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Does nurses ’ health affect their intention to remain in their current position ?

Professor of Nursing Research and Practice Development, Professor of Epidemiology, Research Fellow, Faculty of Health, University of Technology Sydney, Sydney, NSW, Professor of Nursing, Charles Perkins Centre, Sydney Nursing School, University of Sydney, Sydney, NSW, Professor of Nursing and Health Services Management, University of Technology Sydney, Sydney, NSW, Edith Cowan University, Perth, WA and Director of Studies, Health Services Management, Faculty of Health, University of Technology Sydney, Sydney, NSW, Australia


Introduction
Demand for nursing is rising globally alongside population ageing, longer life expectancies and the rise in non-communicable diseases and disability: these demands are increasingly unlikely to be met by current growth in nursing numbers (Campbell et al. 2013). One strategy to reduce the shortfall is to improve retention, which requires an understanding of why nurses and midwives leave. 'Intention to leave' is often used as a proxy for turnover as this strongly predicts actual departure (Derycke et al. 2010). Nurses' intention to leave their position has been shown to be affected by a wide range of factors (Chan et al. 2013).
Intrinsic or personal factors influencing nursing turnover include the individual's psychological and physical health status. Emotional responses related to burnout, stress and family conflicts (Flinkman et al. 2008), and physical conditions including muscularskeletal problems, fatigue and chronic disease, increase absenteeism that in turn can affect nurses' decision(s) to leave their employment (Stichler 2013, Daouk-€ Oyry et al. 2014. The health status of nurses (Hayes et al. 2006) and its impact on intention to leave, and thus workforce retention, is an area that is much understudied.

Background
Reports on the health status of the nursing and midwifery workforce have predominantly focused on consequences of the specific occupational issues attributed to these professions, such as manual handling, exposure to chemical and infectious agents, violent and distressing incidents and stressful situations (International Council of Nurses 2006). Other studies have sampled nurse populations to assess specific healthrelated issues, or reported findings from women where nursing boards were used for recruitment, for example the US Nurses' Health Study (http://www.nurseshealthstudy.org/). However, large studies of nurses and midwives as a workforce are rare and there has been minimal consideration of the rates of behavioural, lifestyle and chronic disease characteristics that dominate population health. While there are indications that health can exert significant influence upon the work ability and retention of staff (Camerino et al. 2006, which are important considerations for a workforce and its managers, there has been limited exploration of this in nursing or midwifery. Equally importantly, intention to leave results in the negative effects of staff turnover on team stability and the expense of staff replacement, estimated at, on average, $49 255 per full-time equivalent (FTE) in Australia ,b Roche et al. 2014.
Nursing as an occupation is physically demanding. The nature of nursing work can place physical demands on the body that may reduce the capacity for a nurse to remain employed; 'lighter' workloads, flexible work schedules and ergonomic supports may be needed for older nurses (Tourangeau et al. 2010, Uthaman et al. 2016. However, the extent that health issues affect nurses' intention to leave employment or the profession is not known. European nurses with self-reported poor health raised concerns over their ability to continue working that in turn influenced their decision to remain employed (Laine et al. 2009); for Korean nurses with self-reported poor health, the intention to leave was dependent on the work environment (Cho et al. 2015).
The nursing workforce is ageing, and this is accompanied by an increasing risk of development (or progression) of chronic disease (Stichler 2013). Chronic illness has the potential to reduce nurses' and midwives' capacity to work, affect their comfort and satisfaction with work and, consequently, their intention to leave. Increasing age has been linked with lower perceived work ability, in turn linked to a greater intention to leave among nurses across Europe (Camerino et al. 2006). The age of the nursing workforce is rising steadily across the developed world, with average ages of 44.6 years in Australia (Australian Institute of Health and Welfare 2013), 45.4 years in Canada (Canadian Institute for Health Information 2011) and 44.2 years in the USA (USBOL 2013). Poor self-rated health has been directly linked with intention to leave both the current job and the nursing profession (Lai et al. 2008).
There is limited research on health risks, rates of chronic disease and disease-related symptoms in the nursing and midwifery workforce. However, poor health has been reported by 58% of Greek and 60% of Lithuanian nurses (Pappas et al. 2005, Malinauskiene et al. 2011. Brazilian nurses have reported high rates (32%) of hypertension (de Souza Urbanetto et al. 2014), linked to higher body mass index (BMI). Overweight and obesity has been reported in at least two-thirds of nurses in the USA, UK, Australia, New Zealand and in Scotland (Bogossian et al. 2012, Kim et al. 2013, Kyle et al. 2016. Concerns have also been raised about poor sleep quality, reported to affect, for example, 70% of Norwegian intensive care unit (ICU) nurses (Bjorvatn et al. 2012), with patient care errors significantly more likely from sleepdeprived nurses (Johnson et al. 2014).
Symptom type and severity may be key considerations for workforce retention. For example, pain has been commonly reported; in Estonia 69% and 84%, respectively, of nurses and midwives reported pain lasting longer than a day within the last month and year (Freimann et al. 2013); 68% of Taiwanese and 86% of Norwegian nurses reported pain within the previous 30 days and 12 months, respectively (Bjorvatn et al. 2012, Chiou et al. 2013. Our preliminary work found 15.5% had experienced moderate pain and 5.2% severe/very severe pain in the previous 4 weeks (Perry et al. 2015a). Other common symptoms such as depression and inadequate sleep have been associated with higher likelihood of intention to leave (Lai et al. 2008, Chiang & Chang 2012. This study is founded on the World Health Organisation (WHO) definition of a healthy workplace (Box 1; Burton 2010). To date, there is little acknowledgement of the potential contribution of personal physical health resources for the nursing and midwifery workforce, little information on their physical health and symptom load or how this may relate to intention to stay or leave the workforce. This study therefore investigates nurses' and midwives' physical health, rates of symptoms and disease, and seeks to determine if these factors contribute to intention to leave.

