Research Proposal on Nurse Retention & Motivation

The rising shortage of nurses and the increasing difficulty to recruit and retain nurses in the workforce of any health facility are widely known as two of the most alarming problems that hospitals around the globe are faced with today. One of the glaring indicators of this shortage crisis is the rising number of vacancies for nursing positions in both developed and developing countries (Zurn, Dolea and Stilwel, 2005).  In addition, high turnover rates are also attributed to the growing shortage of nurses.

In fact, a gamut of recent research studies has identified various factors related to turnovers. Robinson, Clements & Land (2003) have determined job stress resulting from job burnout as a probable cause for nursing turnovers. Other factors could be the hospital’s organizational culture (Gormley, 2003), dissatisfaction on the job (Dworkin, 2002), inadequate compensation and benefits (Apker, Ford & Fox, 2003), poor work schedules (Cangelosi, Markham and Bounds, 1998) and unsatisfactory nurse-physician relationships (Rosenstein, 2002).

A significant implication of these previous researches is that the motivation of nurses to work and stay in a hospital are likely to depend partially on these factors. Thus, it is crucial for hospital administrators, health center managers and other organizational leaders in health institutions to determine which factors are affecting the motivation and performance of their nursing staff to be able to formulate the right incentives, retention programs and compensation structures that would entice the nurses to perform better and stay longer in their institution. This paper is an effort to study the case of the Nursing Staff from a major medical institution on how motivation and other factors can be used to enhance the performance of nurses and encourage them to stay and build their careers in the institution.

The Medical Center Hospital (MCH) in Odessa, Texas is one of the leading hospitals in the area and claims to be the only “full-service hospital in Ector County” (mchodessa.com, 2006). It also serves as the regional referral center that covers all the 17 counties comprising the Permian Basin. As much as it is a very progressive and dynamic institution, however, it is not spared from the nursing workforce shortage. As of November 8, 2006, the MCH, which accommodates about 350 beds, is in need of approximately 40 nurses to join its workforce (mchodessa.com, 2006).  These vacancies imply that presently employed nurses could be working overtime and doubly hard to make up for the lack of personnel and still keep the quality standards that the hospital instills in its patient care.

Given such situation, it is therefore crucial for the management of MCH to prevent this type of scenario which poses long-term detrimental effects on its workforce. To do this, they must be able to avoid turnovers and retain the presently employed nurses for as long as they can.  As such, it is important to determine what factors affect the nurses’ motivation to perform well and stay in the organization. Also, it is imperative that these factors be compared with respect to the extent of influence they have on the nurses’ motivation and job satisfaction levels.  The problem facing MCH is how this can be done and this study proposes to resolve that problem.

It is hoped that through careful and thorough consideration and analyses of the various factors affecting employee motivation and performance in MCH, the hospital would be able to formulate and implement viable solutions that would enhance nursing performance in the workplace and at the same time improve the company’s image to its patients, stakeholders and the public in general. Specifically, this study aims to:

1. determine the motivation and satisfaction levels of nurses in MCH while at the same time identify the factors that affect the work motivation of the employees in MCH and use these factors to explain and offer solutions for nurse retention problems
2. compare the motivational factors involved in terms of influencing satisfaction levels among nurses and enhancing their roles and job competencies
3. provide an empirical test of a major motivation theory (either McGregor’s or Herzberg’s theory), in addressing its applicability to this study
4. based on the research findings, to make the necessary recommendations for the improvement of MCH and of other health care facilities in terms of enhancing motivation levels to decrease the workforce shortage and increase nurse retention in the long-run.

This study hopes to answer the following research questions: What is the current (as of 2006) motivation and satisfaction levels of MCH nurses and what are the factors affecting these? How may these factors influence their performance and their decision to stay in MCH?

This study may be significant to the contribution of knowledge on factors affecting the motivation and performance of workers in the health industry. One of the underlying objectives is to provide MCH with a better recognition and understanding of the interaction and relationship, if any, between employee satisfaction and motivation levels and nursing turnovers, which ultimately reflect on overall business performance.

