Brewer, Carol S. PhD, RN, FAAN; Kovner, Christine T. PhD, RN, FAAN; Yingrengreung, Siritorn PhD, RN; Djukic, Maja PhD, RN
New nurses constitute an important part of the nursing workforce. The National Council of State Boards of Nursing (NCSBN) reported that there were 116,256 RNs licensed by examination in 2009.1 About 90% of newly licensed RNs start their careers in hospitals, according to both a 2004 NCSBN survey on the transition to practice and our more recent research.2, 3 Among such RNs, job turnover is high: about 26% leave their first hospital job within two years, although more than 90% of these obtain another job in nursing.3 Such organizational turnover (turnover that involves leaving an organization, rather than the profession) is expensive, in terms of both the costs of replacing those who leave and the decreased efficacy and productivity of remaining staff.4, 5
But the job market for newly licensed RNs may be changing. The United States has been in a recession since late 2007, with general unemployment rates often in double digits. As the recession has progressed, the media have reported anecdotal evidence that new RNs have had difficulty getting jobs, at least in their desired clinical areas or on their desired shifts.6-8 In 2009 Buerhaus and colleagues, studying the effects of recession on the RN workforce, lowered their earlier projections for the nursing shortage, noting that more older RNs were either deciding not to retire or were returning to work and often working longer hours.9 They also found that between 2001 and 2008, nurses under age 35 accounted for just 28% of the total increase in the nursing workforce. It's important that organizations understand how the prospect of a tightening job market will affect nursing turnover, so that they can adapt their retention strategies. Yet little is known about the mechanisms by which RNs make decisions about employment during a recession. We wanted to know more.
PURPOSE AND BACKGROUND
Purpose. The purpose of this study was to compare perceptions about job opportunities, as well as key attitudinal variables (such as job satisfaction and intent to stay), in two cohorts of newly licensed RNs. The first cohort was surveyed between January and April 2006, before the economic downturn; the second cohort was surveyed between January and March 2009, when the country was about a year into a major recession. We hypothesized that if the two cohorts showed no differences in some work attitudes but did show differences in perceptions of job opportunities and in intent to stay, this could indicate that a difference in intent to stay is related to differences in perceptions about the job market. If that is the case, then we should be concerned that when the economy improves, turnover in the newer cohort will likely increase.
Background. Literature in the field has demonstrated relationships between turnover and four groups of variables: personal characteristics, work attributes, work attitudes, and job opportunities.10, 11 In particular, three work attitude variables have consistently been shown to directly or indirectly affect turnover: job satisfaction,12-16 organizational commitment,11, 17, 18 and intent to stay.11, 16, 18-25 Perceptions about job opportunities have also been linked to turnover. A study of Swedish nurses found that those who felt it was possible to find other nursing employment were more likely to leave their current jobs.26 During a recession, such perceptions may be more important to newly licensed RNs than satisfaction, organizational commitment, and the nurses’ intentions.
Sample. Our data came from two sources: a subset of new RNs licensed between August 1, 2004, and July 31, 2005, who were part of a larger 2006 study on turnover27 and a later cohort of new RNs licensed between August 1, 2007, and July 31, 2008. We used state licensure lists to select both samples, but we used fewer states in the later survey. For the 2007–2008 cohort, we selected all respondents who resided in the 15 states (Alabama, Kentucky, Maryland, Michigan, Nevada, New Jersey, New York, North Carolina, Oklahoma, Oregon, Pennsylvania, South Carolina, Tennessee, Texas, and West Virginia) that had the most accessible and accurate lists of newly licensed RNs; for the comparison cohort, we included all respondents from the same states in the 2006 survey. Inclusion was limited to those RNs who had graduated from an academic nursing program in the United States in or after 2002 and who had not practiced nursing outside the country before earning first-time licensure in the United States.
Data collection. The surveys for both samples were almost identical. We sent a maximum of five mailings to both samples. We sent everyone an alert letter, a survey with a $5 incentive, and a reminder and thank-you postcard. We sent nonresponders up to two more copies of the survey. Using American Association for Public Opinion Research methodology,28 we calculated estimated response rates of 58% for the 2004–2005 cohort and 57% for the 2007–2008 cohort. In 2006 the analytic sample comprised 3,380 RNs; in 2009 it comprised 1,765 RNs.