Methods
This cross-sectional study used an online questionnaire to collect data from nurses and midwives working in New South Wales (NSW), Australia. The study was approved by the relevant hospital and university Human Research Ethics Committees (LNR11/POWH/ 242; LR/2013000741) and the questionnaire was open between June 2014 and February 2015.

Sample
All nurses and midwives working in NSW were eligible to participate. Participants were recruited using multiple strategies, although the primary means was via emails to the membership of the New South Wales Nurses and Midwives Association (NSWNMA) -a professional association and trade union. The survey was also publicised through advertisements in trade journals, employment e-newsletters, professional nursing and midwifery networks and social media. Three reminder emails were sent.
In 2014 there were 97 843 nurses and midwives registered in NSW (Nursing and Midwifery Board of Australia 2015), with Assistants in Nursing (AINs) estimated at 25% of the Australian nursing workforce . It was impossible to gauge actual numbers invited given the diverse recruitment techniques, but with 5446 surveys submitted, and 405 (7.4%) excluded because of missing data or ineligibility, a total of 5041 responses were analysed.

Data collection
The questionnaire comprised: (1) demographic, (2) workforce and (3) general health and well-being characteristics. Well-established tools were employed where possible, selected or adapted from long-running, extensively validated national and international surveys such as the Nurses and Midwives e-Cohort Study (NMeS) (Turner et al. 2009), the Australian Longitudinal Study on Women's Health (ALSWH) (Brown et al. 1996) and the Australian Health Survey (Australian Bureau of Statistics 2011a). Sources of the main variables, with an indication of their psychometric properties, are set out in Table 1. The survey was pilot-tested in paper format with nurses and midwives (n = 381) in two acute hospitals in Sydney (Perry et al. 2015a,b) resulting in minor revisions.

Predictor variables
Demographic and workforce variables Data were collected to characterise the sample including by age, gender, highest educational qualification, ethnicity and carer commitments outside of work using previously-employed formats from the Australian Census (Australian Bureau of Statistics 2011a, b). Workforce variables included work role, setting, contract (full/part time, casual, pool or other), hours and shifts worked, workplace location, injuries and abuse.

