Health care organizations are complex and face a myriad of challenges. Maintaining a cadre of well-qualified, dedicated employees is one of the greatest challenges faced by an organization. All organizations experience both voluntary and involuntary turnover, which, for the most part, will have a negative effect on the organization. This is particularly true in health care—and especially in the nursing profession, which has experienced very high rates of turnover, historically and cyclically.
Turnover is a voluntary process where an employee decides for whatever reason that he or she no longer wants to be employed at a particular organization. In the book The 7 Hidden Reasons Employees Leave, author Leigh Branham defines turnover as a process of disengagement that occurs over a period of time and that ends with voluntary termination. This definition is significant, giving the organization an opportunity to stop the process if they can figure out what is causing the person to want to leave. Although there are many reasons why individuals leave their jobs, Laureen J. Hayes and colleagues identified job satisfaction as being a significant factor for nurse turnover in their 2006 literature review published in the International Journal of Nursing Studies.
Because there are many factors that influence a person’s job satisfaction—such as leadership support, autonomy, and positive work environment—it is quite challenging to develop a comprehensive retention program. However, knowing the most common factors and what nurses value can be very helpful for the nurses and the organization. The journey to becoming a nurse is challenging, and once you become a nurse the challenges remain, but the rewards often outweigh the challenges. Certainly, no one goes into nursing believing that they will eventually become disenfranchised to the point where they want to leave their position, or in some cases, the profession. Unfortunately, this is exactly what happens to many nurses, especially new nurses.
Why is Turnover So High?
Turnover has been particularly problematic in nursing. In 2007, Christine T. Kovner and colleagues reported in the American Journal of Nursing that within the first year of transition turnover rates were as high as 50%. New nurses face countless challenges as they transition into practice. Reality shock affects all new nurses to some degree, with some leaving their organization and others leaving the profession altogether. It’s very overwhelming to leave the cocoon of support in nursing school and suddenly be on your own. Being autonomous, developing time management, critical reasoning, and organizational skills, and becoming clinically competent are just some of the challenges faced by new nurses.
Experienced nurses often leave due to a negative work environment, which leads to job dissatisfaction and burnout. Not only does turnover have a negative effect on patient outcomes, but it may result in more turnover as units become understaffed and more nurses experience burnout. Furthermore, turnover costs to society are estimated to be between $1.4 and $2.1 billion, according to a 2013 study published in the Journal of Nursing Management.
Turnover has been the subject of multiple studies since the mid-1900s—several theories and models have been developed to explain why turnover occurs. For example, William H. Mobley and colleagues developed a conceptual model in 1979 that considered individual, organization, and environmental factors. Another model was developed in 1994 by Thomas W. Lee and Terrence R. Mitchell—the “unfolding model” of turnover, which has four paths. The first path describes a “shock,” which leads to the second path where the employee evaluates his or her fit. In the third path, the employee analyzes his or her fit within the organization, and in the fourth path, the employee leaves the organization.
More recently, Amy L. Kristof-Brown and colleagues described how person-environment fit has been utilized to explain organizational turnover in a 2005 article published in Personnel Psychology. The general premise being that when an employee’s (person) needs are met by the organization they will have a good fit, which will result in greater job satisfaction and lower turnover. The model has been further developed into categories of person-supervisor, person-organization, person-group, and person-job fit. In my doctoral dissertation on job satisfaction and turnover, I utilized person-supervisor fit and found a relationship between value congruence on leadership support and job satisfaction in registered nurses. Although there were several different antecedents of job satisfaction, leadership support was a significant factor. It is helpful to have a basic understanding of turnover and the various theories, especially when developing orientation and retention programs.
Why Job Satisfaction Matters
Interestingly, salary was not identified as a significant factor in job satisfaction in many studies, yet job satisfaction is one of the most common factors that influence an employee’s decision to leave an organization. Some of the most common predictors of job satisfaction are: autonomy, work environment, supervisor support, and work stress. Nurse-physician collaboration, nurse-patient ratios, ability to deliver safe patient care, interpersonal relationships, and recognition can also have an effect on job satisfaction.
Although very few studies have been conducted on job satisfaction and minority nurses, Ying Xue published a study on job satisfaction among racial and ethnic minority nurses in the International Journal of Nursing Studies in 2015. The results revealed that a majority of nurses were satisfied with their jobs; however, black, American Indian/Alaska Native, and multiracial nurses had lower job satisfaction in comparison to white nurses. Xue recommends further studies be undertaken in order to develop programs to improve job satisfaction and decrease turnover in minority nurses.
The need to be autonomous is something most nurses value, but this increases as a nurse becomes more experienced. Experienced nurses value their autonomy and ability to use their knowledge, critical reasoning, and expertise when caring for their patients. New nurses, on the other hand, recognize their limitations and the need for support by their peers, mentors, and supervisors during their transition into professional practice. Unsurprisingly, both new and experienced nurses want to be supported by their manager—just in varying degrees.
