Journal of Nursing Education

EDITORIAL 

Curriculum Issues Related to Nurse Turnover

Betty J Gorrell, BS, MS, EdD; Michael Langenbach, BE, MS, PhD

Abstract

ABSTRACT

The problem of turnover rates among registered nurses has implications for nursing curriculum and for continuing education programs. After a brief presentation of turnover issues, curriculum implications will be discussed under three broad areas: (a) content about turnover included in nursing management textbooks; (b) nursing curriculum issues that influence the survivability of graduates of schools of nursing and thereby affect turnover rates; and (c) continuing education needs of registered nurses. This paper is not a summary of solutions for turnover. The problem of turnover is complex and poorly understood. The curricular issues provide challenges to traditional nursing education that would increase the likelihood of the development of "hardy" nurse graduates who have survival skills for the practice environment.

Abstract

ABSTRACT

The problem of turnover rates among registered nurses has implications for nursing curriculum and for continuing education programs. After a brief presentation of turnover issues, curriculum implications will be discussed under three broad areas: (a) content about turnover included in nursing management textbooks; (b) nursing curriculum issues that influence the survivability of graduates of schools of nursing and thereby affect turnover rates; and (c) continuing education needs of registered nurses. This paper is not a summary of solutions for turnover. The problem of turnover is complex and poorly understood. The curricular issues provide challenges to traditional nursing education that would increase the likelihood of the development of "hardy" nurse graduates who have survival skills for the practice environment.

Turnover

The employee turnover rate among registered nurses is high. Estimates of turnover by nurses vary from 15% to 70% (Benedict, Glasser, & Lee, 1989; Curran & Minnick, 1989; Jones, 1990; Pooyan, Everhardt, & Szigeti, 1990; Prestholdt, Land, & Mathews, 1988; Prior, Cottington, Kolski, & Shogan, 1990; Swansburg, 1990; Taunton, Krampitz, & Woods, 1989; Weisman, Alexander, & Chase, 1981; Wise, 1990). This rate is the highest of any professional or technical group (Harris, 1989; Price & Mueller, 1981).

Costs to replace a registered nurse who has resigned a position are estimated to range from $1,280 to $50,000 (Prestholdt et al., 1988; Seybolt, 1986; Wise, 1990). In addition to these negative financial consequences, turnover destabilizes work groups and has serious implications for patient care. The efficiency and effectiveness of nursing services are disrupted by nurses leaving an organization (Cavanagh, 1989; Price & Mueller, 1982).

Nursing literature is replete with Divariate and multivariate studies that have attempted to describe the relationship between turnover and a variety of variables such as intent to stay, organizational qualities, individual or demographic characteristics, family responsibilities, job satisfaction, and job factors (Alexander, 1988; Cavanagh, 1990; Curry, Wakefield, Price, Mueller, & McCloskey, 1985; Parasuraman, 1989; Prescott, 1986; Prestholdt et al., 1988; Price, 1977; Price & Mueller, 1981; Taylor & Covaleski, 1985; Weisman et al., 1981). Additional studies have considered the relationship of intention to leave with similar variables (Choi, Jameson, Brekke, Anderson, & Podratz, 1989; Fimian, Fastenau, & Thomas, 1988; Pooyan et al., 1990; Seybolt, 1986; Steel & Ovale, 1984). Only limited success in prediction has occurred: 17% of the variance in turnover was accounted for in the 1981 Price and Mueller study; 13% of turnover variance by Curry et al. in 1985; 8% of variance in one hospital and 10% in a second hospital in Weisman et al. (1981); and 6% by Parasuraman in 1989.

In addition to limited ability to explain turnover, contradictory findings have been reported concerning the predictive power of the diverse factors listed above. The contradictory nature of these findings is influenced by conflicting definitions of turnover in the studies, reliance on models developed from business versus clinical settings, inclusion of different categories of nurses (registered nurses, licensed practical nurses, and "others"), analysis of statistics at both the unit and hospital levels, variation in the definitions of the selected predictors, differences in how predictors were measured, analysis at both the individual and organizational levels, and lack of consideration of time lag between intent to leave and actual turnover.

Curriculum Content About Turnover

In an attempt to analyze "typical content" in nursing curricula, six nursing management textbooks were reviewed. These were Gillies (1989), Kron and Gray (1987), Marriner (1984, 1988), Sullivan and Decker (1992), Swansburg (1990), and Vestal (1987).

