FACTORS AFFECTING THE TURNOVER OF NURSES IN THE TERTIARY

HOSPITALS IN DAVAO CITY

____________________

A Thesis Presented to

the Graduate School Faculty

of Nursing, San Pedro College, Davao City

_____________________

In Partial Fulfillment

of the Requirements for the Degree

of Master of Arts in Nursing

By:
Princes Ishreen Dilangalen Sinsuat, RN
 Davao Doctors College
General Malvar St., Davao City
Master of Arts in Nursing

BACKGROUND OF THE STUDY

INTRODUCTION

Nursing is one of the most challenging but satisfying and worth it course. It is because

even there are lot of challenges to be experience from this, as you decided to continue your

journey as a student nurse the sorrowful will be ignore and it will be change into precious gem of

your life.

Nurses is essential. It plays a vital role to promote health and saves life. In health care

system, nurses issues confused everyone. It raises some questions either globally or nationally.

According to Shields and Ward in a year 2017, high nurses turns to have a negative

impact in capacity of organization fails to meet the clients needs and wants. It increases in cost of

labor such as direct and indirect. In direct cost, recruiting, selection and training of personnel is

included. The more it is exposed to negativity, the more it address the cohesiveness and

decreased quality work and work satisfaction ( Chui et.al, 2018). Based on what Yin and Yang’s

(2018) analysis, internal environment factors like stress that cause staff shortages, leadership

style, supervisory relations, advancement opportunities and inflexible administrative policies can

be correlate to fast turnover of nurses.

According to Krsek et.al, 2019), globally, the reasons for leaving of common nurses in

USA, Canada, England, Scotland and Germany is emotional exhaustion and problems in work

desigs. The average cost of nurses is estimated to $88, 000. Health care organizations can have

an estimated $300,000 in nurse which is every 1% increase in turnover.

 Davao Doctors College
General Malvar St., Davao City
Master of Arts in Nursing

In the Philippines, statistics show that 1,000,000 nurses since 2001 up to present are

unemployed, underemployed, or chose another career (Sunstar, 2018). But then even some of the

nurses experience these, the turnover rate of nurses is still increasing. The salary becomes high in

novice nurses. The depletion of skilled medical workers, hundreds of hospitals in the Philippines

have fully or partially closed (Lorenzo et al, 2019). Lorenzo added that there is 10% high rate of

salary in Philippine Heart Center in 2006. In a study conducted in Benguet General Hospital,

among 86 regular nursing staff, are newly hired (Saguidec, 2018). Moreover, findings shows that

there is an increase of salary rate in private hospitals than in government hospitals.

To promote or address the concern, this study will find out the factors affecting the

turnover of nurses in the tertiary hospitals in Davao City. This study will contribute to the

reduction of health care costs, improve quality care and foster greater well – being of nurses.

REVIEW OF RELATED LITERATURE

Nursing rotation is defined as the process by which nurses leave or are transferred in a

hospital setting. It includes voluntary, involuntary, external and internal rotation. Voluntary

(avoidable) and involuntary (unavoidable) rotations do not always distinguish because costs are

incurred whether the employee resigns or requests to leave. Voluntary (resignation) turnover is

defined as employee-initiated revenue (thus excluding layoffs, layoffs, promotions within the

agency, or death) (Razza, 2017). In addition, turnover reflects the effect of the balance between

organizational advantage (pull factor) and prudence at work (motivator) (Mano - Negrin and

Kirschenbaum, 2019).
 Davao Doctors College
General Malvar St., Davao City
Master of Arts in Nursing

From the definition of volatility, some renewal of nursing staff can also be seen as

beneficial to the organization. Nursing staff mobility provides an opportunity to reduce costs by

reducing new employee salaries, welfare costs, and holiday pay (Jones, 2018). When workers

move to their best-performing jobs, productivity can be improved by providing better

adjustments, which contributes to an effective labor market (Gray et al., 2017). However, when

revenue reaches 50%, its net impact on productivity may be negative (Price and Mueller, 2017),

because the employees that the organization would rather retain are lost.