Approval for the study was obtained from each author's university's institutional review board.
Measures. The survey tool included questions related to each of the four groups of variables (personal characteristics, work attributes, work attitudes, and job opportunities). Questions pertaining to personal characteristics were based on wording used in the 2004 National Sample Survey of Registered Nurses.29 The survey sent to the later sample also included some questions about work behaviors in relation to the recession, such as whether the recession had led to an increase in hours worked. A national advisory group composed of nursing and medical workforce experts reviewed both surveys before data collection, and changes were made on the basis of their comments. We revised the surveys further after pilot testing with newly licensed RNs not in our sample.
Questions related to personal characteristics included age, sex, overall health, and nursing-related educational status (degrees both attained and currently being sought). Questions related to work attributes included such variables as wages, total income, shift worked, overtime worked, and whether the work setting was in a hospital with Magnet designation. Questions related to work attitudes included the aforementioned variables of job satisfaction, organizational commitment, and intent to stay; we also included items on workload, organizational constraints, and the nurse–physician relationship, among other topics, as representative of workplace issues that nurses are concerned about. Questions related to job opportunities included variables such as the possibility of internal promotion and the perceived availability of other nursing jobs locally and nonlocally.
Work attitudes were measured using scales that have been used in previous research with RNs.11, 18, 27, 30-32 The number of items in each scale varied from three (for work–family conflict) to eight (organizational constraints). All scales had established validity and reliability for nurses. Cronbach α scores for all scales used in our surveys were 0.70 and above. We modified the scales somewhat to minimize respondent burden; in selecting items to delete, we used the principal components analysis that two of us (CTK and CSB, with colleagues) had used in a previous study of RNs.33 More detailed information about survey scales and items can be found in an earlier article published in AJN (“Newly Licensed RNs’ Characteristics, Work Attitudes, and Intentions to Work,” September 2007).
Data analyses. Because response rates for the 2004–2005 sample varied by geographic region, we weighted responses for the 2007–2008 sample so that the response rates by region were similar to those for the 2004–2005 sample. To be sure that the 2007–2008 cohort reflected the response rates of the 2004–2005 cohort, all analyses were done with weighted samples. We used t tests and χ2 analyses. The software used for analysis was PASW Statistics 18, with 0.05 as the significance level.
Personal characteristics. For the majority of variables, there were no differences between the two cohorts. Variables with significant differences were overall health status, enrollment in a formal nursing education program, and highest nursing degree attained (see Tables 1 and 2). The RNs in the 2007–2008 cohort reported significantly better overall health status: on a scale of poor to excellent, 23% rated their health as excellent, compared with 19% in the earlier cohort. Although the same proportion of each cohort was enrolled in a formal nursing education program, more new nurses in the later cohort than in the earlier one were enrolled full-time (46% and 30%, respectively).
Work attributes. There were few differences in work attributes between the two cohorts (see Table 1). There was no difference in the proportions of respondents working in direct care or in their average patient load. A slightly higher but statistically significant proportion of respondents in the 2007–2008 cohort than in the 2004–2005 cohort reported working a “12-hour” or “other” shift rather than an “8-hour” shift, but there was no difference in whether they worked days rather than evenings or full-time rather than part-time. Significantly more new nurses in the 2007–2008 cohort than in the 2004–2005 cohort belonged to a union (28% and 24%, respectively). There was no difference in the proportions of respondents in each cohort who reported working in a designated Magnet facility. Most (82%) of the RNs in each cohort strongly agreed with the statement that within one year they planned “to have a job that requires an RN license.”
Besides their overall health, both cohorts were asked about on-the-job injuries. The later cohort reported fewer needlestick injuries (7% fewer) and sprains or strains (4% fewer) than the earlier cohort. There was no difference in reported incidence of verbal abuse.
