Review Of Literature Research Proposal

Nursing turnover continues to rise suggesting that further research needs to be done in an effort to determine the causes of the high turnover problem and develop novel strategies to retain new recruits as well as fresh graduate nurses on medical surgical units. The following research proposal will address the nursing turnover problems through examining the causes and effects. The study will also investigate the effects, if any, of nurse empowerment and teamwork have on new graduate nurses on medical surgical units.

Background and Significance

Continual building on clinical skills of new graduate nurses throughout the first year of employment is essential for increasing their empowerment, improving teamwork, developing critical thinking skills, insuring the best outcomes for patients, and ensuring nurse retention. In January 2014, Nursing Solutions, Incorporated completed a “National Healthcare Retention Survey”. The survey consisted of 75,281 registered nurses employed at 113 hospitals in 28 states. The survey found that the turnover rates for nurses jumped from 13.1% in 2012 to 14.2% in 2014. In addition, the survey determined that registered nurse turnover during the first year is 25.7%, and the highest rate of turnover occurs on medical/surgical units. (Nursing Solutions, Incorporated, 2014).
Previous research suggests that as frustration and stress experienced by nurses raises, nursing turnover rates increase. Thirty to sixty percent of new graduate nurses leave their position in the first year alone, costing the organizations approximately $82,000 per nurse (Hoffart, Waddell, & Young, 2011). In addition, highly increased nurse frustration and stress levels cause higher medical errors; medical errors can lead to lawsuits, which cost roughly $83 million dollars annually (CNA Insurance Company, 2011). Medical errors are also associated with long-term consequences of human suffering and costs to society, estimated at $19.5 billion. The total economic impact of medical errors in the United States is close to $1 trillion dollars a year (Andel, Davidow, Hollander, & Moreno, 2012). The primary objective and significance of this research study is to gain a better understanding of this ever-growing nurse turnover and the financial crisis thereof such that we can invest in solutions aimed at helping nurses improve patient safety, all in an effort to reduce the costs associated with medical errors.

Numerous research studies explored the association or correlation between nurse turnover and teamwork or empowerment (Hunt, 2012; Kalisch & Hee Lee, 2012; Kalisch, Lee, & Rochman, 2010; Kalisch, Lee, & Salas, 2010; Laschinger & Smith, 2013; Mohamed, Newton, & McKenna, 2013; Weaver-Moore, Leahy, Sublett, & Lanig, 2013). Most, if not all, these studies show that teamwork and empowerment are critical factors in nurse turnover and, when cultivated well among the new recruits, can reduce nurse turnover and promote healthy work environments leading to improved patient outcomes. Nonetheless, the literature appears to have certain gaps in linking the two since the nurse turnover rates are still increasing (Nursing Solutions, Incorporated, 2014).
Research has demonstrated that transitioning from a graduate nurse to a floor nurse can be overwhelming. According to a qualitative study of 38 new nurse graduates conducted by Clark and Springer (2011), more than half the nurses (n = 57%) felt overwhelmed. Aside from handling the stress of clinical challenges, new nurses must also learn to integrate themselves into strong cultural bonds among nurses (Milton-Wildey, Kenny, Paramenter, and Hall, 2013). A combination of these multiple stressors can potentially lead to nursing turnovers and medical errors (Smith, Andrusyszyn, & Spence Laschinger, 2010). A recent study concluded that 70% of all adverse events result from a lack of communication and collaboration between nursing teams (Laschinger & Smith, 2013).
In a quantitative as well as qualitative study carried out by Moore, Leahy, Sublett and Lanig (2013), nurses reported that fostering nurse-to-nurse relationships is essential in establishing a healthy work environment. The study revealed how teamwork affects nurses, patient care, health organizations, and the nursing profession as a whole. Therefore, it is vital to research relationships among nursing staff. In a research study done by Mohamed, Newton and McKenna (2014) on ‘belongingness’, the following question was asked: “is it important to feel accepted by other health care team members?” The results demonstrating that 99.0% agreed (M=3.41, SD = 0.510) highlights the essential importance of developing new ways to encourage positive relationships among units. One potential way to accomplish this is by empowering new graduate nurses. According to Kanter (Kanter, 1977), highly empowered nurses will empower other nurses, thereby building effective teams (Laschinger & Smith, 2013).
A research study by Wang, Kunaviktilul, and Wichaikhum (2012) found a strong correlation between empowerment and personal accomplishments (r = 0.13, p <0.05). These results indicate that when nurses experience opportunity, support, information, and resources, they feel a sense of pride that benefits not only them but also the entire organization (Wang, Kunaviktilul, & Wichaikhum, 2012). Nurses with a sense of high personal accomplishments at an organization are more likely to choose to remain there, rather than moving to an unfamiliar and new environment. Thus, empowerment and the ensuing personal accomplishments could reduce nurse turnover rates.

