Nurses’ work environment and intent to leave in Lebanese hospitals: Implications for policy and practice

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Abstract

Background

The dual burden of nursing shortages and poor work environments threatens quality of patient care and places additional pressures on resource-stretched health care systems, particularly in the Eastern Mediterranean Region (EMR). There is a paucity of research in the EMR examining the quality of nurses’ work environment and its association to nurses’ intent to leave their jobs/countries.

Objectives

Systematically examine the characteristics of nurses’ work environment and their relation to nurses’ intent to leave their jobs within the context of Lebanon. A secondary objective is to assess the utility and validity of the NWI-R within the context of the EMR.

Methods

A cross-sectional survey design was utilized to survey a total of 1793 registered nurses in 69 Lebanese hospitals. The survey instrument included questions on nurses’ background, hospital characteristics, intent to leave, and the Revised Nurse Working Index (NWI-R). Data analysis included descriptive statistics for demographic characteristics, t-test and ANOVA to assess differences in agreement scores, and a multinomial logistic regression model to predict intent to leave. Thematic analysis of open-ended questions was utilized to extract themes that fit under issues relating to nurses’ work environment in Lebanese hospitals.

Results

The NWI-R subscale with the lowest mean score related to control. Younger nurses had lower scores on organizational support and career development. Regression analysis revealed that for every 1 point score decrease on career development there was a 93% increase in likelihood of reporting intent to leave country. Likewise, for every 1 point score decrease on participation there was an observed 51% and 53% increase in likelihood of reporting intent to leave country and hospital, respectively. Findings show that hospital characteristics (size, accreditation status and presence of a recruitment and retention strategy) were significantly associated with NWI-R subscales.

Conclusions

Participation, control and career development were key work environment challenges contributing to the attrition on nurses from Lebanese hospitals. Although some of the issues identified are country specific, others would certainly be relevant to other countries in the EMR. Addressing these challenges would require a strong and coordinated action from governments, professional bodies, policy makers and health managers.

Introduction

Nurses’ work environment has been highlighted as a priority for health care organizations given its importance in improving retention and reducing shortages (Shields and Ward, 2001, Zurn et al., 2004, El-Jardali et al., 2009a). Researchers have established that poor work environments are the primary underlying cause for nurses’ attrition and turnover, and that healthy work environments improve nurses’ well-being and satisfaction and contribute to improving retention (O’Brien-Pallas et al., 2003, Baumann et al., 2001, Shamian and El-Jardali, 2007). Enhancing the quality of nurses’ work environments is critical in light of the existing global shortages of qualified nurses (Aiken et al., 2004), particularly in developing countries (El-Jardali et al., 2008). The dual burden of shortages and poor work environments threatens quality of patient care and places additional pressure on resource-stretched health care systems (Kingma, 2007, Labonte et al., 2006, Aiken et al., 2002). Creating safer and more attractive work environments is pivotal for reducing high nursing turnover rates and subsequent shortages. This requires a better understanding of the interplay between the various aspects of the nurses’ work environment and how they relate to nurses’ intent to quit their current job to pursue other opportunities whether in the country or abroad (El-Jardali et al., 2009b). This paper systematically examines the various aspects of nurses’ work environment and how it relates to intent to leave within the context of Lebanese hospitals.

Section snippets

Background

Healthy work environments have been defined as mechanisms, programs, policies, initiatives, actions and practices that provide health workers with the physical, mental, psychological and organizational conditions that can improve their health and well-being (Shamian and El-Jardali, 2007). This is linked to better quality of care, enhanced patient safety and societal outcomes in addition to better organizational performance (Griffin et al., 2006 as cited in Shamian and El-Jardali, 2007, page 7).

Objective

The objective of this study is to systematically examine the various aspects of nurses’ work environment in Lebanese hospitals and how they relate to nurses’ intent to leave their jobs. A secondary objective is to assess the utility and validity of the NWI-R within the context of the EMR.