This chapter primarily laid-out the background and bases for conducting this case study. Basically, the main research problem is to find out the current satisfaction and motivation levels of the nursing staff in MCH and determine the factors that affect them.  The answers to the research problem pose some implications on how MCH’s management can improve on its human resource processes and procedures in order to attain the desired outcome, that is, decreased turnovers and increased nurse retention.

In the next chapter, the theoretical foundations of the most important concepts used in this paper will be established. Discussions on motivation and job satisfaction will be presented and elaborated. Similar studies, the frameworks used and their methodologies will likewise be discussed.

Many factors may be attributed to employee turnovers and retention efforts in the health industry.  To some health workers, wages and good organization policies may be the key to have them stay in one institution for a long period. To others, good relationships with superiors and fulfillment on the job are highly important. Whatever these factors may be, it is important to determine their overall effects on the motivation level of the employee. This study shall examine the levels of nurse satisfaction in MCH as shaped by work motivation vis-à-vis the factors that affect the latter. It is thus important to discuss the theories that form the foundation of these major concepts as utilized in this research.

Apart from references to the works of major motivation theorists, this study shall also review the applications of the theories to the health facility setting from the following studies:

1. Nurse retention and recruitment: developing a motivated workforce. Issue Paper by Pascal Zurn, Carmen Dolea, and Barbara Stilwell of the World Health Organization Department of Human Resources for Health (2005). A comprehensive literature review on motivation as applied to the issues of nurse recruitment and retention. The paper provides relevant statistical data from hospitals worldwide and offers appropriate recommendations for policy interventions.
2. Nursing satisfaction and job enrichment in Turkey by Havva Öztürk, RN; PhD, Nefise Bahcecik, RN; PhD and Steven L. Baumann, RN; PhD (October 2006). A survey research exploring the effects of job enrichment to the satisfaction levels of nurses working in a training and research hospital under the Turkish Republic Ministry of Health. The study made use of Hackman and Oldman’s job enrichment theory to develop the questionnaire. The results showed that the five dimensions of Hackman and Oldman’s theory (skill variety, task identity, task significance, autonomy, and feedback) proved to be important to majority of the nurses.
3. Factors related to nurse retention and turnover by Joseph Cangelosi, Scott Markham & William Bounds (1998). An exploratory research effort comprising of 13 structured, in-depth interviews with physicians from major hospitals in U.S. southeastern metropolitan areas and conversations with six hospital nurse administrators. The study’s qualitative data yielded four major reasons for nurse turnovers: salary or benefits, convenience, work schedule and job-related stress. The study found that nurses who move from one hospital to another once or more than once become more satisfied in their work.
4. Nurse-physician relationships: impact on nurse satisfaction and retention by Rosenstein AH (2002). A survey was designed and administered by the VHA West Coast to a large network of hospitals for the purpose of assessing the views of nurses, physicians and executives on the effect of nurse-physician relationship and disruptive physician behavior (among other factors) to the satisfaction, morale and retention of nurses. The study gathered data from 1,200 respondents and found that there was a significant relationship between disruptive physician behavior and nurse retention and satisfaction. The study recommended that these issues be treated seriously in health facilities to prevent frequent nurse turnovers from occurring.

Research is a process of systematically obtaining accurate answers to significant and pertinent questions by the use of a method of gathering and interpreting information.  (Balsley & Clover, 1988). This research undertaking is designed to be a descriptive and evaluative study using quantitative data that will be subject to frequency and correlation statistics. The tool for deriving data shall be in the form of a survey questionnaire to be administered to the nursing staff of MCH.

One of the most effective management tools for determining employee perceptions and/or attitudes has been the conduct of organizational surveys. A comprehensive employee satisfaction survey could be the key to a more motivated and loyal workforce and therefore it is important to understand exactly which issues have the greatest impact on employee satisfaction. This study will be utilizing a custom survey questionnaire constructed out of the theoretical discussions made in the previous section.

Some of the factors that are foreseen to be incorporated in the questionnaire are:

• Pay and classification
• Performance management
• Role clarity
• Policies and procedure
• Rewards
• Discipline and grievance handling
• Stress-related factors
• Leadership perceptions
• Work Schedules
• Working environment

Additional factors may be included depending on what the literature review will cover.  The said questionnaire will be administered to all of the nurses employed in MCH within a period of one week. In addition, the questionnaire will also be used to gather demographic data from the nurses such as age, length of stay, employment status etc. These data, in turn, will be examined for any correlation effects on the questionnaire ratings.