Research Problem

In any healthcare organization, there is a need to provide opportunities to learn additional skills or improve existing skills for novice nurses in an effort to build their confidence and improve communication proficiency amongst colleagues in other units. These additional skills will enable the nurses to gain more knowledge and thereby can provide quality services at all times (Cockerham, Figueroa-Altmann, Eyster, Ross & Salamy, 2011). However, most of the healthcare organizations do not recognize the benefits of providing these additional skills as well as invest in resources to impart and accomplish these clinical skills.
The present study will explore two critical gaps in knowledge. First, given that previous research has shown that senior colleagues emotionally test new nurses, there is a vital need to research evidence-based approaches to empower new nurses (Parker, Giles, Lantry & McMillan, 2012). Second, despite the overwhelming evidence on the importance of teamwork, most of the previous studies have only focused on the problem within particular departments (Kalisch & Hee Lee, 2012). The problem is that it is not known whether increasing new graduate nurse empowerment and improving teamwork among individuals and the units will be effective. In addition, there is the question of what are the best strategies to empower new nurse graduates?

Study Purpose

For the purposes of this study, two crucial aspects of the nurse turnover problem will be addressed. First is to find a way to increase empowerment in new graduate nurses. In addition, conceivably it will increase their confidence levels by giving them access to information on other units to further develop knowledge and skills. The other aspect is to find a way to improve teamwork, conceivably by fostering relationships and building trust among colleagues in other units. The overall objective of this comparative quasi-experimental quantitative study is to examine the effect of new graduate nurse empowerment (independent variable) to unit-to-unit teamwork (dependent variable), by giving new graduate nurses (population) the opportunity to float from a medical/surgical unit to an O.R. setting for observation (configuration of research).

Theoretical Framework and Conceptual Definitions

The study draws on Kanter’s theory of structural empowerment (Kanter, 1977; Groves, Burns, & Gray, 2013, p.131). Kanter’s theory offers a framework for cultivating meaningful relationships among nurses. The four main components of Kanter’s theory of structural empowerment include: access to opportunity, information, support, and resources. In addition, Kanter’s theory includes teamwork aspects of formal and informal power (Smith, Andrusyszyn, & Laschinger, 2010). Kanter’s theory maintains that if nurses feel empowered, it has a positive effect on their attitudes and behaviors. Kanter’s theory of empowerment provides opportunity for new graduates to observe, ask questions, and build a strong knowledge base. Furthermore, allowing access to other units’ information and resources increases organizational commitment, supports collaboration (teamwork) and cohesiveness, and establishes vital respect among new graduates and nurses in other units (Smith, et al., 2010).
Teamwork is linked using Kanter’s Job Activity Scale to measure the concept of formal power in an organization. Power is achieved when employees are given the opportunity to experience flexibility, visibility, and relevance in the workplace. Additionally, teamwork is linked using Kanter’s Organizational Relationships Scale to measure the concept of informal power that is achieved when strong relationships are formed among supervisors, peers, and subordinates within the organization (Smith et al., 2010; Laschinger, 2012). Empowerment is linked using Kanter’s Conditions for Work Effectiveness Questionnaire to measure the concepts of opportunity to increase knowledge and skills; information to provide a sense of purpose; resources to accomplish organizational goals; and support to receive guidance and feedback from supervisors, peers, and subordinates (Smith et al., 2010; Laschinger, 2012).

Conceptual Definitions

The conceptual definition of teamwork is a group of two or more people who work together to achieve a common goal. Nursing teamwork involves registered nurses, licensed practical nurses, nursing assistants, and unit secretaries working together on patient units in a hospital setting (Kalisch & Hee Lee, 2013). The conceptual definition of empowerment is based on the belief that giving employees opportunity, information, resources, and support will increase competence, autonomy, and commitment, thereby benefitting the organizations as a whole (Larkin, Cierpial, Stack, Morrison, & Griffith, 2008).

Hypothesis

Based on Kanter’s theoretical model (Kanter, 1977) and the review of literature, the following hypothesis is developed and will be tested.
New graduate nurses who are given the opportunity to form strong, respectful relationships among peers in other units (intervention) will show a greater increase in empowerment than those who are not given (comparison) the opportunity to form relationships.

Design and Rationale

In this study, a quasi-experimental, pre-test, post-test comparison group design is utilized to establish a cause and effect relationship among the variables. The design is appropriate given that the study is being conducted to identify and examine the significance of the effect of a nursing intervention. The independent variable may or may not be manipulated or controlled by the researcher but the effects of both the independent variable and dependent variable will be measured. In addition, the subjects will selected based on convenience and not randomly (Grove, Burns, & Gray, 2013).