No discussion of turnover occurred in Kron and Gray (1987) or in the second edition of Marriner (1984). In Marriner's third edition (1988), turnover was briefly presented under retention of personnel and job satisfaction. Turnover is mentioned in Vestal (1987), but only as one cause of hidden human resource cost. Three texts (Gillies, 1989; Swansburg, 1990; Sullivan & Decker, 1992) presented a more complete discussion of turnover.

Gillies (1989) used an entire chapter to discuss turnover, Sullivan and Decker (1992) combined absenteeism and turnover in one chapter, and Swansburg (1990) presented a brief discussion under the subject "retention" within a personnel management chapter. Gillies and Sullivan and Decker discussed the cost of turnover, its value to an organization, causes of turnover, strategies to control turnover, and measurement means and issues. Much of the content in Swansburg was devoted to formulas that can be used to calculate turnover rates and a guide to conducting an exit interview.

The framework for the discussion of turnover in Sullivan and Decker (1992) was a nonnursing organization model of voluntary employee turnover. Although the seminal work and model development of Price and Mueller (1981) and the recent nursing turnover model developed by Parasuraman (1989) were mentioned by Sullivan and Decker, neither was chosen as the framework for the text. While Sullivan and Decker's plea for the simplicity of their selected model was important, use of the model does not seem appropriate when its ability to predict turnover among nurses has not been established.

A second issue concerning the selection of a nonnursing model is that the selection represented a subtle lack of support of research by nurses. (This need to support nursing and feminist research is discussed below.) A final criticism of Sullivan and Decker's (1992) text is the lack of discussion of the limited success that has been achieved in prediction of which nurses will leave an organization.

Emphasis in the textbook by Swansburg (1990) was job dissatisfaction rather than actual turnover. Although job satisfaction has been found to be a factor in turnover decisions, it has had limited ability to predict actual turnover. Additional problems in Swansburg's text were inadequate references and the use of references that focus on retention rather than turnover. The only seminal work from the turnover and retention literature included as references were McClure, Poulin, Sovie, and Wandelt's study on magnet hospitals (1983) and Wandelt, Pierce, and Widowson's study of why nurses leave nursing (1981).

The textbook of Gillies (1989) provided the most comprehensive account of turnover. The weakness of this text was the section on methods for reducing turnover. Suggested solutions were oversimplified and did not provide adequate references to turnover literature. The complexity of the issue of resolving turnover was not considered.

This brief review of content about turnover in nursing textbooks can only provide hints of an answer to the question concerning the adequacy of nursing curricula in providing anticipatory socialization about turnover. Of even greater significance is the overall approach to professional socialization within the total nursing curriculum. The next section of this paper addresses these broader concerns.

Curriculum Issues in Nursing

The primary purpose of curriculum is creating access to knowledge. Decisions concerning goals, content, and methods are driven predominantly by the purpose in curriculum projects (Langenbach, 1988).

Nursing curricula in the past were primarily organizational effectiveness models. Ultimately, in this model, the needs of the organization determined the final outcomes of the curriculum (Langenbach, 1988). According to Watson (1988), nursing curricula had "failed to address the issue of how to prepare nurses as full health care giving professionals and had focused instead on how to prepare students to be institutional employees" (p. 1). The results of this curricular approach were domestication and commercial abuse of nurses. Nurses were educated to be loyal to the hospital institution and not to question the moral implications of a system that impeded professional development (Ashley, 1976).

Nursing's history of being committed to the well-being of patients was used to persuade nurses that they should not be autonomous and should not be concerned with working conditions and salaries.

Nursing was perceived by many, including nurses, as a selfless, all-serving, altruistic calling. The act of caring for others, even if that meant subordination of the individual to the goals ofthat care, was to be compensation enough for the services rendered. . . . Early social beliefs that woman's role should be submissive, supportive, and obethent were extremely compatible with pervading concepts of the expectations that our society placed on nurses. The paternalism that has existed in the health care delivery system has also made the process of collective bargaining for nurses a slow one. (Ellis & Hartley, 1988, p. 295)

Rejection of a philosophy that bars autonomous demands for justice in compensation is not incompatible with a philosophy of commitment to patient care. Today, nursing curricula have begun to emphasize a metaphor of advocacy where loyalty is to the patient rather than to authority (Munhall, 1988). Munhall indicated that curricular implications of this shifting metaphor included infusing curriculum with professionalism, protesting whatever demeans the status of nurses, developing nursingperson identity, and emphasizing the ethic of care.