The questionnaire is custom-designed to determine the factual and perceptive views of the nurses on work motivating factors. To do this, the nurses will be asked to complete the questionnaire in two ways. First, they will be asked to rate the statements according to their importance vis-à-vis being motivated to work in general. Next, they will be asked to rate the statements in terms of how applicable they were in the actual work situation at MCH. Thus, there will be one set of statements, which the nurses will rate twice.

Since this will be an organization-wide survey, it is hoped that all nurses of MCH will be included as participants in this study. During the actual conduct of the survey, however, the nurses shall still be given a choice whether to complete the questionnaire or not. Thus, it is expected that the turnout rate will not be 100%.

This researcher plans to write a formal letter to the hospital’s Human Resource department that will state the study’s main purpose and primary objectives. There will be a proposed schedule for the administration of the questionnaire so that disruption from work will be kept to a minimum. The hospital will be guaranteed of a copy of the entire study after it has been completed. After acquiring the approval of the hospital’s management, it will be suggested that the administration inform all nurses about the upcoming survey 3-5 days prior to the actual commencement of the survey.

The questionnaire will be accompanied by a cover letter stating its purpose and a consent form to ensure that answering the questionnaire will be voluntary.

Anonymity of the subjects may or may not be kept. That is, the nurses will have the option to place their name on the survey form. For purposes of control, however, they will be asked to indicate their department and position on the form, apart from the other demographic information that will be included. Nevertheless, the survey shall guarantee confidentiality of individual responses.

The nurses will be informed that the risk for completing the questionnaire shall be kept to a minimum since they will have the option to indicated their name or leave it out. The will also be briefed that the results of the questionnaire may help in the formulation of hospital policies that, in turn, may be beneficial to them in the long-run.

At the end of each scheduled survey day, the forms will be gathered and counted. After all the survey forms have been completed, a report shall be submitted to the HR department regarding the number of respondents so that they will be aware of the nurses’ level of participation and to verify with them the actual percentage of the respondents against the entire nursing population in MCH. Demographic data will first be noted then ratings for the questions will be counted for frequency.

The questionnaire has been used as a research instrument to gather large amounts of data in a relatively short period of time. The data to be collected are limited and relative to the variables being examined in the questionnaire. Its advantages are quite apparent. For one, it is very easy and inexpensive to administer to a large number of people simultaneously. Second, participants are likely to be comfortable in answering the questions since they can maintain their anonymity. As such, they may tend to answer critical or sensitive questions more truthfully and uninhibitedly. Also, since the questions are pre-determined and standardized, the manner of asking the question is generally consistent and devoid of any variability that may be due to changes in the manner of delivery if asked verbally, as in an interview.

The downside of this, however, is that questions may tend to be interpreted differently by the participants and there is usually no way to clarify or ask for further questions unless the researcher is present during the time of the questionnaire completion. Another disadvantage of this method is the possibility of low response rates if it is administered to a large sample. This may be due to a number of factors, one of which may be the failure of the respondent to turn in his or her answers on time. Also, this method cannot be used when the subjects are illiterate. In the case of MCH, however, literacy will not be an issue, thus eliminating the negative effect that this factor may cause.

The rating system shall be of a Likert scale-type, a five-point scale that is used to quantify opinion based on the formulated questions or items. The scale usually covers a range of one extreme aspect of the variable to another. The premise of the questionnaire as used in this study will be to establish which factors affecting work motivation and satisfaction are perceived to have the highest or lowest impact on these two variables. The next step will be to point out which of the selected factors are relevant or lacking in the MCH. Thus, in this case, two ranges will be constructed, one for the aspect of “importance” and for “agreement” as described above. The results will be tabulated and analyzed using SPSS. Correlation analysis will be done to determine if there are significant relationships between the results of the questionnaire and the nurses’ employment status in the hospital.