Population and Sample

A non-probability sample of convenience will be used to conduct this study at a hospital located in South East Texas. The study would consist of 120 new graduate medical surgical nurses working on two units. The 2-South consists of 65 new nurse graduates and 3-West consists of 55 new nurse graduates. Inclusion criteria would require that all nurse participants graduate with an ADN or BSN degree, have < 1 year experience, are employed full-time, have not floated to other units, only work at the hospital conducting the study, and have given voluntary informed consent. Exclusion criteria include new nurse graduates who did not fulfill any one of the inclusion requirements.
The sample size of 120 is adequate for the study and allows for attrition. The sample size confirmed to be adequate with power analysis results as follows. A power analysis using the one-tailed t-test yielded a sample size of 102 nurses, 51 nurses in the experimental group, and 51 nurses in the nonequivalent comparison group. The power analysis was obtained using a medium effect size (d = 0.50; alpha = 0.05; power = 0.80), using the Power-G program (Faul, Erdfelder, Buchner, & Lang, 1996). The effect size was established using power analysis data obtained from a previous study titled “Structural empowerment and anticipated turnover among critical care nurses” (Hauck, Quinn Griffith, & Fitzpatrick, 2011, p. 272).

Human Subjects Protection

The national institutional review board must approve the proposed research submission since it involves human subjects and falls under the purview of protecting human subjects. The hospital’s institutional review board committee for ethics has already approved the proposed study. The patients and nurses involved in the study will be informed on the purpose of the study, the risk and benefits, compensation (if applicable), voluntary nature of participation. Prior to enrollment, a signed statement indicating that they have read and understood the consent form will be required. The study participants will sign the consent on their pre-op teaching. Following the signing of the consent form, the nurses are allowed to ask questions regarding their participation at an in-service given by the researcher. The nurses must also give informed consent to their identity disclosure to both the researcher and the hospital.

Operational Definitions

The CWEQ-II (Laschinger et al., 2001) is a modification of Kanter’s six empowerment structures. The first four subscales contain three questions, each regarding access to opportunity, information, support, and resources. Scoring consists of a 5-point Likert scale ranging from 1 (none) to 5 (a lot) (Hauck et al., 2011).
The operational definition for the independent variables is ‘The Job Activity Scale II’ containing 3 questions measuring Formal Power. Scoring consists of a 5-point Likert scale ranging from 1 (none) to 5 (a lot) (Hauck et al., 2011). The operational definition for the dependent variables is ‘The Organizational Relationship Scale II’ containing 4 questions measuring Informal Power. Scoring again consists of a 5-point Likert scale ranging from 1(none) to 5 (a lot) (Hauck et al., 2011).

Measurements

A pre-CWEQ-II questionnaire using the (JAS-II) and the (ORS-II) sections will be administered by two research assistants to 120 new graduate nurses from the two medical/surgical floors on the first day of the month. The results will be collected and placed in a lock box for evaluation. Within a week of administering the questionnaire, when the time is convenient for the O.R., the treatment group (n=65) from 2-South will receive the intervention (observation of the O.R. setting). The comparison group (non equivalent comparison group; n=55) from 3-West will not receive the intervention. A post-CWEQ-II questionnaire using the (JAS-II) and the (ORS-II) sections will be administered by the same two research assistants to the 120 new graduate nurses from the same medical/surgical floors. The results will be collected again and placed in a lock box for evaluation and scoring.
A pre-CWEQ-II questionnaire using the four sub-scales section will be administered by two research assistants to 120 new graduate nurses from two medical/surgical floors on the first day of the month. The results will be collected and placed in a lock box for evaluation. A post-CWEQ-II questionnaire using the same four sub-scales sections will be administered by the same two research assistants to the 120 new graduate nurses from the same medical/surgical floors. The results will again be collected and placed in a lock box for evaluation and scoring.

Summary

Implementing novel evidence-based research ensures that the stakeholders buy into the key role played by empowerment and teamwork in nurse retention. The new graduate nurses must have the opportunity, information, support, and resources that are vital for success of the healthcare organizations. In reviewing evidenced based studies, it is clear that further research needs to be conducted in an effort to understand the cause and effect of stress, frustration and unhealthy work environments encountered by new graduate nurses. This study suggests a possible relationship between teamwork and empowerment. This relationship may lead to greater cooperation among nursing units, thereby, reducing nurse turnover, improving patient outcomes, and saving monetary resources for the healthcare organizations.