Work schedule and Workload

The division of labor among nursing staff is a pressure issue of the satisfaction of all

nurses, managers and individual employees with their working hours. Long shifts, overtime,

weekends, nights, holidays, and weekend overtime were found to be predictors of expected

fluctuations (Strachota et al., 2017). In a study conducted by Kalisch et al. in 2018, nurses agreed

that an 8-hour, 5-day plan is the first choice. Some studies have shown that people who work in a

12-hour shift are much more stressed than those who work in an 8-hour shift.

This has a negative impact on patient safety and the cognitive function of caregivers. On

the other hand, Stone et al. (2019) found that there was no difference in patient results when

comparing 8-hour and 12-hour shifts. Researchers found that nurses who worked 12 hours were

less emotionally exhausted, more satisfied with their work, and 10 times more likely to be

satisfied with their schedule. The Institute of Medicine recommends that nurses should not work

more than 12 hours in shifts to reduce errors caused by fatigue.

 Davao Doctors College
General Malvar St., Davao City
Master of Arts in Nursing

Studies have shown that when staff are stable, it is more likely to achieve continuity and

quality of care, and direct shifts are a form of stability. Adams and Bond (2018) believe that the

stability of the team will generate cohesion between caregivers, thereby achieving more effective

working relationships and achieving higher quality of care at a lower cost.

Similarly, continuous high workload will increase work pressure and reduce job

satisfaction, thereby increasing the possibility of fluctuations (Strachota et al., 2018). Nursing

workload will definitely affect the amount of time nurses can spend on various tasks. When the

workload is heavy, nursing staff may not have enough time to complete tasks that directly affect

patient safety, which may affect the nursing staff’s decision to perform various procedures,

reduce the time for nurses and doctors to cooperate and communicate, thereby affecting the

quality of collaboration among caregivers. Relationship and can lead to stress (such as cynicism,

anger, and emotional exhaustion) and burnout (Carayon and Gurses, 2020). In a study conducted

by Barrett and Yates (2018) on nurses in the oncology department, 40% were overworked, 48%

were dissatisfied with the salary, 70% were emotionally exhausted, and 48% of the samples were

overworked for a period of time. I cannot promise to work for another 12 months.

Similarly, Lee et al. (2019) A study of 181 nurses showed that the most frequently

mentioned reasons for nurses leaving their jobs were work overload, shift changes (personnel

organization) and interpersonal conflict. Workload management also includes minimizing or

eliminating the time required for management activities. This allows caregivers to focus on the
 Davao Doctors College
General Malvar St., Davao City
Master of Arts in Nursing

aspects of their work that give them the greatest sense of accomplishment and accomplishment in

caring for patients (Hunt et al., 2019).

Stress and Burnout

Work stress and burnout are still a major problem in the nursing field, affecting both

workers and organizations. Stress is a global phenomenon. Everyone lives under pressure,

regardless of nationality, race, economic status, spirit, work, lifestyle, age or gender. In its pure

definition, pressure is any pressure exerted on a person who needs to respond.

It affects cellular aging, immune function, well-being, job satisfaction, communication,

company performance, and retention of valuable employees (Pipe et al., 2019). The source can

be work, family, finances, time, colleagues, or anything else that drives people to deal with

unexpected or uncertain things (Johnson, 2018). On the contrary, Lazarus (2019) advocated a

psychological view in which stress "is a special relationship between a person and the

environment, which is assessed by a person to be stressful or excessive to his or her resources

and endanger his or her well-being".

Nurses are susceptible to occupational stress because nursing practice involves many

clients and working environment stressors (Kozier et al., 2019). For personal caregivers, work

pressure will eventually lead to illness. In the healthcare sector, work stress can lead to

absenteeism and turnover, both of which affect the quality of healthcare (Jennings et al., 2018).

also showed that high stress is a risk factor for patient safety and practice errors, and leads to

high turnover of
 Davao Doctors College
General Malvar St., Davao City
Master of Arts in Nursing

caregivers (Krsek et al., 2019). Therefore, Cartledge (2018) found that work-related stress is the

main factor leading to the loss of intensive care personnel.