Although the average number of hours worked was significantly lower in the 2007–2008 cohort than in the 2004–2005 cohort, neither average wages nor average income was significantly higher in the later cohort when these were adjusted for inflation (see Table 3). In comparison with the earlier cohort, in the 2007–2008 cohort, the average total number of hours worked per year was more than a week less (52 hours), and the average number of hours of voluntary overtime worked per week was just shy of an hour less (P = 0.0001). In the later cohort, the average total yearly income was $48,472; this was $3,830, or 9%, higher than that in the earlier cohort. But when adjusted for inflation—the inflation rate was 10.12% from 2004 to 2008—the adjusted average total yearly incomes in each cohort didn't significantly differ. (We calculated the inflation rate using data in the relevant Bureau of Labor Statistics Consumer Price Index tables.) The estimated average hourly wage, including overtime, was also not significantly different at $22.37 in the 2004–2005 cohort, adjusted for inflation, from $22.68 in the 2007–2008 cohort.
Work attitudes. Nurses in the 2007–2008 cohort perceived their work environment as significantly better than did those in the 2004–2005 cohort, although differences in means were small, ranging from 0.03 to 0.09 for all measures except organizational commitment, where the difference was 0.17 (see Table 4 18, 30-32). The 2007–2008 cohort found nurse–physician relationships to be significantly better and the quantitative workload to be significantly lower than did the 2004–2005 cohort. Similarly, the 2007–2008 cohort reported being significantly more committed to their organizations than did the 2004–2005 cohort. There was no difference between the cohorts in levels of job satisfaction or perceived organizational constraints. Although the 2007–2008 cohort reported a significantly greater intent to stay with their current employers than the 2004–2005 cohort did, nurses in the later cohort were significantly more likely to be searching for a new job.
Job opportunities. Compared with the 2004–2005 cohort, the 2007–2008 cohort perceived significantly fewer job opportunities, both locally and nonlocally (see Table 4 18, 30-32). Although the number of unemployed nurses in each cohort was quite small (25 and 63 RNs in the 2004–2005 and 2007–2008 cohorts, respectively), the most common reasons for being unemployed differed significantly between the cohorts. Respondents were asked to indicate which of several reasons “best represents” why they were unemployed; one choice, “No entry-level nursing jobs are available in my geographic area,” was cited by 8% of the earlier cohort and by 25% of the later cohort. Of the unemployed RNs in each cohort, there was no difference in the proportion looking for work in nursing (60%). Unemployed RNs who were looking for work outside of nursing were a very small percentage of the total sample.
There was no difference between the cohorts in the proportion of RNs who had left their first job by the time of the survey. Among those who had left, in the 2004–2005 cohort, the most common reason given was poor management (40%), followed by stressful work (38%) and “other personal reasons” (35%) (see Table 5). In the 2007–2008 cohort, other personal reasons and poor management were cited almost equally (about 33% for each). The later cohort cited stressful work significantly less often (22%) than did the earlier cohort. Other reasons RNs gave for having left their first job were, in descending order of frequency in both cohorts, moved to another area and “misinformed about my job.” About the same proportion of RNs in each survey left their first job because of relocation, regardless of perceived opportunities.
Turnover costs per RN can be as much as 1.3 times an RN's annual salary, as Jones has shown.34, 35 Using the number of new RNs licensed in 2007 (92,919)36; our 2007–2008 cohort's average annual salary ($48,472) and the percentage that reported working in hospitals (89%); and, from our longitudinal study on turnover, the percentage of new RNs who leave within their first year of hospital work (18%),37 as well as the Jones multiplier,34 we estimated crude turnover costs of $938 million to the U.S. health care system. If we use the two-year turnover rate among all new RNs (26%) from our longitudinal study on turnover,37 the estimated crude turnover costs rise to more than $1.4 billion.
In January 2009, when we fielded the 2007–2008 survey, the country was in a severe recession. We wanted to know whether this event influenced newly licensed RNs’ work behaviors but hadn't asked comparable questions of the 2004–2005 cohort. The remainder of this section reports findings from the 2007–2008 cohort only.
Even during the recession, new RNs were still leaving their jobs (see Table 6 at http://links.lww.com/AJN/A38). About 41% had left or planned to leave their current job in less than three years, and 36% had planned to stay in their first job less than three years when they took it. Yet almost all (93%) planned to stay in nursing if they left their current job. Among nurses who had already left their first job, 32% said their employer could not have done anything to prevent them from leaving. Of the rest, 12% cited improved management and 11% cited a change in shift or hours as factors that could have induced them to stay. Other such inducements included an increase in pay (8%), better benefits (3%), and a bonus or cash incentive to stay (1%). Among the respondents who had already left their last employer, 63% had a new job when they left.