Health and wellbeing
Health and wellbeing was assessed in relation to general health, disease diagnoses and symptoms, hospital admissions and sick days. The Short Form 12-Item Health Survey version 2 measured health-related quality of life (SF-12 v2 â ) (Ware et al. 1996, Gandek et al. 1998a, Roelen et al. 2014. Participants were asked if they had been diagnosed with any of a number of chronic diseases; experienced any of a list of Box 1: The WHO definition of a healthy workplace (Burton 2010) 'A healthy workplace is one in which workers and managers collaborate to use a continual improvement process to protect and promote the health, safety and wellbeing of workers and the sustainability of the workplace by considering the following, based on identified needs: • Health and safety concerns in the physical work environment; • Health, safety and well-being concerns in the psychosocial work environment including organization of work and workplace culture; • Personal health resources in the workplace; and • Ways of participating in the community to improve the health of workers, their families and other members of the community'.  common symptoms or had any hospital admissions in the previous year (Brown et al. 1996).
Participants' perceptions of their current sleep pattern, and the nature, severity and impact of any insomnia were measured with the Insomnia Severity Index (Bastien et al. 2001, Morin et al. 2011. Intensity of bodily pain was evaluated using a six-point rating scale of 'no' to 'very severe' pain, with pain frequency scored on a four-point rating from 'never' to 'often', during the past 4 weeks , Brown et al. 1996.

Outcome variable
Intention to leave was sought with the question 'Do you have plans to leave your current job?' in the next 6 or 12 months ).

Statistical analyses
Data were entered into the Statistical Package for the Social Sciences (SPSS version 22.0 IBM, USA) for analyses. Missing values were imputed by the overall mean where there were multiple item surveys and less than 20% missing; other missing values were treated on a case-by-case basis. Comparisons between nurses  and midwives who did or did not intend to leave in the next 12 months were conducted using chi-squared for categorical data and t-test for continuous data.
Where data achieved small numbers in multiple categories, categories were collapsed. For example, remoteness area, calculated from town/suburb name, was collapsed from five to three categories (ASGS 2011), pain intensity was collapsed from six to three categories, and nurse/midwife practitioner was combined with the advanced practice category). Independent predictors of intention to leave within 12 months were determined using backward-stepwise logistic regression modelling. Variables entered into the model were selected based on the literature and statistical significance in preliminary analyses (see Tables 2 and 3).

Health
Overall, nurses and midwives perceived their health as 'good' to 'very good' (mean 2.5, SD 0.95), taking a median of three sick days per year [interquartile range (IQR) 1-6], with 16.8% reporting hospital admission in the previous year (Table 3). With 64.9% reporting at least one chronic disease, their most prevalent diagnoses included depression (22.0%), hypertension (17.2%) and asthma (15.0%). On average, respondents reported mean of 3.4 (SD 2.7) different symptom types sometimes or often. The most commonly reported symptoms included back pain (46.6%), severe tiredness (43.9%) and stiff joints (39.2%). Bodily pain and sleep issues were common, with pain occurring at a moderate intensity or more in 33.4% and mean insomnia score of 7.8 (SD 5.7).

Predicting intention to leave
With other variables accounted for, logistic regression modelling revealed that older nurses and midwives were less likely to intend to leave within 12 months, with every 5 years of age reducing the odds of leaving by