Freudenberger (2017) coined the term "burnout" to describe an employee's response to

long-term stress, which often occurs in jobs that have many direct interactions with people.

Burnout is conceptualized as a syndrome characterized by emotional exhaustion,

depersonalization, and decline in personal performance. The possible consequences of burnout

are emotional stress, physical illness, and interpersonal conflict in nursing. In the workplace, job

burnout can lead to low professional ethics, high absenteeism, high turnover and work accidents

(Wisniewski, 2017). There is evidence that for every additional patient per nurse, burnout

increases by 23% and dissatisfaction increases by 15% (Aiken et al., 2019). In addition, Cameron

et al. (2019) conducted a comparative analysis by department type and concluded that nurses in

mental health institutions were the most dissatisfied with their jobs, were more likely to quit their

jobs, and were more likely to report burnout than nurses in other institutions.

Promotional Opportunities and Career Development

Promotion is defined as gaining a higher status in the workplace through effective work,

which usually improves the status, position, and salary of employees in the organization (Heery

and Noon 2017). According to Shields and Ward (2017), in companies with no promotion

opportunities, employee turnover is high. Compared with workload or salary, dissatisfaction with

promotion and training opportunities has a greater impact on nursing staff mobility (Shields and
 Davao Doctors College
General Malvar St., Davao City
Master of Arts in Nursing

Ward, 2018). Multivariate analysis of the method used by Davidson et al. (2019) In a

longitudinal

survey of hospital nurses, it is shown that the predictors of willingness to discharge are

perceptions of limited promotion opportunities, high routines, limited decision-making scope,

and poor communication.

Therefore, WHO should provide professional development opportunities for its nurses to

achieve higher job satisfaction and higher retention rates. Accordingly, once promoted,

employees will become more loyal to their organization (De Souza, 2020).

In addition, professional development is also important for nursing staff. Career

development and lifelong learning in nursing can increase job satisfaction, increase the retention

rate of nursing staff, and continue to provide quality care (Collins et al., 2020). In addition, the

perceived interest in personal professional development and the feeling of being valued can

affect the caregiver's intention to stay (Yoder, 2017). Development opportunities include career

ladders, continuing education, certification, participation in professional nursing organizations,

and obtaining degrees.

Recognition and Reward

Acknowledging the value and significance of individual contributions to organizational

work is a basic human need and a necessary prerequisite for personal and professional

development. Lack of recognition can lead to dissatisfaction, low morale, reduced productivity

and undesirable results. Lack of recognition is considered to be the main cause of employee
 Davao Doctors College
General Malvar St., Davao City
Master of Arts in Nursing

turnover and is related to the decline in nursing satisfaction. In addition, recognition is an

important factor in caregiver retention and satisfaction (Hunt, 2019). A study by Tourangeau and

Cranley

(2017) found that praise and recognition are important predictors of caregivers' intention to

continue working in the organization. Researchers have proposed some strategies for gaining

recognition within the organization, including recognizing outstanding employees and providing

positive feedback. These promote a positive practice environment, make employees feel valued

and valued, reduce volatility and increase organizational commitment (Gess et al., 2018). In a

study conducted by a large tertiary emergency hospital in Philadelphia, the "BRAVO"

recognition program was implemented to recognize the outstanding behavior and contributions

of its employees. As a result of increased employee loyalty, 242 submissions were submitted in

2008 and 674 submissions in 2019 (Hinson and Spatz, 2017). Some strategies for providing

positive feedback include creating a vacation team and notifying employees via email or

handwritten notes when management sees that they have done something positive (Gess et al.,

2018).

Part of organizational rewards is to have correct and fair compensation and benefits.

