The World Health Organization has estimated that the worldwide shortage of nurses and midwives will reach 7.6 million by 2030.1 Within this estimate, the regions of Africa, the Americas, eastern Mediterranean, Southeast Asia, and Western Pacific have predicted shortages ranging from 0.5 million in the Americas to 2.8 million in Africa.2 More specifically, to avoid further shortages, the United States requires an additional 370,000 nurses by 2028,3 Australia requires 85,000 nurses and midwives by 2025,4 and Canada requires 60,000 nurses by 2022.5 Meanwhile, in 2018, the number of new entrants to the Nursing and Midwifery Council register to practice in the United Kingdom was exceeded by the number who left.6
To overcome this shortage there are two strategies that can be used: recruit new nurses and midwives into the workforce, and/or retain nurses and midwives once they are in the workforce. The latter strategy has had less focus until recently.4-6
Across the world, reported turnover rates of nurses vary and range between 5% and 60%.7-10 A 2014 study of registered nurse (RN) turnover conducted in Western Australia, New South Wales, and the Australian Capital Territory found an annual turnover of 15.1%, with rates ranging from 12.6% in New South Wales to 16.7% in Western Australia,10 while a study in Indonesian private hospitals found turnover rates between 15% and 44%.7 The turnover rates for RNs are higher in the early years of nursing4,5,7 with a reported mean turnover of 22% in the first three years of practice in Indonesian hospitals,7 28% in Canada,5 up to 55% in Australia,11 and 21.2% in the first year of practice in the United States.12
The high turnover of nurses and midwives in the health care system has consequences for the economy, patient care, and staff. A loss of productivity and the costs associated with replacement of nurses and midwives often impact public funds.13 Disruption of nursing and midwifery teams and increased workloads heighten levels of stress and burnout for those that remain, which contributes to job dissatisfaction.13 Further, the consequences of nurse and midwife shortages impact staff–patient ratios and skills mix, which adversely impacts patient outcomes with lower quality of care provided.14
Reasons for leaving the profession are complex as many personal and workplace issues can impact job satisfaction. However, nurse retention relates strongly to the nurses’ levels of psychological resilience.15 Recent efforts have been made to understand the key individual variables that contribute to resilience in nurses. The International Consortium of Workforce Resilience posits that nurses who believe that they have the ability to solve problems at work (self-efficacy), can detach and reflect on difficult experiences (mindfulness), and use effective strategies to manage day-to-day stress (coping) are likely to be more resilient than nurses who do not have or use these particular skills.16 While a low level of psychological resilience has been associated with negative outcomes such as burnout, it is also critical to consider the context or the environment in which the nurse is working and how this impacts on their ability to build and maintain resilience. Cusack et al.17 theorize that environmental factors of support and development of nurses’ and midwives’ competence, professionalism, and well-being, alongside the individual's personal and professional characteristics, are necessary to build resilience. A recent paper by Rees et al.18 found that both individual factors (resilience and negative affect) and environmental factors (the practice environment) explained burnout scores when considered together. The relationship between staff retention and a positive practice environment has been established, and strategies to create a positive practice environment have been identified.19 Based on these, an international research group, RN4CAST Consortium,19 aims to produce models forecasting intention to leave and find new approaches to more effectively manage nursing resources, particularly retention of nurses within the workforce.
While these studies are focused on retention of nurses at any stage of their career, researchers have studied newcomers to nursing and midwifery as a specific group due to the higher turnover rate. Authors20 of an integrative review on negative workplace behavior towards graduate nurses reported disrespectful, unprofessional, and uncivil behavior towards them. The authors noted that at some workplaces the negative behavior was as high as 57.1% and that the “precipitating factors included perceived lack of capability, magnifying power and hierarchy, leadership style and the influence of management.”20(p.41) This behavior towards graduates resulted in low job satisfaction, cynicism, burnout, and intention to leave.
Further, there has been considerable research into graduate nurse transition from the student role to qualified nurse.21 Factors studied included the support provided to graduate nurses as well as the preparation of their preceptors and mentors.22 While a systematic review on effective strategies and interventions to assist transition is being updated,23 another recent systematic review synthesized the characteristics of interventions that were successful in reducing turnover and increasing retention of early career nurses.24 Although the relationship between the newcomer and the mentor or preceptor was identified as an important characteristic influencing newcomer retention, the individual characteristics of the newcomers were not identified, and the remaining characteristics were environmental. Transition to different geographical locations and specific specialties have also been explored25,26; for example, a scoping review of support for new graduates’ transition to rural and remote practice.25 While this review only considered the first year of transition, it found that the lack of supportive programs and training for mentors, and poor resourcing impacted retention.
While these latter studies focus on environmental factors, it is evident that both individual and environmental factors, and the interaction between them, contribute to newcomers’ decisions to remain in or leave their professions in nursing and midwifery.