Discussion
Nurses and midwives who intended to leave their jobs within 12 months differed significantly from those not intending to leave by age, family carer responsibilities, work setting and location, but also according to position, experience of workplace abuse and job satisfaction. These factors were mostly unsurprising. However, this study also showed significant differences by health, with those intending to leave reporting poorer general health, more sick days and hospitalisations, more diagnoses of anxiety and more pain, tiredness, indigestion, depression, breathing and sleep problems. This is the first study to focus on the health of the Australian nursing and midwifery workforce, showing that it exerts a significant independent effect on intention to leave and hence on workforce turnover. This is an important indicator nationally, as the profile of study participants was similar to that of the national Australian nursing and midwifery workforce, with mean ages of 48.0 years for study respondents vs. 44.6 years for Australian nurses and midwives, 88.5% vs. 89.8% female, 59.7% vs. 62.6% working in a hospital setting (Australian Institute of Health and Welfare 2013) and 65.8% vs. 68.4% located in metropolitan locations (Australian Bureau of Statistics 2013). The health status of the nursing and midwifery workforce broadly reflected that of the Australian population, although only 50.6% reported very good to excellent health compared with 55.1% of the population (Australian Bureau of Statistics 2012). Similar prevalence was seen in high rates of mental health diagnoses (e.g. 22% for depression vs. 22.3% of females aged 16-85 years in the previous 12 months (Australian Bureau of Statistics 2007) and chronic diseases (for example, 17.2% reported hypertension compared with 21.5% of Australians aged 18 years and over with measured high blood pressure) (Australian Bureau of Statistics 2013). The prevalence of asthma, however, was notably higher at 15.0% compared with 10.2% (Australian Bureau of Statistics 2013) and, with the significance of breathing difficulties for intention to leave, this warrants further examination.
Overall, findings are similar to data reported internationally, for example, of poorer self-reported health (Pappas et al. 2005, Malinauskiene et al. 2011, obesity (Bogossian et al. 2012, Kyle et al. 2016, pain and inadequate sleep (Bjorvatn et al. 2012, Chiou et al. 2013. However, societal assumptions about links between increasing age with increasing ill-health and reduced employment intention (Australian Public Service Commission 2011-2012) were not confirmed in this nursing workforce, where ageing predicted less likelihood of intention to leave. Older nurses and midwives, with their accumulated years of knowledge and experience, are likely to be well aware of job demands and opportunities within nursing and to take steps to move into positions where requirements do not exceed what their health allows . In a predominantly female workforce, cultural expectations and life-stage considerations including childbearing may have had some effect (Liu et al. 2012). Younger nurses and midwives may be more or less likely to express an intention to leave for reasons that may relate to social and cultural expectations of women, including childbearing, childcare and caregiver responsibilities. They may also wish to move from a job that is unsatisfying or includes shift work, or is a specialty or role that does not match their career aspirations (Flinkman et al. 2008, Shacklock & Brunetto 2012, Heinen et al. 2013. Younger nurses and midwives expressing an intention to leave their current job may indicate positive choices for longer-term career advancement, although this also has implications for their current workplace. Differential effects shown in relation to geographical location may, at least in part, reflect the greater workplace choices afforded by cities.

Strengths and limitations
The influence of job satisfaction in relation to intention to leave has been consistently recognised, and it is a strength of this study that it confirms what is already known (De Milt et al. 2011, Heinen et al. 2013). However, a limitation is the inability to calculate a survey response rate, given there is no way to know how many NSW nurses and midwives were alerted to or had access to this electronic survey. Electronic surveys are attended by well-recognised potential bias to response as well as reliance upon self-report data. Nonetheless,

Conclusions
Age and health status proved significant influences on future employment intentions in this study of over 5000 nurses and midwives. Fewer nurses and midwives than the population in general rated their health as optimal, and the concern is that, as they age, their health is likely to decline. As an international priority, staff health needs to be aligned with the public health priorities for patients and the general population: increasing exercise, improving diet, reducing obesity, smoking and excessive drinking.

Implications for nursing management
Employers should invest in strategies to keep their workforce healthy, such as facilities for healthy eating and exercise, health maintenance and wellness programmes, which can be offset against the cost of staff replacement. Employers need to give serious consideration to matching roles to nurses' and midwives' physical and health abilities, to continue to make use of their years of knowledge and expertise. As these occupations are acknowledged as physically and emotionally demanding (exacerbated by shift work), this is particularly important for front-line staff. Educators, managers and policy makers should take heed of the significant influence of health for staff retention and move proactively to safeguard their health to maintain staff of this workforce for the future.

Source of funding
Funding for this study was provided by the Australian Research Council (ARC) and the New South Wales Nurses and Midwives Association (NSWNMA).