Methods
Setting
The current study was conducted at a large community hospital 50 km from central Toronto, Canada. The hospital has approximately 400 inpatient beds and offers a variety of speciality services including cancer care, cardiac care, pediatrics, and mental health services.
Sampling and data collection procedures
Data were obtained from frontline nurses (i.e., registered nurses and registered practical nurses), allied health professionals (AHPs) (e.g., respiratory therapists, physiotherapists, pharmacists), and clerical staff. The study sample included all staff in the above roles who had worked for at least 6 months on one of the four participating clinical units—i.e., intensive care unit (ICU), general medicine, adult inpatient mental health, and emergency department (ED). The exclusion criteria included anyone in a leadership role (e.g., nurse manager) or anyone who was not in direct contact with patients (e.g., clerical staff responsible for the administrative duties such as booking appointments for a nurse manager).
Survey data were collected between September 30, 2015, and February 1, 2016. During that time, the lead author visited each of the four units several times to recruit as many eligible full-time, part-time, and casual staff as possible. Non-probability convenience and snowball sampling procedures were used as it was not feasible to acquire accurate staffing numbers from unit managers since casual staff were supplied by staffing agencies and assigned to a unit based on need. The on-site visits were spread across both the day and night shifts so the researcher could meet and give surveys to as many eligible staff as possible. During each unit visit, a short oral presentation on the study’s purpose, inclusion/exclusion criteria, survey characteristics (e.g., voluntary, anonymous, cross-sectional), etc. were given to solicit staff participation. Surveys were only handed out to the staff that acknowledged that they met the study’s inclusion criteria and were willing to participate in the study. Respondents were asked to indicate the clinical unit they worked on; however, no individual identifiers were solicited (i.e., survey data were anonymous). A drop box was placed on each participating unit to collect completed surveys. As a small incentive to participate, a $20 gift card raffle draw was held on the final day of data collection on each unit. A returned completed survey by a respondent constituted his/her consent to participate in the study.
Measures
A survey was constructed using previously validated scales to assess participants’ perceptions of supervisory leadership, teamwork, mindful organizing, and turnover intention. Demographic data on tenure, profession, and gender were also collected.
Explanatory variables
Supervisory leadership support for safety was measured using the Canadian Patient Safety Climate Survey (Can-PSCS) [
26]. The Can-PSCS is a theory-based instrument that has strong psychometric properties validated by confirmatory factor analysis and is currently being used in health settings as part of the Accreditation Canada’s Qmentum Accreditation Program. The supervisory leadership scale reflects the staff perceptions of frontline-level leadership commitment to patient safety. This scale consists of two items (e.g., “my supervisor/manager seriously considers staff suggestions for improving patient safety”) and was previously shown to have strong internal consistency reliability,
α > 0.80 [
26]. Staff perceptions of the quality of teamwork on their respective unit were measured using the Safety Attitudes Questionnaire teamwork climate scale. This scale has six items (e.g., “the physicians and nurses here work together as a well-coordinated team”) and was previously shown to have good psychometric properties (e.g.,
α = 0.78) in acute care settings [
27]. The supervisory leadership and teamwork both use a 5-point agreement Likert scale (1 = “disagree strongly” to 5 = “agree strongly”).
The Safety Organizing Scale (SOS) captures the principles of mindful organizing and consists of nine items (e.g., “when errors happen, we discuss how we could have prevented them”), each measured on a 7-point Likert scale (1 = “not at all” to 7 = “to a very great extent”)
. The SOS was previously shown to have good psychometric properties—e.g., α = 0.88 [
20].
Outcome variable
Turnover intention was operationalized as behavioral intent of an employee to leave his/her current job by either transferring to a different unit in the same organization or by seeking employment at a different organization while staying in his/her occupation. A three-item turnover intention measure was used in this study: “there is a good chance that I will leave this job in the next year or so”; “I frequently think of quitting this job”; and “I will probably look for a new job in the next year.” This turnover intention measure has good psychometric properties and showed good discriminate validity in a confirmatory factor analysis of 45 items on job-related attitudes [
28]. Cronbach’s
α of the scale was previously shown to be > 0.80 [
28,
29]. Each item of the turnover intention scale was measured using a 7-point Likert scale where a higher score indicated a higher likelihood that a person would quit his/her current job.
Any negatively phrased items in the supervisory leadership, teamwork, or mindful organizing scales were reverse coded to ensure that a high score on an item corresponded to a high score on a scale. The three negatively phrased items associated with turnover intention scale were not reverse coded as it made intuitive sense that a high score on the scale corresponded to a higher intention to leave. A mean score for each scale was calculated if a respondent answered more than half of the questions associated with that scale. The study survey is provided in Additional file
1.
Analysis
All analyses were carried out using SPSS, version 11. Manual double entry of survey data was used to minimize data entry errors [
30]. Cronbach’s
α values were calculated for supervisory leadership, teamwork, mindful organizing, and turnover intention to assess the reliability of these scales in the current dataset [
31,
32].
Simple bivariate analyses (Pearson
r) were carried out to assess the strength and significance of the relationships among the dependent and non-demographic independent variables. The residual scatter and probability-probability plots for turnover intention were examined to ensure that the assumptions of multiple linear regression were met [
31,
32].