Nurse-physician collaboration varies among organizations, and even nursing units. Although there are many supportive physicians that have developed positive working relationships with nurses, there are some physicians who are very disrespectful to nurses, unfortunately. Suzanne Gordon wrote extensively about this issue in her book, Nursing Against the Odds: How Health Care Cost Cutting, Media Stereotypes, and Medical Hubris Undermine Nurses and Patient Care. Still, physicians are not the only ones who are problematic. Many nurses, especially new nurses, are victims of workplace bullying by their peers and supervisors. This issue is so serious that the Joint Commission issued a Sentinel Event Alert in 2008 requiring organizations to have a “zero tolerance policy” against “intimidating or disruptive behavior.” Your organization is required to have policies to address this issue, so please reach out to the appropriate people if you are experiencing any type of bullying. There is no need to suffer in silence.
A negative work environment is among the top reasons why nurses leave their jobs. Although there are many factors that influence the work environment, the nurse manager plays a pivotal role in creating a positive work environment. Many nurse managers are promoted from within and may not have the experience and/or education required of an exemplary leader. There are many different styles of leadership, and a true leader knows when to use the various styles. For example, in an emergency situation one might have to take an authoritarian approach; however, in most other situations, a democratic or participatory approach might be best. Transformational leadership, which is often seen in Magnet hospitals, has frequently been cited as the preferred style of leadership by many nurses.
Leadership support plays a significant role in turnover and is frequently cited as an antecedent of job satisfaction. Furthermore, value congruence on leadership support is positively related to job satisfaction among staff nurses. I measured the difference in scores of nurse managers and their staff nurses by using Kouzes and Posner’s Leadership Practices Inventory®, and the results were published in the Journal of Nursing Management. Notably, when value congruence increased, job satisfaction also increased. This is an important finding as it supports the influential role of the nurse manager and can be used to develop training programs for nurse managers so they can become expert leaders.
Nurse-patient ratios have recently been a major topic of debate among staff nurses, administration, professional organizations, and the collective bargaining units. There are compelling arguments for both sides of this issue, and the main goal is to enable nurses to provide safe and quality care. The American Nurses Association (ANA) recommends legislation that empowers nurses to collaborate on staffing plans and that is flexible to allow for changes in acuity and census. They also posit that establishing a minimal state staffing level could be beneficial. According to ANA, only 14 states currently have laws or regulations on staffing. Although there is a lack of consensus on whether or not to mandate nurse-patient ratios, nurses want to work in an environment that allows them to provide patient-centered care. Nurses also value recognition from patients and administration in the form of letters or just a simple “thank you.” Naturally, nurses expect to be paid at a level commensurate with their education and experience; however, these other factors are more important to many nurses. It is important to note that job satisfaction is different for each individual, so it is best to have each employee complete a questionnaire on job satisfaction and tailor retention programs accordingly based on the individual needs of the nurse, unit, and organization.
Improving Your Work Environment
There are many things you can do to improve your work environment and job satisfaction. Finding the right “fit” can take time, so it is very important to learn as much as you can about an organization when applying for a new position. It is helpful to visit your potential unit and meet the nurse manager and the staff during the interview process. Be sure to inquire about the orientation program, mentor/preceptor programs, and staff development. Communication and interpersonal relationships are key to a positive work environment. Completing a self-assessment of your skills and developing a self-improvement plan can be quite helpful. Being proactive will also serve you well.
If you are having difficulties, be sure to reach out to your manager for support. And if you are having difficulties with your nurse manager, follow your chain of command and seek assistance from his or her superiors. Cultural differences can often lead to miscommunication and misunderstanding; therefore, it is of the utmost importance to continue to learn as much as you can about the various cultural beliefs and values of your colleagues and patients.
Stress is another common issue that can lead to burnout and job dissatisfaction. Engaging in self-care is very important, especially when caring for others. There are many strategies for dealing with stress—yoga, meditation, aromatherapy, healthy eating, exercise, and deep breathing exercises, just to name a few. If your organization offers a program, be sure to take advantage. If not, perhaps you can make a suggestion that a program be created. Moreover, if you feel that your particular nursing unit is having any of the issues discussed in this article, you might want to explore the possibility of a task force comprised of various staff members to identify strategies for improving the work environment.
In summary, job satisfaction is related to turnover. While there are many factors at play, taking a proactive approach can make a major difference in lowering turnover rates. Create a positive work environment and it will benefit patients, employees, and the organization alike.
“The mediocre teacher tells. The good teacher explains. The superior teacher demonstrates. The great teacher inspires.”