A majority of the new nurses (71%) hadn't changed their work patterns in response to the recession (see Table 7 at http://links.lww.com/AJN/A39). However, 20% had increased their average number of work hours, and smaller percentages changed jobs (2%) or took an additional job (5%). Fewer than 1% were laid off.
More complete results and weighted values are reported in the tables.
Some caution is needed in interpreting these findings. Because of the large sample sizes, significant differences were found with small effect sizes (the classic problem of statistical significance without clinical significance). The question that remains, of course, is how much change in intent to stay and other variables does it take to affect actual turnover? If turnover behaviors are responsive to changes in their predictors, small changes could have a big impact (and the reverse might be true as well). This is an important area for future research.
New nurses in the 2007–2008 cohort were more likely to intend to stay at their jobs than were those in the 2004–2005 cohort; they were also more committed to their employers. Yet job satisfaction was about the same in both cohorts. One possible explanation for the later cohort's greater intent to stay and organizational commitment is that employers may have made some strides in addressing work–life issues during the three years between surveys, as evidenced by the slight improvement in nurse–physician relationships, the decreased quantitative workload, and the lower incidences of needlesticks and of sprains and strains. On the other hand, if this were true, it would follow that job satisfaction should also have risen, and this was not the case.
An alternate interpretation is that the national recession and the 2007–2008 cohort's overall perception of significantly fewer job opportunities made those nurses more reluctant to leave a secure job. This lack of job options might also have led newly licensed RNs to feel more organizational commitment. The perceived improvements in working conditions may have been just too small to influence job satisfaction. It's interesting that nurses in the later cohort were also more likely to be searching for a new job and that a majority of those who did leave had already found a new job prior to leaving. Indeed, both poor management and stressful work—which can be intrinsically associated with poor management—were cited as important reasons for leaving. We interpret these findings as evidence of a pattern of “putting up” with a current employer, in which nurses recognized that there were fewer job options, yet at the same time kept an eye out for that “perfect” job. And although the same proportion of each cohort was enrolled in school, more respondents in the 2007–2008 cohort were enrolled full-time. This is also consistent with the later cohort's perceptions of fewer job opportunities, as well as with the trend toward increased enrollment in nursing schools that has been noted by Aiken and colleagues.38
Although it's been reported that RN salaries have been rising over the last decade,39 we found that, after adjusting for inflation, neither wages nor income had increased among the new nurses we surveyed. (The nurses in each cohort were from the same 15 states, so regional wage differences weren't an issue.) This result isn't surprising if, as Buerhaus and colleagues indicate, the current nursing shortage is easing—in part because of the recession and slowed growth in demand for RNs—resulting in less upward pressure on wages.9 Another implication is that new graduates may be differentially affected by this slowing of demand, if employers shift toward hiring experienced nurses over newly licensed ones. Anecdotal reports bear this out.40, 41
The proportion of new RNs in the earlier and later cohorts who reported having left their jobs within the first year (12% and 13%, respectively) was about half the proportion in our longitudinal study who reported actually leaving within two years (26%).37 Looking ahead, the relatively high proportion of new RNs who expressed an intent to leave their jobs within a specific time frame suggests that there may be a pent-up desire for jobs that better fit their needs. On the other hand, only 7% of the nurses in this cohort planned to leave nursing if they left their current position, indicating good retention within the nursing profession.
Among nurses in the later cohort who had left a job, about one-third said that there was nothing their employers could have done to change their decision to leave; yet poor management and a lack of flexibility in schedules were among nurses’ top complaints. Nurses might be more amenable to staying if these perennial problems could be addressed more effectively. For example, effective career counseling to keep RNs in jobs that better match their goals within an organization might at least prevent RNs from leaving the organization, if not the unit.
