measuring instrument was used.

Authors:

doc. PhDr. Viera Hulková, PhD., MPH Faculty of Health Care, Alexander Dubček University of Trenčín in Trenčín ORCID 0000-0003-2631-1803

RNDr. Vladimír Meluš, PhD., MPH Faculty of Health Care, Alexander Dubček University of Trenčín in Trenčín ORCID 0000-0003-4788-8257

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