—William Arthur Ward
The role of the academic nurse educator is both rewarding and challenging. Furthermore, the nurse educator plays a pivotal role in the nursing profession as well as in the development and preparation of future nurses and advanced degree nurses. The nursing profession is currently experiencing a faculty shortage. According to the American Association of Colleges of Nurses, the national vacancy rate for the 2014–2015 academic year is 6.9%, which limits our ability to adequately prepare our future workforce. Consequently, this is the perfect time to consider transitioning into an academic role.
Some of the factors related to the current faculty shortage include an aging workforce, lack of a diverse cadre of educators, educational requirements, the cost associated with advancing one’s education, and lack of competitive financial compensation. Although the financial compensation is not competitive with current nursing salaries, the educator role is extremely rewarding and offers a certain degree of flexibility and autonomy.
There are several paths you can choose on your journey into the world of academia. All nurses are teachers in their own right, and nurse educators build upon these foundational skills via education and experience. Seeking out opportunities, such as the role of preceptor, patient educator, or hospital-based educator, can help you prepare for a future role in academia. Academic teaching shares many of the basic tenets of all educators; however, academic faculty must meet the triad of excellence in teaching, service to the profession and the organization, and scholarship. Completing a graduate degree in nursing education will certainly help to prepare you for the rigors of academia. There are a myriad of faculty development and scholarship programs that are offered by organizations, such as the Jonas Center for Nursing and Veterans Healthcare, Johnson and Johnson, and the Robert Wood Johnson Foundation, which help address the faculty shortage, the lack of diversity, and the related shortage of nurses.
The Institute of Medicine’s report, The Future of Nursing, also identified the need for the advanced education of all nurses and increased diversity at all levels of nursing. Academic nurse educators must possess the required clinical and educational competencies; however, there is always a need for experienced clinical nurses to fulfill the role of clinical instructor, and this is a great place to begin one’s transition.
Types of Academic Educator Roles
The role of the academic nurse educator varies based on the specific type of educational setting and program. Basic nursing programs include diploma, associate degree, and baccalaureate degree. Graduate programs include master’s degrees and doctoral degrees in a variety of specialty areas. Many programs are offered in traditional brick-and-mortar colleges and universities, but online programs have become very popular.
Academic teaching roles include adjunct, clinical instructor, lecturer, assistant professor, associate professor, and full professor. There are also a host of administrative positions for experienced educators—dean, associate dean, and director. All of these roles require related clinical experience and education.
Educational Requirements and Experience
The educational and experiential requirements for nursing faculty members are somewhat different depending on the actual role. In regards to educational level, faculty members must have a graduate degree at the master’s level to teach in an associate degree program and a doctoral degree to teach at the baccalaureate or higher level. There are exceptions to this rule, however. For example, a clinical instructor does not have to have a doctoral degree but does need the related clinical experience that is relevant to the clinical teaching role (e.g., a pediatric clinical instructor must have at least two years of experience working in a pediatric setting). Diploma and associate degree programs most often require their faculty members to have a master’s degree and related experience. Baccalaureate and graduate programs require faculty to hold a doctoral degree and related experience. Some academic institutions will hire faculty who do not hold a doctoral degree but are currently enrolled in a program. It is important to note that most academic institutions require that at least one degree be in nursing—baccalaureate or master’s.
Although it is not mandatory to have a master’s degree in nursing education, it is certainly helpful for your future role in academia. Another option is to complete a post-master’s certificate program in nursing education. This is especially helpful for nurse practitioners and clinical nurse specialists who are highly experienced clinicians but require further development in the principles of teaching, teaching and learning theories, course development, test construction, and evaluation.
A doctoral degree is required for most tenure track positions and/or when teaching in a graduate program in addition to most baccalaureate programs. Doctoral degrees include Doctor of Philosophy (PhD), Doctor of Education (EdD), Doctor of Nursing Science (DNSc), and Doctor of Nursing Practice (DNP). There are numerous other doctoral programs, but these are the most common ones for nurse educators. Academic institutions may have different requirements regarding educational and clinical experience, so be sure to do some research before deciding on which degree program to attend.
Nurse educators tend to teach in the area of their specialty, such as medical-surgical, psychiatric nursing, or pediatric nursing, but one must be versatile because you may be asked to teach new or unfamiliar content. Because health care and technology are rapidly changing, it is vital to engage in lifelong learning and development and stay abreast of the current literature.
Major Responsibilities and Key Attributes
Nurse educators have numerous responsibilities and, as such, require certain attributes and qualifications that will guide them in their transition into the world of academia. In OJIN: The Online Journal of Issues in Nursing, Penn, Wilson, and Rosseter argued that nurse educators must have the following: teaching skills; knowledge, experience, and preparation for the faculty role; curriculum and course development skills; evaluation and testing skills; and personal attributes. Additionally, nurse educators are also expected to serve as advisors and mentor students, serve on committees, and make significant scholarly contributions.