The term "nursing care" has been used throughout nursing's history. Caring "characterizes nurses' work and is seen by nurses as inappropriately undervalued in the larger society" (Macpherson, 1991, p. 29). Leininger ( 1984) stated that care is the essence, the dominant domain of nursing. Green-Hernandez (1991) added that the nurse's ability to practice caring derives from a feminineconnectedness with clients and colleagues. According to Leddy and Pepper (1989), "nursing's central concern is humans interacting with their environment, holistically striving for diversity, complexity, and a sense of well-being through the actualization of their personal potential" (p. 60).

Watson (1988) argued that nursing has developed a rationalist-objectivist model of education, which neglects its philosophical context of human caring. Bevis (1988) indicated that nursing curricula are behaviorist and, being training oriented and technical, cannot support professionalism. Traditional curricula had tolerated dependent roles for learners, separated doing from knowing and being, restricted teaching-learning to behavioral objectives, and focused on cognitive-technical outcomes thereby creating competency without caring (Watson, 1988). Watson advocated acknowledging and acting on caring as a moral ideal that guides the nurse through the caregiving process.

Bevis (1988) identified a hidden curriculum within schools of nursing, which was the curriculum of "subtle socialization" into how to think and feel like a nurse. The process of socialization attempted to delineate the expected outcomes that were to be learned and the how and why of that learning (Hardy & Conway, 1988). Professional socialization into nursing involved an initial socialization through an educational curriculum followed by resocialization into the work environment. The end product of professional socialization was a nurse with both technical competencies and internalized values and attitudes required by the profession (Cohen, 1981).

Cohen (1981) found that nursing students with a core personality pattern of dependency, obethence, and low self-esteem were more likely to persist in nursing school and students who were aware of and comfortable with their aggression were more likely to leave. She further indicated that barriers to development of autonomy and initiative by nursing students included (a) the societal view of nursing as requiring practitioners to have only limited ability and knowledge, (b) authoritarian atmospheres within schools of nursing, (c) tacit assumptions in nursing curricula that there is only one right way of doing nursing (any other is a mistake that might kill a patient), and (d) limited student anticipatory socialization for work roles. Diekelmann (1988) stated that the power and control teachers wield in nursing schools continues to be problematic and that one means of creating new relationships was dialogue with students about their lived experience and reactions to curriculum.

Cohen (1981) proposed solutions for curriculum inhibitions on development of autonomy. Her suggestions were inclusion of the concept of medical uncertainty into the curriculum and education of the socializers (nursing educators acknowledging their authoritarianism and lack of trust in other nurses). The lack of trust in other nurses by nursing faculty was evidenced, according to Cohen, by negative messages to students concerning nurse colleagues in practice fields. Macpherson (1991) suggested an alternative to this problem of lack of trust and horizontal violence. Her alternative was exploration of support, caring, and friendships among nurses and identification of obstructions to the development of nurse friendships. Berrey (1991) supported this notion in her analysis of the life history of nursing leader Rozella Schlotfeldt. Berrey identified the "networks of love and support from other women" (p. 64) as a significant element in Schlotfeldt's success.

The indictment of nursing education presented by Cohen (1981) can find a parallel in Freire's (1968) statement that conventional education domesticates rather than liberates. Langenbach (1988) stated that the model of curriculum promulgated by Freire and his followers involved a "criticism of conventional teaching and advocacy of educational ideas and methods that promote liberation" (p. 97). Freire emphasized that the purpose of knowledge is to release the individual from domination and that education is a dialogic process between learners, aimed at mutual enlightenment.

An instructional alternative for nursing education is a pedagogy that is empowering. The major concern of such an approach is developing students' powers of inquiry, self-knowledge, and ability to remake knowledge and nursing culture (Diekelmann, 1988).

The term power creates discomfort in nurses, but power is inherent in their abiliiy to control their own practice and to serve as effective patient advocates. If power is viewed as a capacity to produce change, then power-sharing and empowering of others may be unique ways that women approach the concept. Nursing's emphasis on patient teaching throughout its history indicated a desire to empower their clients. Kozier and Erb (1988) suggested that as nurses gain and use power, the result is a reconceptualization of the client as a partner in power relationships in health care. They further suggested that the following strategies could be used by nursing to develop power: (a) appraise actual and potential sources of power, (b) identify ways to enhance positional power, (c) recognize and develop nurses' expert power, (d) recognize and expand connection power, and (e) communicate vision.