A search of PROSPERO, the Cochrane Library, the JBI Database of Systematic Reviews and Implementation Reports, and MEDLINE revealed a number of related systematic and integrative reviews, and individual studies. Typically, these reviews and studies focused on a few factors that contributed to effective graduate nurse transition13,20,22-25 or retention of nurses at any stage of their career.7-9,15,18 No reviews or studies appear to have captured all the characteristics that influence the retention or turnover of newcomers or their intent to leave or stay in nursing, and there are few studies focusing on midwifery. No current or in-progress scoping or systematic reviews on the topic were identified. This scoping review seeks to identify and map the literature that describes as many individual and environmental factors as possible to inform a proposed mixed methods study. The future study plans to understand characteristics of newcomers who stay in nursing and midwifery, natural and induced attrition during the first three years in the nursing and midwifery professions, any differences within and between nurses and midwives to identify vulnerable groups, and any context-specific factors.
What environmental and individual factors influence nurses and midwives to stay in or leave their profession within the first three years of clinical practice in their discipline?
This review will consider studies that include RNs and registered midwives (RMs) who are newcomers within the disciplines of either nursing or midwifery. Included within this are RMs who qualified subsequent to being RNs, or vice versa, as midwifery and nursing are separate disciplines.
Newcomer is defined as a nurse or midwife employed in the first three years of practice in his or her registered discipline. Three years is chosen as evidence suggests that nurses’ stress levels are higher in the first two years of practice compared to after the third year, which therefore has an influence on the decision to stay or leave the profession.27 Further, a recent study reported the RN turnover rate as eight times greater in the first three years of clinical practice compared to later years.7
Nurses and midwives whose educational preparation leads to registration that allows them to work only under the supervision of RNs or RMs will be excluded; this includes enrolled nurses, licensed practical nurses, and licensed vocational nurses. Nurses who worked under the supervision of RNs or RMs and subsequently became RNs or RMs will be excluded as they are not newcomers to the discipline.
This review will consider studies that explore individual or environmental factors that influence the decisions to leave or to remain in nursing and midwifery within the first three years of practice. Individual factors are defined as personal characteristics and may include, but are not limited to, age, sex, marital status, psychological capital (self-efficacy, hope, and optimism), anxiety, perceived preparedness, mindfulness, neuroticism, and coping.
Environmental factors are structures that influence the practice environment in which care is delivered, such as staffing, workload, physical and human resources, management, support (workplace interventions that nurture and enable newcomers, such as working relationships or leadership), and development (interventions that empower newcomers, such as professional development, mentoring, or explicit role expectations).17
Combinations of both individual and environmental characteristics may contribute to factors such as resilience, job satisfaction, and burnout,18,26 which can influence whether nurses and midwives leave or stay in their discipline; therefore, these factors will also be included.
Many of the individual, environmental, and combination factors can be measured with reliable, validated instruments such as the Spielberger State Trait Anxiety Inventory form Y2 (STAI-Y2), the Connor-Davidson Resilience Scale, the Professional Quality of Life Scale version 5 (ProQol5), the Positive and Negative Affect Schedule short form (PANAS-SF), the Five Facet Mindfulness Questionnaire (FFMQ), and Practice Environment Scale-Nursing Work Index (PES-NWI). These, and other validated and non-validated instruments, will be included.
This review will consider studies carried out in primary, secondary, or tertiary health care settings, including the community, mental health, and aged care. Articles from any country will be considered for inclusion. The newcomers will have been working clinically and provided direct patient care. Newcomers who were employed in education, research, administration, or non-nursing/midwifery roles will be excluded.
Types of sources
The following research designs will be considered for inclusion: experimental and quasi-experimental study designs including randomized controlled trials, non-randomized controlled trials, before and after studies, and interrupted time-series studies; analytical observational studies including prospective and retrospective cohort studies, case-control studies, and analytical cross-sectional studies; descriptive observational study designs including case series, individual case reports, and descriptive cross-sectional studies. Qualitative studies will also be considered, including, but not limited to, designs such as phenomenology, grounded theory, ethnography, qualitative descriptive, action research, and feminist research. In addition, mixed methods studies, systematic reviews, program evaluations, and quality improvement reports that meet the inclusion criteria will be considered. All research articles will only be considered if they have been peer reviewed. Factors from individual studies that have been incorporated in an included systematic review will not be counted a second time. Dissertations and theses will be included. Conference papers will be included when full papers are available and have undergone peer review. Policy documents will be excluded as they should be based on peer-reviewed documents.
The earliest publication highlighting attrition in nursing and the difficulties of transition for graduate nurses was in 197428; therefore, all articles from this date to present will be considered for inclusion in this review. Further, only articles published in English will be included.