Heery and Noon (2015) define wages as the payment of many components including basic

wages, benefits, bonuses, extra work compensation and rewards. Therefore, salary is the work

remuneration that employees receive after completing their work, including various financial and

non-financial rewards (Erasmus et al., 2017). Martocchio (2019) describes rewards including

internal and external rewards. Extrinsic rewards include monetary rewards and non-monetary
 Davao Doctors College
General Malvar St., Davao City
Master of Arts in Nursing

rewards. Non-monetary rewards include not only basic salary, but also other benefits such as

welfare. When employees get high salaries, their performance will improve. Money is

considered to be a reward for the work done by the worker to support the family and the

remuneration for the work done (Yaseen, 2015).

Remuneration has been studied as a factor that affects the caregiver's decision to work

and continue to work (Swarwout, 2018). In addition, Cowin (2016) pointed out that salary is an

important part of nanny retention, because when there is an inequality between their work and

the work of others, they will feel dissatisfied and disappointed with their work. Low wages will

lead to low job loyalty. Men are twice as likely to leave foster homes as women (Twibell et al.,

2015). In addition, Stolte and Myers (2015) reported that salary and benefits, working hours, and

personal performance are the most frequently cited reasons for dismissal of obstetric nurses.

Management Style

Management refers to the process by which people do things. It uses authorization within

the formal organization to organize, direct, and control subordinates to coordinate care services

(Tan et al., 2018). From a theoretical and business perspective, leadership style is a key issue.

However, the success of nursing management lies in the flexibility and adaptability to different

situations that improve the quality of care, for example by recruiting and retaining enough

nursing staff (Nassar et al., 2015).

Research shows the importance of nursing management to job satisfaction. Chapter

(2017) studied the effects of nursing characteristics, ward characteristics, and working
 Davao Doctors College
General Malvar St., Davao City
Master of Arts in Nursing

environment on the job satisfaction of nurses in the pediatric intensive care unit, and found that

work pressure and nursing management have the greatest impact. Leadership that values

employee contributions will promote loyalty. In addition, Robinson et al. (2018) concluded that

in terms of exploitative or authoritative leadership styles, leadership styles are significantly

related to caregiver retention.

Leveck and Jones (2016) also found that leadership style, team cohesion, work pressure,

organization and professional job satisfaction affect nursing staff retention and quality of care.

Other studies refer to participatory leadership styles as improving job satisfaction (Yeatts

and Seward, 2000). In participatory leadership, managers have full confidence in employees

when making decisions (Tan et al., 2019), thereby promoting team cohesion and job satisfaction.

Studies have shown that, compared with the traditional intensive care unit (ICU) characterized

by bureaucracy and high technology, the special care unit (SCU) with shared governance and the

least technical nurse-managed special care unit (SCU) is more satisfied with the supervision

dimension; Nurses working in SCU and ICU prefer the SCU practice model to the ICU model

(Song et al., 2017). On the other hand, a study conducted at the Alexandria New Medical Center

found that nurses’ consulting leadership style is more effective and nurses are more loyal. In the

consulting leadership style, the manager is full of confidence in the employees, and the

responsibility for goal setting is relatively average (Tan et al., 2019).

Regardless of the leadership style, hospital managers should plan and implement

effective strategies. By creating a caring and conducive working environment for nurses'
 Davao Doctors College
General Malvar St., Davao City
Master of Arts in Nursing

professional practice, they should be given more autonomy and control, so as to improve

employees’ job satisfaction. Degree and nurse retention rate.