Study design

A cross-sectional design was utilized to survey nurses currently practicing in Lebanese hospitals. Nurses were eligible to participate in this study if they had at least 1 year of work experience in the hospital and if they had completed one of the following educational programs: Bachelors of Science in Nursing (BSN), or Baccalaureate Technique (BT), or Technique Superior (TS), or License Technique (LT) and Diploma. Nursing programs in Lebanon are of two types, university programs which provide

Univariate analysis

Table 1 details the distribution of means and standard deviations across the six subscales. The subscale with the highest mean score was the one measuring nurse/physician relationships (mean = 2.99, SD = 0.60). The subscale with the lowest mean score was the one measuring control (mean = 2.56, SD = 0.56). Results indicate that although nurses were satisfied with their interaction and relationship with physicians, they were displeased with the control they have over their work.

Bivariate analysis

A comparison of means was

Discussion

Study findings indicate that Lebanese nurses are facing critical work environment issues, some of which are strongly associated with intent to leave. Low agreement scores on the subscale measuring participation were highly associated with intent to leave the country and the hospital. This indicates a need to involve nurses in decisions related to their professional practice. Involving nurses in such decisions, even simple aspects of their profession such as scheduling, can empower them, improve

Conclusions

Several work environment issues facing nurses in Lebanese hospitals have been unearthed in this study, including: degree of nurses’ participation, control and career development; particularly for younger nurses who are at a higher risk of turnover and migration.

The aforementioned issues are not beyond the control of nursing stakeholders and do not necessarily require substantial financial investment. However, they require a paradigm shift in the way some of the organizations view their nursing

Acknowledgements

Authors would like to thank the Eastern Mediterranean Regional Office of the World Health Organization for funding this project and the Lebanese Order of Nurses for their support of this national research. Authors would also like to thank Ms. Mirvat Merhi for her assistance in managing the project, distributing the questionnaires and collecting data in addition to Ms. Hala El-Khoury and Ms. Lama El-Jizi for data entry. The authors would also like to thank Ms. Randa Rustom for assistance with

References (55)

  • A. Baumann et al.

    Commitment and Care: The Benefits of a Healthy Workplace for Nurses, their Patients and the System. A Policy Synthesis

    (2001)
  • A. Bowling

    Research Methods in Health

    (1997)
  • R. Boyatzis

    Thematic Analysis and Code Development: Transforming Qualitative Information

    (1998)
  • A. Chandra

    Why do nurses leave and what can health organizations do to retain them

    Hospital Topics

    (2003)
  • C. Chu et al.

    Health-Promoting Workplaces—International Settings Development

    Health Promotion International

    (2000)
  • CSPro 3.2, 2008. U.S. Census Bureau, Population Division. Available on...
  • El-Jardali, F., 2003. The impact of hospital rationalization and the interrelationships among organizational culture...
  • F. El-Jardali et al.

    Human resources for health planning and management in the Eastern Mediterranean region: facts, gaps and forward thinking for research and policy

    Human Resources for Health Journal

    (2007)
  • F. El-Jardali et al.

    Policy-relevant health systems research priorities in nine low and middle income countries in the Middle East and North Africa Region

    Health Policy and Planning

    (2009)
  • F. El-Jardali et al.

    A national cross-sectional study on nurses’ intent to leave and job satisfaction in Lebanon: implications for policy and practice

    BMC Nursing

    (2009)
  • F. El-Jardali et al.

    Assessment of nurse retention challenges and practices in Lebanese hospitals: the perspective of nursing directors

    Journal of Nursing Management

    (2009)
  • M. Estryn-Béhar et al.

    The impact of social work environment, teamwork characteristics, burnout, and personal factors upon intent to leave among European nurses

    Medical Care

    (2007)
  • A Field

    Discovering Statistics Using SPSS (and Sex and Drugs and Rock ‘n’ Roll)

    (2009)
  • Griffin, P., El-Jardali, F., Tucker, D., Grinspun, D., Bajnok, I., Shamian J., 2006. What's the fuss about? why do we...
  • M.M. Gullatte et al.

    Retention and recruitment: reversing the order

    Clinical Journal of Oncology Nursing

    (2005)
  • H.A. Huijer et al.

    Nursing in Lebanon

    Applied Nursing Research

    (2005)
  • E.K. Kelloway et al.

    Building healthy workplaces: what we know so far

    Canadian Journal of Behavioural Sciences

    (2005)
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