An unfortunate defense against the patriarchal pattern of dominance and subordination in which nursing has functioned was internalized oppression.

Internalized oppression is a mechanism by which one takes the values of and from the dominant culture, thereby ensuring the continuance of that culture or system. . . . Through this intimate enforcement system, the target or victim of oppression incorporates and introjects the dominant values, such as inferiority of women to men, blacks to whites, or nurses to physicians. In our case, the nurse accepts her oppression as inevitable and constantly references the oppressor's needs before her own in order to survive and protect the client. (Klebanoff, 1991, p. 153)

Berrey extends the insidious effects:

Thus, in this man's world, woman has her place. Because the myth is so powerful, women and men can live their lives, taking as true the social mythology given them. . . . The consequences of this misperception are ravaging, particularly for women. For when all one's best efforts do not suffice, the woman is subject to profound feelings of emptiness, which are filled up with harder work; with renewed efforts to identify with the male power structure, attempting to see with his eye, speak with his voice; with attempts to hide in shame one's identification with other women (if one even allows herself that any longer); or with attacks on other women so as to publicly disavow herself from her own kind and declare allegiance to men. (Berrey, 1991, p. 60)

Freire (1968) indicated that it is necessary to unveil the world of oppression in order to transform it. Solutions proposed by Klebanoff (1991) included changing nurses' internal voices; denning and claiming nursing as an autonomous, healing profession; engaging in rigorous efforts to appreciate one's self and other nurses and nursing's accomplishments; paying attention; expecting the men in nurses' lives to be informed and active allies; and learning how others are different from nurses and how they have been oppressed so as to become dependable allies.

One consequence of living in an androcentric or patriarchal society is that women's lives are obscured and trivialized (Berrey, 1991) and invisible in history (Cott & Degler, 1987). Inclusion within nursing curricula of historical descriptions of the lives of eminent female nurses who were instrumental in nursing's development would provide perspective and identity for students.

While considering alternative ideologies as a base for curriculum content, Greenleaf (1988) asserted that Adam Smith (18th century philosopher) broke important ground with his statement that the common good was best served by everyone acting in their own self-interest. Prior to this viewpoint, self-interest was considered antithetical to attending to the interests of others. If individuals pursued their own interests without constraints, then the free market would assure the best outcome for all. Curri cular emphasis on this "freeing" idea could liberate nurses to challenge economic submissiveness.

Concerns about nursing curricula were presented in the above discussion. These concerns included (a) past emphasis upon organizational effectiveness and rationalistobjectivist curriculum models, (b) domestication of learners, and (c) socialization of nursing students into dependent and subordinate practitioners. Suggested alternatives include curricular emphasis on professionalism, caring as a moral ideal, power sharing, the value of self-interest, loyalty to clients versus institutions, development of nurse friendships, and identification with eminent nurses of the past. Teaching ideas and strategies were advocated to include a deemphasis on behaviorism and inclusion of a pedagogy that is liberating and empowering.

Continuing Education

The above section concerning undergraduate nurse education focused on philosophical issues rather than means of "fixing" turnover. This section on continuing education has similar goals. Forces influencing continuing education in the future, ways of knowing by practicing professionals, and means of acquisition of knowledge by practitioners are discussed.

Lambert and Lambert (1989) identified forces for the future in nursing continuing education. Forces included (a) economics or who will pay the bill for nurses' continuing education, (b) increased legislation monitoring continuing education, and (c) social forces requiring evidence of currency and competency of professionals.

Nursing will be part of the "learning society." Nurses will become more adept in assessing their own learning needs and will be more selective in their learning opportunities. More continuing education will be available to larger numbers of nurses and it will be offered by a wide range of providers. Innovative teaching strategies will be used by providers; the traditional conference-workshop format will be only one of many educational approaches available. Self-directed learning will become more generally accepted by individuals. (Lambert & Lambert, 1989, p. 213) Tanner (1988) stated that commonly held views of the knowledge required for nursing practice were (a) that practice knowledge was applied research-based knowledge, (b) that knowledge flowed from theory to practice, and (c) that practice was rigorous problem solving using "true," scientific knowledge. In opposition to these views, Tanner argued that there were multiple ways of knowing and that knowing in practice occurred in the spontaneous, intuitive performance of nurses. Knowledge was tacit, implicit, and embedded in practice ("our feel for the stuff with which we are dealing" (p. 205).