THEORETICAL/CONCEPTUAL FRAMEWORK

The research is based on two theories, namely Herzberg's two-factor theory and Maslow's

hierarchy of needs theory. Herzberg proposed in his theory of external (hygiene) and internal

factors (motivating factors). Hygiene factors involve company policies, supervision, technical

skills, current working conditions and wages. On the other hand, motivating factors are factors

that can increase the enthusiasm of workers or employees to do their jobs. Motivating factors are

recognition, reward, positive evaluation and achievement. Therefore, adjustments should be

made between motivational factors and hygiene factors, as this may lead to job satisfaction or

dissatisfaction. If the company pays a salary lower than the employee's salary requirement, it will

cause dissatisfaction. On the other hand, when an employee gets the reward he deserves, he will

feel satisfied. If the company imitates too much pressure, such as making all employees work

overtime in order to achieve production goals, it may lead to dissatisfaction.

This theory is important for research because motivation can increase job satisfaction

and productivity, and therefore can motivate caregivers to stay in the organization. Abraham

Maslow assumes that people’s motives are unmet needs. When a person's need for something is
 Davao Doctors College
General Malvar St., Davao City
Master of Arts in Nursing

not met, the person feels motivated or motivated to meet that need. According to Maslow's

theory, the needs of motivating people are divided into five basic categories:

1. Physiological needs, including food, water, sex and shelter;

2. Security needs, including insurance, physical examination and home in a safe environment;

3 .Social needs include the desire for love, friendship, and company. People try to meet these

needs by spending time with family, friends, and colleagues;

4. Appreciation needs are the need for self-esteem and respect for others; and 5. The need for

self-realization describes the desire to reach their full potential. Maslow believes that these needs

are organized in a hierarchy from the most basic to the least. At the top of the hierarchy are needs

that people will not try to satisfy until most other needs are met. In addition, the theory assumes

that people tend to rely on work to meet most of their physiological and safety needs through

benefits such as salary and health insurance. Therefore, organizations must understand the

current needs of certain employees in order to increase job satisfaction and increase employee

loyalty.
 Davao Doctors College
General Malvar St., Davao City
Master of Arts in Nursing

Independent Variable Dependent Variable

Factors for Turnover

 Workschedule and Nurses’ Turnover

workload
 Stress and burnout
 Promotional opportunities
and career development
 Recognition and reward
 Management style

 Age
 Gender
 Educational qualification
 Marital status
 Length of experience
 Salary range

Moderating Variables

Figure1. Conceptual Model: Factors affecting the turnover of nurses in the tertiary hospitals in
Davao City

STATEMENT OF THE PROBLEM

 Davao Doctors College
General Malvar St., Davao City
Master of Arts in Nursing

The purpose of this study is to determine the factors affecting the flow of nursing staff in
tertiary hospitals in Davao City. Specifically, the purpose is to answer the following questions:

1. What is the age, gender, socioeconomic status, marital status, length of hospitalization, and
salary range of the nurses?

2. Is there a significant correlation between nursing staff turnover rate and the following factors:

a. Work schedule and workload

b. Stress and burnout

c. Promotional opportunities and career development

d. Recognition and reward

e. Management style

3. What factors have the greatest impact on the flow of nurses in tertiary hospitals in Davao
City?

4. Is there a significant relationship between the factors influencing nurse rotation and the
demographic profile of nurses?

HYPOTHESES

The hypotheses for this study are:

H1: There is a significant correlation between the factors affecting nurse turnover and the nurse
turnover rate.

H2. There is a significant correlation between the factors that affect the flow of caregivers and
the demographic characteristics of caregivers (such as age, gender, and length of experience).
 Davao Doctors College
General Malvar St., Davao City
Master of Arts in Nursing

CHAPTER II

METHOD

This chapter describes how researchers collect data. This includes research design,
environment, participants, measures and procedures.

DESIGN
This study will adopt an exploratory and quantitative design to better and more
comprehensively understand the factors that affect the turnover of nurses and which factors
really affect the turnover of nurses in tertiary hospitals in Davao City.

