The current national rate of turnover for registered nurses (RNs) is 16.7%, a 2% increase from 2016 (Nursing Solutions Inc., 2018). Licensed practical nurse turnover has been reported as high as 18% (Wisconsin Hospital Association, 2018). The national RN vacancy rate is 8.2% (Nursing Solutions Inc., 2018). The estimated cost of RN turnover is $38,000 to $61,000 annually (Nursing Solutions Inc., 2018). Hospitals lose $4.4 - $7 million annually due to RN turnover alone (Nursing Solutions Inc., 2018).
The Army Nurse Corps is not immune to the nurse attrition problem. Nurse attrition hinders the Army Medical Department mission by diminishing readiness (Army Medicine, 2019). Yet, the retention of a stable nursing staff within the Army Nurse Corps has been linked to reductions in adverse events and higher quality care (Breckenridge-Sproat et al., 2017; Patrician et al., 2017). In order to compete with the private sector in retaining highly competent and skilled nurses, it is critical to identify, through rigorous research methods, those system characteristics that contribute to or conversely, reduce attrition so that evidenced-based retention strategies can be designed and implemented. Although there is an empirical literature linking favorable nursing practice environments (NPE), team performance, patient safety, and nurse job satisfaction with lower nurse attrition and intent to leave (ITL), these relationships have rarely been explored in primary care settings, and there have been virtually no studies that have tested these relationships in Army primary care settings.
Purpose
The purpose of this proposed study is to examine the associations among the NPE, team performance, staff perception of overall safety, staff nurse job satisfaction, and staff nurse ITL in Army primary care clinics. The proposed study seeks to address three specific aims: 1) describe staff nurse perceptions of the NPE in primary care clinics in Army MTFs, 2) examine the relationships among the NPE, team performance, staff perception of overall safety, staff nurse job satisfaction, and staff nurse ITL, and 3) assess the mediating role of team performance in the relationship between staff nurse perception of the NPE and a.) staff perception of overall safety, b.) staff nurse job satisfaction, and c.) staff nurse ITL.
Conceptual Model
Donabedian’s Quality Medical Care model is the overarching theoretical basis for this proposed study which postulates that healthcare quality is the result of structures influencing processes, which in turn, influence outcomes (Donabedian, 1966). The conceptual model guiding the proposed study is an extension of Donabedian’s model, adapted from the Nursing Organization and Outcomes Model (NOOM) (Aiken, Clarke, & Sloane, 2002). The NOOM provides the context lacking in Donabedian’s linear model and is specific to nursing. The NOOM purports that organizational support for nursing, also known as the NPE, is directly associated with process of care and staff nurse job outcomes (Aiken et al., 2002; Lake, 2002).
In ambulatory care, especially primary care settings, nurses are member of interdisciplinary teams. An interdisciplinary healthcare team is a group of at least two or more healthcare professionals serving in specialized roles while adaptively, interdependently, and dynamically interacting to accomplish a common goal (Swezey et al., 1992). Teamwork has been defined as “interrelated thoughts, actions, and feelings of each team member that are needed to function as a team and that combine to facilitate coordinated, adaptive performance and task objectives resulting in value-added outcomes” (Salas, Sims, & Burke, 2005). Thereby, teamwork is a broad concept encompassing structures, processes, and outcomes. The current study seeks to examine teamwork processes as conceptualized by the Big Five of Teamwork framework (Salas et al., 2005). Team performance has been defined as the current operational and functional state of a team within an organization (AHRQ, 2010). In comparison to task objectives, team performance is best suited for examination across various geographical locations, staff demographics, and beneficiary demographics.
Methodology
Associations will be examined utilizing secondary data collected in 2016 by the Army Nurse Corps and the Defense Health Agency Patient Safety Program. Secondary data represent military and civilian government service personnel assigned to primary care clinics within Army military treatment facilities. Staff responses are included from approximately fifty-seven percent of the Army’s primary care clinics. A power analysis performed utilizing the Raosoft sample size calculator at a ninety-five percent confidence level, and assuming a ninety percent response distribution suggests a minimum sample size of sixty-one clinics (Raosoft Incorporated, 2004). Prior to analyses the data will be cleaned and the two existing data sets will be merged and linked by clinic and/or military treatment facility name. All analyses will be completed using IBM Statistical Package for Social Sciences software, version 25.
Continuous variables will be described by means and standard deviations and include the NPE, team performance, and staff perception of overall safety. Categorical variables will be described by frequencies and proportions and include staff nurse job satisfaction and staff nurse ITL. Pearson’s correlation test will be utilized to evaluate the correlation between 1) NPE and team performance, 2) NPE and staff perception of overall safety, and 3) team performance and staff perception of overall safety. T tests will be used to examine the associations between 1) NPE and staff nurse job satisfaction, 2) NPE and staff nurse ITL, 3) team performance and staff nurse job satisfaction, and 4) team performance and staff nurse ITL.
Generalized linear modeling will be utilized to examine the associations among NPE, team performance, staff perception of overall safety, staff nurse job satisfaction, and staff nurse ITL. The categorical dependent variables, staff nurse job satisfaction and ITL, are ordinal in nature and will be evaluated as ordinal scale variables. Random component, systematic component, and link function will be measured. Random component will specify the conditional distribution of the staff perception of overall safety, staff nurse job satisfaction, and staff nurse ITL. Systematic component analysis will specify the associations among NPE, team performance, and NPE and team performance. Link function will transform the expected value (or mean) of staff perception of overall safety, staff nurse job satisfaction, and staff nurse ITL to the linear predictors: NPE and team performance.
In addition to performing the GLM, mediation analysis will be performed utilizing Hayes’ PROCESS macro for SPSS (Hayes, 2018). It is anticipated that team performance will mediate the relationship between NPE and 1) staff perception of overall safety, 2) staff nurse job satisfaction, and 3) staff nurse ITL. Causal influences of each variable in the predicted model will be estimated through ordinary least squares regression analyses (Hayes, 2018). Analyses will include an examination of the direct, indirect, and total effect models.
Conclusion
An exploration of the NPE in Army primary care clinics and staff and organizational outcomes is essential to ensure staff nurse retention and the provision of safe, quality care in these settings. The proposed study will inform military nursing leaders regarding system characteristics that contribute to or reduce staff nurse attrition in Army primary care settings. Findings from the proposed study will provide military nursing new knowledge necessary to design and implement evidence-based retention strategies to compete with the civilian sector in retaining highly competent and skilled nurses in primary care settings.
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