Tanner (1988), in contrasting the rational model of the nursing process, described intuitive inquiry by the practicing nurse:

Action precedes analytic thought rather than occurring as a result of it. The knowing is in the doing, and we may theorize about it later. There are no formal strategies of clinical judgment that can be described free of the context in which the action occurs. Rather, an understanding of any human activity must be historically and contextually situated. The knowledge used as the basis for clinical judgment is practical, derived from experience with similar and dissimilar situations. The knowledge is embedded in the practice and may or may not be rendered explicit or formal. Rational, analytic approaches to clinical judgment are characteristic of beginner rather than expert performance, (p. 213)

Schon (1987) stated that professional practice involves determinate zones of practice that are transformed by the professional to determinate ones (ones the professional knows how to solve). Professional practice is characterized by uniqueness, uncertainty, instability, and value conflicts. Observation of working practitioners reveals two forms of knowing, knowing-in-action and reflection-inaction. Knowing-in-action is acquired from research and from reflection-in-action undertaken to solve problems in the indeterminate zones of practice. In reflection-in-action (the core of professional artistry), the practitioner rethinks his knowing-in-action, reshaping what he is doing while he is doing it.

Implicit in Tanner's (1988) concerns and Schon's (1987) model is the responsibility of continuing education to cultivate professional artistry by improving practitioners' ability to reflect-in-action. Continuing education assists practicing professionals in reflecting on their own tacit theories of practice. As a practitioner consciously describes "how they reflect and what teaches them" (Cervero, 1988, p. 45), the practitioner is more effective at employing reflection-in-action. "Instructors would teach like coaches, explaining how they would perform under these conditions, demonstrating their own approaches to skillful performance, and reflecting with students on the frameworks that underlie their work" (Cervero, 1988, p. 46).

The American Nurses Association (ANA) is a major provider and accrediting agent of continuing education offerings in nursing. Because of these two factors, the ANA has a strong influence on standards and on types of nursing continuing education programs that are available for nurses. In a critique of ANA's continuing education model, Langenbach (1988) indicated two major impediments. These were emphasis on continuing education units (contact hours) and on the use of predetermined, measurable objectives. According to Langenbach, these two emphases limit the range of expectations for learning, encourage the production of dependent versus selfdirected learners, and emphasize instruction versus inquiry modes of learning. Such an approach would not promote "professional artistry" and betrays the coaching role of continuing education instructors (as suggested by Cervero, 1988). Finally, the emphasis on preset objectives by ANA obviates Langenbach's conclusion that "some of the most significant human learning cannot be predetermined or meet a criterion of measurement (p. 132).

Fox, Mazmanian, and Putnam (1989) studied learning in the lives of practicing physicians. While their focus was on implications for basic medical education, they presented conclusions that are valuable considerations for continuing education for nurses. These were among thenconclusions:

* Techniques to promote personal well-being are needed and have frequently been crowded out of basic curricula.

* Stages of career development (breaking in, fitting in, and getting out) influence education needs.

* A desire for competence was the greatest incentive for practitioners to engage in continuing learning.

* Practitioners need assistance in clarifying forces for and requirements of change.

Based on these conclusions, continuing education instructors can assist learners by helping practitioners perceive clearly what forces are prompting change and what change is needed. Finally, learning strategies and methodology should be related to learning purpose.

Conclusion

The nursing curriculum has deified the rational, the scientific. Truth was "out there" and waiting to be discovered through rationalistic research. Application of the problem-solving nursing process was the essence of nursing. Information-giving has been the solution to the critical task of transferring massive amounts of nursing knowledge to students (thereby also meeting the demands of our rational-objectiviet curriculum and accreditation process). Although never denying the humanistic base of nursing, most nurse educators focus on the scientific and technical aspects of nursing.

We believe the time has come to place value on individual perspectives and acknowledge the multiple realities of what nursing is and who nurses are. While continuing to teach the nursing process to novice learners, we should also acknowledge the role of holistic judgment, of pattern recognition, of emotion, and of a sense of salience in patient care. We should increase the involvement of practitioners in students' education to provide access to multiple, divergent perspectives of nursing practice and to observe the process of "reflection-inaction." Our teaching should increasingly aim not to control or domesticate students, but to affirm and even liberate. Such affirmation and liberation bode well for creating "hardy" nurse graduates who have the necessary survival skills for the practice environment.

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