The proposed scoping review will be conducted in accordance with JBI methodology.29
The search strategy will aim to locate both published and unpublished primary studies, reviews, and text and opinion papers. An initial limited search of MEDLINE (Ovid) and CINAHL Plus (EBSCO) was undertaken to identify articles on the topic. The text words contained in the titles and abstracts of relevant articles, and the index terms used to describe the articles were used to develop a full search strategy for MEDLINE (see Appendix I). This search strategy has been peer reviewed by the PRESS Forum. The peer-reviewed search strategy, including all identified keywords and index terms, will be adapted and translated across databases on the various platforms. The reference lists of articles included in the review will be screened for additional papers. Key studies will be checked against citation databases Scopus and Web of Science for forward citations.
The databases to be searched include (on the Ovid platform) MEDLINE, Embase, Emcare, Global Health, JBI Evidence-based Practice, Maternity and Infant Care, and PsycINFO; Cochrane Library; (on the EBSCO platform) CINAHL Plus with full text; (on the ProQuest platform) ERIC, ABI/INFORM, Business Source Complete, Healthcare Administration; (on the Informit platform) Health Collection, APAIS-Health, AMI; (citation databases) Scopus and Web of Science.
Sources of unpublished studies and gray literature to be searched include OpenGrey, Google Scholar, ProQuest Dissertations and Theses, CORE, BASE, and OpenDOAR.
Following the search, all identified records will be collated and uploaded into EndNote X9 (Clarivate Analytics, PA, USA) and duplicates removed. Each title and abstract will then be screened by two reviewers independently for assessment against the inclusion criteria for the review. Potentially relevant papers will be retrieved in full and their citation details imported into the JBI System for the Unified Management, Assessment and Review of Information (JBI SUMARI; JBI, Adelaide, Australia). The full text of selected citations will be assessed in detail against the inclusion criteria by two independent reviewers. Reasons for exclusion of full text papers that do not meet the inclusion criteria will be recorded and reported in the scoping review. Any disagreements that arise between the reviewers at each stage of the selection process will be resolved through discussion, or with a third reviewer. The results of the search will be reported in full in the final scoping review and presented in a Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) flow diagram.30
Data will be extracted from papers included in the scoping review by independent reviewers using a data extraction tool developed by the reviewers. The data extracted will include specific details about the population, concept, context, methods, and key findings relevant to the review question. Psychometric properties and details of the instruments used to measure the individual and environmental factors identified will be extracted.29 The data extraction tool will be modified and revised as necessary during the process of extracting data from each included paper. Modifications will be detailed in the full scoping review. Any disagreements that arise between the reviewers will be resolved through discussion, or with a third reviewer. Authors of papers will be contacted to request missing or additional data, where required.
The extracted data will be presented in diagrammatic and tabular form in a manner that aligns with the objective of this scoping review. Mind maps may be used to visually organize the information. A narrative summary will accompany the tabulated and diagrammatic results and will describe how the results relate to the review's question.
This review is funded by a RARE Seeding Grant from the School of Nursing, Midwifery and Social Sciences, Central Queensland University, which had no influence on the content of this manuscript.
Appendix I: Search strategy
Database: OVID MEDLINE(R) ALL <1946 to January 10, 2020>
Search conducted on 13 January 2020
- (new graduate nurs∗ or new graduate midwi∗ or new nurs∗ or new midwi∗ or graduate nurs∗ or graduate midwi∗ or novice nurs∗ or novice midwi∗ or neophyte nurs∗ or neophyte midwi∗).ti,ab,kf. (4294)
- (early career adj3 (nurs∗ or midwi∗)).ti,ab,kf. (66)
- (newcomer∗ adj5 (nurs∗ or midwi∗)).ti,ab,kf. (16)
- (recent∗ graduate∗ adj3 (nurs∗ or midwi)).ti,ab,kf. (57)
- (newly hired adj3 (nurs∗ or midwi∗)).ti,ab,kf. (69)
- (newly qualified adj3 (nurs∗ or midwi∗)).ti,ab,kf. (336)
- nursing staff/ or nursing staff, hospital/ (65,294)
- ∗Nurses/ (28,529)
- ∗Nurse Midwives/ (5443)
- 1 or 2 or 3 or 4 or 5 or 6 or 7 or 8 or 9 (101,415)
- (intent∗ adj3 (stay∗ or remain∗ or resign∗ or leav∗ or quit∗)).ti,ab,kf. (2522)
- (Retention adj3 (staff or Nurs∗ or midwi∗)).ti,ab,kf. (1932)
- (Attrition adj3 (staff or nurs∗ or midwi∗)).ti,ab,kf. (234)
- (Turnover adj3 (staff or nurs∗ or midwi∗)).ti,ab,kf. (1753)
- Career intention∗.ti,ab,kf. (281)
- Personnel turnover.ti,ab,kf. (99)
- exp Personnel Turnover/ (5067)
- 11 or 12 or 13 or 14 or 15 or 16 or 17 (9890)
- 10 and 18 (3150)
- limit 19 to English language (3031)
- limit 20 to yr=“1974 -Current” (3021)
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