Why Nurses Want to Leave the ICU: Work Environment and Clinical Competence

Abstract & Commentary

By Leslie A. Hoffman, RN, PhD, Department of Acute/Tertiary Care, School of Nursing, University of Pittsburgh, is Associate Editor for Critical Care Alert.

Dr. Hoffman reports no financial relationship to this field of study.

Synopsis: ICU nurses who stated a desire to leave were influenced by their perceptions of the work environment and clinical competence of other nurses in their unit.

Source: Stone PW, et al. Organizational climate and intensive care unit nurses' intention to leave. Crit Care Med. 2006;34:1907-1912.

This study reports findings from a survey of 2,323 ICU nurses regarding their intention to leave due to working conditions and factors predicting this intention. The sample was part of a larger study of patient safety that involved 110 ICUs from 66 hospitals across the United States. The study excluded step-down, intermediate care, and telemetry units. The average RN was 39 ± 9 years old, had 16 ± 9 years experience in health care, and was employed in his or her current position for 8 ± 8 years.

In this stable, experienced workforce, 391 (17%) of the RNs indicated their intention to leave within 1 year. Reasons included working conditions (n = 202; 52%), positive career move (n = 87; 22%), personal or family reasons (n = 44; 11%), retiring (n = 10; 3%) and no reason (n = 48; 12%). There were no significant differences in demographics or characteristics of the setting (region, type of ICU, bed size) between nurses who stated they intended to leave due to working conditions compared to other reasons. Those who indicated they would be leaving due to working conditions rated all organizational climate factors significantly lower (P < .001) than other nurses. Differences were largest in "support for professional practice," defined as opportunities for advancement and involvement in hospital governance. The smallest difference was found in perceptions of nurse/physician collaboration.

When analyzed using logistic regression, three items were significantly related to the intention to leave. A one unit increase in the professional practice score decreased the odds of intention to leave by 48% (Odds Ratio [OR], 0.52; 95% CI, 0.42-0.64; P < .01). Perceptions of high nursing competence of other nurses employed in the ICU setting were also associated with reduced likelihood of an intention to leave (OR, 0.61; 95% CI, 0.44-0.83; P < .01). A one-year increase in the current position decreased the odds of citing an intention to leave by 3% (OR, 0.97; 95% CI, 0.94-0.99; P < .05).

Commentary

It is encouraging that, in this stable, experienced sample of ICU nurses, the majority (83%) indicated that they did not intend to retire or resign their current ICU position in the coming year. Slightly more than half (52%) of those who indicated an intention to leave cited "working conditions," with professional practice rated most highly as the factor influencing this decision. Other important factors were perceptions of the clinical competence of nurses employed with them in the ICU and the number of years in the current position. Factors cited in past studies, eg, nurse/physician collaboration, staffing, scheduling were not rated as highly in influencing this decision.

One possible explanation for these findings relates to the sample selection process. Nurses included in this study were employed in hospitals who were invited to participate in an ongoing national study on patient safety. It is possible that, given the selection process, the hospitals that volunteered represented the "cream of the crop" in regard to practices known to impact retention of valued critical care nurses. If so, the message of this study is that ICU nurses in these settings need to be challenged with new opportunities for career advancement within the bedside career ladder and be given a role in unit governance.

One method of achieving this recognition is through attaining Magnet Status. The Magnet Recognition Program was developed by the American Nurses Credentialing Center to recognize health care organizations that provide the very best in nursing care. A Magnet hospital is stated to be one where nursing delivers excellent patient outcomes, job satisfaction is high, and turnover low. Magnet status is also said to indicate that nursing is involved in decision-making in patient care delivery, changing nursing practice through research, and are encouraged and rewarded for advancing in nursing practice. Organizations that exhibit these characteristics have found that they have decreased nursing turnover, perhaps due to the greater challenges and recognition they provide to those who wish to improve the quality of care through adoption of best practices and the generation of new research findings.