Being passionate and caring about your profession and your students is very important. As a nurse educator, you will spend a good amount of time developing various course items in addition to reading and evaluating students’ work, so writing and communication skills are vital. You will also need to clearly articulate the information you share with your students and peers, in addition to being a good listener. Time management and organization are also essential because the role of the academic nurse educator is extremely demanding.
Teaching, Service, and Scholarship
The three requirements for tenured and many non-tenured faculty members are teaching, service, and scholarship. Depending on the type of faculty appointment, there will be an expected/required percentage of each one of these. For example, in many academic settings, teaching will be the most heavily valued. However, if you are teaching at the doctoral level at a research university, then scholarship in the form of research will be equally important.
Nevertheless, the most important goal for new faculty is to become an exemplary and expert teacher. This is accomplished with experience, education, reading current literature, mentorship, evaluation (self, student, and peer), and faculty development programs. Nurse educators will eventually develop their own unique style that is influenced by personal beliefs, pedagogies, and philosophy (including the influence of their academic institution’s philosophy). Faculty development is an ongoing process and requires self-direction and motivation. It is important to develop a specific plan for how you will continue to develop your teaching skills.
Scholarship relates to learning, research, and scholarly publications. The type of required scholarly works will be dictated by your academic organization and your specific faculty appointment. Scholarship includes conducting research, peer reviewing for publications, and presenting at conferences.
Service requires one to contribute to the organization and profession without financial compensation. Typically, this includes serving on committees, serving on an editorial board, or serving as a peer reviewer. There are certainly many other ways to meet this requirement, which may also involve serving one’s community.
Rank, Tenure, and Academic Freedom
Many full-time faculty positions are tenured. Ranks include instructor, assistant professor, associate professor, and full professor. When faculty members receive an academic appointment, they are given a contract that states their rank and the number of years they have to demonstrate that they have met the required expectations of teaching, service, and scholarship to earn tenure. Tenure is one of the ways academic freedom is protected. Academic freedom pertains to a faculty member’s right to teach content, conduct research, and write or speak without censure, with the caveat that he or she demonstrates sound judgment when teaching content, especially if it is controversial. Faculty must be careful not to influence their students’ beliefs or abuse their power as educators. All faculty members should be well versed in the rights and legal, ethical, and moral responsibilities that are inherent in this role.
Ways to Transition to a Nurse Educator Role
In addition to experience and education, transitioning to the role of nurse educator requires the development of realistic goals and objectives. If you truly have the desire to teach, you should develop a specific plan with all the steps you will need to complete to meet your goal. Utilizing the nursing process will help you to develop a realistic plan. The first step is to assess your current level of knowledge, skills, education, and attributes. From there, you can begin to develop a specific individualized plan for how to accomplish each objective. Note that, if you do not have an advanced degree, you will need to enroll in a graduate program, so be sure to carefully consider which program will be best for you.
As a graduate student, you may have an opportunity to work as a teacher’s assistant, which will provide you with invaluable experience. You should seek out as many teaching experiences as you can. Consider becoming a mentor or preceptor, join the patient education committee, or develop a continuing education article. You should also consider becoming an adjunct clinical instructor in your specialty area, which is a great way to “test the waters” and eventually transition to a full-time faculty role.
Reading the current literature and attending conferences are also very helpful. You will need to network and consult with your mentor. Furthermore, developing a professional portfolio with a well-developed resume—or curriculum vitae—is crucial when applying for a faculty position.
It is also advisable to participate in mock interviews so that you will be prepared for an actual interview. It’s worth noting that the interview process at an academic setting is unique; you will most likely be interviewed by a search committee. Don’t be surprised if you are asked to demonstrate your teaching skills and share your philosophy of teaching.
Develop a Five-Year Plan
Developing a five-year plan with goals, objectives, and actions with specific dates can be very helpful when planning your transition. The goals should be realistic and achievable, and the objectives should be measurable. The actions are the steps needed to meet your objectives and accomplish your goals. Goals may be related to earning an advanced degree, obtaining a position as an adjunct, or applying for a full-time faculty role.
The plan should be evaluated on an ongoing basis and revised in accordance with your current needs. It is important to remember that plans are not set in stone and can always be revised. When you complete your first five-year plan, you will want to begin another one as you continue on your journey as a nurse educator.
Although the transition may be challenging, there are many strategies you can employ to guide you through this process. The journey from clinician to educator is filled with tremendous growth and learning.
Deborah Dolan Hunt, PhD, RN, is an associate professor of nursing at The College of New Rochelle. She is the author of The New Nurse Educator: Mastering Academe and The Nurse Professional: Leveraging Your Education for Transition into Practice.
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