This chapter details the how data will be gathered from the nurses of MCH. As mentioned, a survey questionnaire will be administered to the nurses to determine their perceptions and attitudes towards work motivating factors in terms of importance and applicability in their actual work settings. The next section will elaborate on the findings of the study and the analyses of the results.

Measures of central tendencies will be applied to the questionnaire ratings. When the rating given to the importance of a factor matched that of the rating representing the presence or relevance of that factor in the organization, then that factor will be considered as having a positive influence in the motivation and satisfaction levels of the nurses.  In other words, it could indeed be motivating and satisfying and there is a big probability that the nurses are in fact motivated and satisfied, as indicated by the ratings. In terms of action points, these factors need not be prioritized for improvements, only for maintenance.

If, however, there was a discrepancy between the two ratings, for example, the factor is deemed to be highly important by majority of the employees but in the actual situation, the majority also disagrees that it is present in the organization, then that factor will be considered as an issue to be addressed and subject to further analysis for action points on improvement. Thus, the question will be, what can be done to improve the situation with regards to that particular factor? These shall be discussed in the last part of the paper.

Factors with split responses or those which will not have clear central tendencies and those in the middle (i.e., Uncertain or Moderate Impact), will be discussed for their implications on the uncertainty in perceptions of the nurses. Length of stay and employment status will be tested for correlation against all rated factors. This will indicate if these factors have affected the responses.

Motivating and satisfying nurses are just two aspects of human resource management but the implications are crucial to the organization. Unmotivated and dissatisfied nurses could mean loss of efficiency, morale, and profits that would eventually lead to the demise of the organization. Thus, it should always remain as an area of concern not only for the time being but also for as long as the hospital intends to survive and flourish in the industry. The next chapter shall describe the limitations of the study and suggestions for further research in the future.

This study intends to use an organization-wide survey which could pose some difficulties for the researcher since MCH is a relatively medium-sized hospital with a high occupancy rate, hence, with busy nurses as well.

First, while it is extremely ideal that all nurses be included in the survey, it is anticipated that not all of them will accede to the request, unless the administration requires them to do so. Second, despite guarantees of confidentiality and risk-free turnouts, the effect of social desirability may still be introduced. That is, the nurses’ response may be biased towards what they think is right for the hospital and not for them.

It is foreseen that the administration may be requested to make the survey mandatory so that respondent turnout will be high. It may also be recommended that the same survey be conducted in another hospital to further validate the results. The limitations of this study have been discussed but it is hoped that the results and conclusions derived from this research will be considered in future studies that will implement similar designs and analyses.

Reference

1. Apker, J., Ford, Z.W.S., & Fox, D.H. (2003). Predicting nurses’ organizational and professional identification: The effect of nursing roles professional autonomy, and supportive communication. Nursing Economics, 21(5), 226-32.
2. Balsley & Clover (1988) Research for Business Decisions, 4th Ed. Gorsuch Scarisbrick Pub.
3. Cangelosi, J.D. Jr., Markham, F.S., & Bounds, W.T. (1998). Factors related to nurse retention and turnover: An updated study. Health Marketing Quarterly, 15(3), 25-43.
4. Dworkin, R.W. (2002). Where have all the nurses gone? Public Interest, 148, 23-37.
5. Gormley, D.K. (2003). Factors affecting job satisfaction in nurse faculty: A meta-analysis. Journal of Nursing Education, 42(4), 174-178.
6. Ozturk, H., Bahcecik, N. & Baumann, S. (2006). Nursing satisfaction and job enrichment in Turkey. Nursing Science Quarterly, 19:4.
7. Robinson, J.R., Clements, K., & Land, C. (2003). Workplace stress among psychiatric nurses. Journal of Psychosocial Nursing & Mental Health Services, 41(4), 32-43.
8. Rosenstein, A.H. (2002). Nurse-physician relationships: Impact on nurse satisfaction and retention. American Journal of Nursing, 102(6), 26-34.
9. The Medical Center Hospital website. Retrieved 14 November 2006 from http://www.mchodessa.com/
10. Zurn, P., Dolea, C. & Stilwell, B. (2005). Nurse retention and recruitment: developing a motivated workforce. Issue Paper # 4. World Health Organization Department of Human Resources for Health. Geneva, Switzerland: International Council of Nurses.