SETTING
The study site will be a private tertiary hospital in Davao City. A tertiary hospital has
approximately 200,400 employees, most of whom come from the nursing department. The
number of nurses employed by the hospital depends on the bed capacity of the facility.
 Davao Doctors College
General Malvar St., Davao City
Master of Arts in Nursing

PARTICIPANTS
The respondents will be selected from the nursing department, staff nurses and hospital
directors (chief nurses, supervisors, chief nurses, including hospital administrator(s)) selected
tertiary institution. Their age, gender, marital status, length of experience and social support
system will be assessed. These respondents will come from different departments and special
clinical areas such as the emergency room (ER), delivery room (DR), operating room (OR), and
 Davao Doctors College
General Malvar St., Davao City
Master of Arts in Nursing

intensive care unit (ICU), where their workloads as well as their positions and ranks vary. mainly
involved in

patient care. Supervisors, head nurses, and hospital administrator(s) are included as they are
facility managers.

MEASURES
Participant survey questionnaires will be used to collect and collect data on the
underlying factors affecting nurse rotation. The questionnaires were developed by the researchers
and will be divided into: respondent profiles, nursing staff work arrangements and reasons for
leaving the
hospital. Section 1 will be answered giving appropriate information regarding the participant's
profile. Parts 2 and 3 will be answered by ticking the letter chosen by the participant according to
the question posed.

For the questionnaire, an explanation/invitation letter related to the research will be

provided to anyone who decides to participate in the proposed study, along with a letter of
consent to provide considerations. ethical. Respondents will also have the option to include or
not include their name and signature in the questionnaire.

ETHICAL CONSIDERATION

The researchers observed the following ethical considerations when conducting this
study. The first is to obtain a degree awarded by the director of the Master of Nursing Program at
San Pedro College. It is collected before the data is collected. Next is informed consent. It was
also obtained from the participating nurses before the start of data collection.

Respondents who willingly consented to participate after thoughtful consideration of the

nature of the study were the only ones who could be allowed in the study. In the end, all
 Davao Doctors College
General Malvar St., Davao City
Master of Arts in Nursing

interviewees were given complete information about the type, purpose, benefits and risks of
participation in order to assess their rights as interviewees. Either have the right to refuse to

participate in this research, or withdraw from participating in this research at any time, as well as
the right to privacy and confidentiality.

PROCEDURES
The following steps will be taken when conducting research after approval:

1. Approval to conduct the study was obtained from the hospital management department,
the nursing director/nursing officer.
2. With the help of the human resources department, the total number of nurses is
determined based on the total number of employees.
3. With their consent, interviewees were randomly selected from the departments assigned
to them.
4. The nursing staff will then be directed to the questionnaire to be filled out for any queries
and clarifications. We encourage you to answer questions as honestly as possible and
keep your answers confidential.
5. All questionnaires will be collected after completion.
6. Data is collected, counted and tabulated.
7. Analyze and interpret the data with the help of a statistician.

STATISTICAL TOOLS

The following statistical tools were used to analyze the data of this study:

Frequency and Percentage. These statistical tools are used to determine the demographics of
the respondents in terms of age, gender, educational attainment, length of service.

Mean. This statistical tool is used to reflect the knowledge level of nurses on insulin
administration and the education knowledge level of patients on insulin administration.
 Davao Doctors College
General Malvar St., Davao City
Master of Arts in Nursing

DATA ANALYSIS

The study aims to know the factors affecting the turnover of nurses in the tertiary
hospitals in Davao City. To present the result of the study descriptive statistical tools will use to
analyze the data such as frequency, percentage distribution, and standard deviation.

SCOPE AND LIMITATIONS OF THE STUDY

The research aims to determine factors affecting the turnover of nurses in the tertiary
hospitals in Davao City. The respondents included is the 53 nurses in tertiary hospitals in Davao
City.
The data collection will be conducted in the span of 4 months. The study consists of
survey questions which are given to nurses of the tertiary hospitals in Davao City as a survey and
reference. This study is limited only to the school year 2021-2022. The researcher limited this
research to those who are not officially nurses of the said hospital.
 Davao Doctors College
General Malvar St., Davao City
Master of Arts in Nursing

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