The role of leadership in overcoming staff turnover in critical care

Abstract

This commentary discusses Laporta and coworkers analysis of a case study on the causes of and solutions for staff turnover in an intensive care setting. Staff turnover is a significant issue for health care leaders due to the shrinking workforce in Western countries and an increased demand for intensive care services as the population ages. The commentary considers reasons for turnover such as burnout and generational diversity, and highlights the importance of a team work approach to address the issue of turnover.

In this issue of Critical Care, Laporta and coworkers [1] review a multidisciplinary working group's analysis of a case study on the causes of and solutions for staff turnover in an intensive care unit (ICU) setting. This issue is of profound significance to health care leaders in Western countries because the workforce is shrinking as a result of impending Baby Boomer retirements and, as the population ages, the demand for intensive care services will grow considerably [2, 3]. These demographic factors are further compounded by the fact that the complexity of care provided in the ICU demands professionals who are highly trained and skilled. In this environment, turnover can be costly to the organization because of the significant expenses associated with recruiting and training workers [4].

There are many well documented reasons for staff turnover in the intensive care setting that are highlighted by Laporta and coworkers [1] as core reasons. These core reasons include job dissatisfaction due to inflexible scheduling practises, insufficient opportunity for professional development, as well as a lack of collaborative decision making around clinical and practice issues. The authors discuss that data on ICU turnover comes from nursing literature and that this research may be applicable to other health care professionals. However, it is important not to assume that reasons for turnover are the same among different groups of health care providers and that staff turnover is something to be avoided at all costs. For example, Misra-Hebert and coworkers [5] state that one contributor to physician turnover is conflict between the physician's and organization's philosophy and goals. Physician turnover in this case may be beneficial both to the physician and organization if the two parties cannot reconcile their differences and the conflict impacts on the ability of both parties to move forward.

There are other important reasons for turnover that should be considered by ICU leaders, and these include burnout and generational diversity. Burnout is a prevalent phenomenon in ICUs, and the nursing literature suggests that issues such as moral distress when engaging in futile care contributes to burnout [6]. In the medical literature causes of physician burnout include volume of work, increased expectations of the public, lack of sleep and the possibility of being sued [7]. The consequence of burnout is that there is a negative impact on quality of care and staff morale, which can ultimately cause turnover. For example, Gunderson [7] indicates that physicians who are dissatisfied may engage in inappropriate prescribing patterns. Neuhauser [8], furthermore, discusses how environments with rigid systems and attitudes among the leadership will decrease staff morale because staff desire flexible policies and autonomy in decision-making.

The generational diversity found in the ICU environment can also be a source of turnover of staff. It is well documented that Generation X (born in 1965–1980) and the Millennial Generation (born in 1980–2000) have a strong desire for more balanced work life than Veterans (born in 1925–1945) and Baby Boomers (born in 1946–1964) [9]. Research conducted by Lorin and coworkers [10] on internal medicine residents of the Millenial Generation showed that although 41% considered a fellowship in critical care, only 3.4% chose this training because of lack of leisure time and stress levels among faculty and fellows. Clearly, it is important for leaders to be attuned to these generational differences when developing recruitment and retention plans and redesigning the workplace environment.

The review from Laporta and coworkers [1] also highlights the importance of ICU leadership working with frontline staff to create a vision and strategy that addresses the core reasons for turnover. It is essential that this vision be aligned with the vision, mission and values, and strategic plan of the health care organization. Furthermore, the team should assess whether their hospital is highly reputable, has high patient satisfaction, and sufficient resources and equipment to provide care. All of these components are signs of a positive work environment, and leadership can build on these attributes to recruit and retain staff [11]. The other key factor in this process is the use of a team work approach. Team work training in the areas of conflict resolution, learning styles and giving feedback will help the staff to work together to create and achieve an inspiring vision [12]. Although the financial and human resource investments required to engage in this process are considerable, there is substantial evidence in the literature that highly functioning, satisfied teams lead to more efficient patient care and better outcomes [13].

Staff turnover is a critical issue that ICU leaders need to understand and address in their unit settings. Attention to this issue with a systematic, evidence-based approach that focuses on team work and collaboration will not only improve retention but will also make the ICU a highly competitive and desirable place to work.