For the purposes of this review the following definitions will be used:
Nurse Turnover: Turnover includes voluntary and involuntary termination as well as internal and external transfers.19 Voluntary termination may include transferring from one department to another within the same organization or when nursing staff voluntarily leave or transfer from their employment position. Voluntary termination excludes dismissals, voluntary retirement, and leaves of absence as a result of death, medical or maternity reasons.20 Involuntary termination is where employment is terminated by the employer. Many studies do not distinguish between voluntary and involuntary turnover, therefore for the purpose of this study nurse turnover will be defined as the process in which nurses leave or transfer within the hospital environment.
Absenteeism: Absenteeism (unplanned absence) will be defined as non-attendance at work where work attendance is scheduled. This includes sick leave, and may include carer's leave and bereavement leave. This leave may be paid or unpaid.21 Work related injury leave will be excluded.
Nurse Stress: Defined as the “relationship between the person and the environment that is appraised by the person as taxing or exceeding his or her resources and endangering his or her wellbeing.”16(p NP)
Nurse Burnout: Physical or mental collapse caused by overwork or stress.17
Skill Mix: The combination or grouping of different categories of workers that are employed for provision of care to patients.22 Categories of workers for this review specifically refers to nursing staff employed for the provision of care.
Types of participants
This review will consider studies that include all nurses working on general wards in the acute care hospital sector. This includes registered general nurses or the international equivalent such as staff nurses and professional nurses, enrolled nurses or the international equivalent such as licensed vocational nurses or licensed practical nurses and unlicensed personnel such as nursing assistants or the international equivalent such as nurse's aides and auxiliary nurses.
This will review will exclude:
Nursing staff working on specialized wards and areas for example intensive/critical care areas, oncology wards, pediatrics, midwifery, mental health, primary care and aged care sectors, as they utilize specific models of care for their scope of practice.
Types of intervention(s)
This review will consider studies that investigate the use of a team nursing model when organizing nursing work. The comparator will be utilization of a total patient care model.
Types of outcomes
The outcome of interest to this review will be staff wellbeing. Methodology for data collection will be grouped from the primary research papers based on the types of outcomes measures or tools that were used to promote homogeneity of pooled data. Data collection tools that have been used in initial searches of papers have included questionnaires for the collection of responses for staff satisfaction. The measurement tools considered for inclusion must be validated and reliable, examples of these tools are the Nursing Work Index tool which measures nursing values in relation to job satisfaction and productivity. This tool has been modified and used in various countries including Australia where it is referred to as the Nursing Work Index - Revised: Australian Tool, (NWI-R:A tool).23 Another reliable tool is the McCloskey/Mueller Satisfaction Scale (MMSS) which is a multidimensional questionnaire designed for hospital staff nurses. There are 31 items; the response format is a five-point Likert scale. The Nurse Satisfaction Scale (NSS) is also a validated tool which measures job satisfaction among nurses. The questionnaire is multidimensional and has 24 items. The response format is a seven-point Likert scale.24
Maslach Burnout Inventory tool has been utilized to measure staff burnout and stress levels other tools that measure staff burnout and stress will be considered for inclusion, providing it is a validated and tested tool for measuring staff burnout and stress levels. Nursing turnover and absenteeism rates will be extracted from included papers. Patient clinical outcomes will be excluded from the review.
Types of studies
This review will consider quantitative studies that focus on but are not limited to staff turnover, absenteeism, staff satisfaction, stress and burnout. Experimental and epidemiological study designs including randomized controlled trials, non-randomized controlled trials, quasi-experimental, before and after studies, prospective and retrospective cohort studies, case control studies and analytical cross sectional studies for inclusion.
This review will also consider descriptive epidemiological study designs including case series, individual case reports and descriptive cross-sectional studies for inclusion.
Studies not published in English will be excluded from this review.
The search strategy aims to find both published and unpublished studies. A three-step search strategy will be utilized in this review. An initial limited search of MEDLINE and CINAHL will be undertaken followed by an analysis of the text words contained in the title and abstract, and of the index terms used to describe the article. A second search using all identified keywords and index terms will then be undertaken across all included databases. Thirdly, the reference list of all identified reports and articles will be searched for additional studies. Studies published in the English language will be considered for inclusion in the review. Studies published from 1995 to September 2013 will be considered for inclusion in the review. In order to analyze the most current and contemporary body of evidence, this review will only consider published articles from 1995 onwards. To justify this time period it is critical to reflect upon the changes that have occurred within Australia in relation to a number of influences including nurse education, changes in health acuity and workforce demands. This period also saw the introduction of Assistants in Nursing (AIN's) into the acute care health workforce. Furthermore, since 1995, nursing practice was heavily influenced by regulatory bodies such as the Australian Nursing and Midwifery Council.25, 26 These influences have greatly affected and influenced models of care delivery. Data from studies prior to this period of time, considering the significant movements and changes in workforce dynamics, would be superfluous to the outcomes of this systematic review.
The databases to be searched include:
Cochrane Library (CENTRAL)
The search for unpublished studies will include:
ProQuest Dissertations and Theses
Initial keywords: please refer to logic grid: (Appendix I).
Assessment of methodological quality
Quantitative papers selected for retrieval will be assessed by two independent reviewers for methodological validity prior to inclusion in the review using standardized critical appraisal instruments from the Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI) (Appendix II). Any disagreements that arise between the reviewers will be resolved through discussion, or with a third reviewer.
Data will be extracted from papers included in the review using the standardized data extraction tool from JBI-MAStARI (Appendix III). The data extracted will include specific details about the interventions, populations, study methods and outcomes of significance to the review question and specific objectives.
Quantitative data will, where possible be pooled in statistical meta-analysis using JBI-MAStARI. All results will be subject to double data entry. Effect sizes expressed as odds ratio (for categorical data) and weighted mean differences (for continuous data) and their 95% confidence intervals will be calculated for analysis. Heterogeneity will be assessed statistically using the standard Chi-square and also explored using subgroup analyses based on the different study designs included in this review. Where statistical pooling is not possible the findings will be presented in narrative form including tables and figures to aid in data presentation where appropriate.
Conflicts of interest
No conflicts of interest to declare
As this systematic review forms partial submission for the degree award of Masters of Clinical Science, a secondary reviewer (Scott King, MSc candidate) will be utilized for critical appraisal.
I would like to thank my supervisors, Associate Professor Lesley Long AM and Dr Karolina Lisy at the Joanna Briggs Institute, Adelaide for their guidance and support with this review.
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Appendix I: Logic grid initial key words
Appendix II: MAStARI appraisal instrument
Appendix III: MAStARI Data extraction instrument