Our data collection methods and analyses do not provide information sufficient to identify a causal relationship between the recession and changes in new RNs’ attitudes and behaviors. It stands to reason that when there's a nursing shortage, even new nurses might be willing to leave one job before searching very hard for the next, because jobs are readily available. But during a recession, with a tightened job market, this may not be the case. Further research is needed to explore how various economic scenarios affect nurses’ job-searching attitudes and behaviors.
Only about 12% of the new nurses in both cohorts were attending school at the time of the survey; of these, the majority were graduates of associate's degree programs. However, in a post hoc analysis, we found that a larger proportion of full-time students in the 2007–2008 cohort held baccalaureates (28%), compared with those in the 2004–2005 cohort (16%). Although their numbers were small, going back to school this early in their careers may represent an effort to invest in their future careers while riding out the recession. The higher proportion in the later cohort of nurses with baccalaureates who were continuing to invest in their education is also consistent with trends found by Aiken and colleagues.38
The much-abated nursing shortage might help explain our finding that in the later cohort, compared with the earlier one, inflation-adjusted wages weren't significantly different and income increases hadn't quite kept up with inflation. Organizations may have been able to effectively freeze entry-level wages because they had enough nurses; they didn't need to attract more. If this was the case, it's probably not a good sign; in the past, it's been shown that declining numbers of new graduates and flattening wage growth often coincide before a new shortage begins.42, 43
Buerhaus and colleagues noted that the nursing shortage has abated partly because the recession has led many older RNs to reenter nursing or delay retirement and to work more hours9; it seems likely that as the economy improves, many of these nurses will reverse these decisions, opening large gaps in staffing. In the meantime, some new graduates who've had trouble finding nursing jobs may choose to leave the profession; others may be biding their time with current employers, waiting for their options to improve before changing jobs. These factors suggest that staff turnover may increase dramatically once the job market opens up again. Therefore, it's imperative that health care organizations’ efforts to improve RNs’ working conditions and wages, and to implement programs aimed at increasing retention and reducing turnover costs, not be thrown aside during the recession. Otherwise, when job opportunities improve, the nursing shortage may again intensify.
Both the lack of gains in nursing incomes and nurses’ increased interest in education are also relevant. If incomes decline, it could affect retention and increase the likelihood of another shortage. But the interest that holders of baccalaureates have in further education, even if a result of the current recession, is encouraging: it means there will be growing numbers of RNs capable of filling advanced clinical and faculty roles. This is important in sustaining an adequate workforce over the long term. Maintaining employer-provided tuition benefits may be an important retention and education strategy—particularly if, in its efforts to balance the federal budget, Congress reduces funding for Public Health Services Act Title VII and VIII incentives for advanced education.44
Limitations. Given that ours was not a randomized, controlled study, we cannot come to definitive conclusions about how the recession and new nurses’ perceptions of a decrease in nursing job opportunities affected the later cohort's work decisions. The sample was limited in that we included RNs from only 15 states; however, since both cohorts were drawn from the same 15 states, we are confident that there were no demographic differences between the two cohorts. It wasn't possible to examine nonresponder bias in either cohort because we had no information about the nonresponders. Surveys conducted during limited periods in time may not capture events that are occurring over longer periods, so we can't be sure that the 2009 survey captured the influence of the recession. It's also unknown whether relatively small differences in a work attitude, such as job satisfaction, though significant, would affect actual behavior, such as turnover. Finally, these surveys were conducted with newly licensed RNs and might not reflect the thinking and behavior of the general nurse population.
Nurses’ working conditions may have improved slightly between 2006 and 2009. However, nurses in the 2007–2008 cohort didn't report being more satisfied in their jobs than those who graduated three years earlier. They continued to rank job stress as a major reason for leaving their employers. We believe it's likely that the 2007–2008 cohort's higher mean level of intent to stay is a result of both the recession and a perceived decrease in the availability of nursing jobs.
It's important for employers to recognize that the current nursing workforce situation is likely to change as the recession continues to ease. Furthermore, passage of the health care reform bill will probably increase the demand for nurses, which in itself could lead to a renewed shortage. Earlier and current employer efforts to retain nurses, such as implementing nurse residency programs in hospitals, achieving designation as a Magnet hospital, and increasing salaries, must continue through the recession to ensure an adequate nurse workforce in the future.
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