To test our study hypotheses, hierarchical regression analysis was utilized. Hierarchical regression analysis permits a researcher to examine the unique variance accounted for by a predictor, over and above the variance contributed by independent variables entered earlier in an analysis [
33]. Demographic variables are typically good candidates for the first step in a hierarchical regression analysis [
34], as they are static variables and should be entered in an analysis before the dynamic variables [
33]. Hence, unit affiliation and staff demographic (i.e., gender, tenure, and profession) dummy variables were placed in block 1 and block 2 of the hierarchical regression analysis, respectively. The three predictors (i.e., supervisory leadership support for safety, teamwork, and mindful organizing) and their associated interactions were placed in blocks 3 and 4, respectively. All predictors with interactions were centered to avoid problems of multicollinearity [
35], and significant interactions were plotted.
Discussion
The survey results only partially supported hypothesis 1 and 2. The direct relationships of supervisory leadership support for safety and mindful organizing with turnover intention were found to be non-significant. Other literature (reviewed above) suggests there is emerging empirical evidence of the positive impact of supportive supervisors on turnover intention. The survey we used solicited staff perceptions of only two
proactive safety behaviors of a supervisor: (1) encouragement of clinical staff to follow established patient safety procedures and (2) consideration of staff suggestions for improving patient safety. It is possible, even likely, that clinical staff perceive safety-related responsibilities of a supervisor more broadly—e.g., others have suggested that the ability to provide timely feedback for reported errors is seen as a central aspect of supervisory leadership support for safety [
36]. Future research that operationalizes supervisory leadership for safety in a broader way may reveal that this variable has a more pronounced direct effect on turnover intention.
In comparison with the current study, all previous empirical research on mindful organizing utilized larger samples which increases the likelihood of detecting significant associations among variables [
37]. In addition, high reliability theory may not yet be part of frontline providers’ lexicon to the same extent as other safety-related concepts—e.g., communication, safety culture. Consequently, it is feasible that the current study’s survey respondents were either unaware of, or did not fully appreciate, the importance of extra-role safety behaviors that underpin the safety organizing scale.
Although we did not find evidence of a direct effect of either supervisory leadership or mindful organizing on turnover intention, our results showing a significant interaction between these two predictors make a novel and important contribution to the literature. These findings suggest that supervisory leadership’s positive impact on turnover intention becomes particularly important when staff perceive poorer mindful organizing at the frontlines (see Table
4 and Fig.
1). In other words, a safety-conscious supportive supervisor can compensate when mindful organizing at the frontlines is perceived to be poor and significantly lower staff turnover intention. And as noted, it is possible that a broader operational definition of supervisory leadership would reveal an even more pronounced compensatory effect. To our knowledge, no previous study has empirically examined the interactive impact of supervisory leadership and mindful organizing on turnover intention. This line of enquiry is especially relevant for loosely coupled organizations such as hospitals where frontline managers/supervisors often hold considerable leeway while implementing organizational policies [
38,
39].
Our results found that perceptions of teamwork have a significant direct effect on turnover intention—every 1-point increase in teamwork resulted in a 1-point decrease in turnover intention (see Table
4). We also found higher levels of turnover intention among nursing and clerical staff compared to allied health professionals. Certain healthcare professionals—e.g., nurses—are more likely to experience poor quality of teamwork due to a variety of interrelated factors—e.g., power/status hierarchy, lack of autonomy [
40]. Others have also found that when healthcare employees perceive a lower quality of teamwork, they are more likely to report higher turnover intention [
3] and intention to leave in turn is significantly associated with actual leaving behaviors [
9]. Healthcare organizations may be able to reduce nursing and clerical staff turnover by focusing their efforts on improving the quality of teamwork.
Limitations and future research
This study was cross-sectional, and therefore, causal associations between the predictors and outcome cannot be established. Also, self-reported measures were utilized that are subject to social desirability biases [
41]. However, assuring survey participants’ anonymity as was done in the current study likely minimized socially desirable responses [
42]. Moreover, while social desirability bias might impact
absolute levels of teamwork, supervisory leadership, mindful organizing, and turnover intention, it is unlikely to influence the relationships
among these variables. Common method variance may inflate the magnitude of the relationships we examined as the predictor and outcome variables were taken from the same survey. Our model explains 20% of the variance in turnover intention. Turnover intention may be due to personal (e.g., spousal relocation or maternity leave) or work-related (e.g., job satisfaction) factors. This study only examined the work-related antecedents. Future research should examine the relative influence of personal and work-related factors on turnover intention.
Physicians were not included in the current study since only a small number of full-time physicians worked on general medicine and mental health units. Moreover, physicians are often not physically present on a clinical unit throughout a shift making their recruitment using the study’s data collection procedures difficult. Physicians are also more likely to be informally seen as team leaders by other clinical staff, and the current study did not include clinicians in leadership roles.
Lastly, convenience and snowball sampling procedures were utilized, and data come from a single large community hospital. It is recommended that future research tests the validity of the current study’s inferences in other types of clinical units (e.g., surgery or pediatrics), professions (e.g., physicians), and hospitals (e.g., small community or teaching) using larger multi-site samples.
Implications for practice
When healthcare employees perceive poor quality of teamwork, they are more likely to report higher turnover intentions as poor teamwork not only hinders their ability to provide good quality care but also negatively impacts their well-being [
10]. Therefore, healthcare organizations can provide on-site inter-professional collaborative workshops on topics that can strengthen working relationships including conflict management, negotiation skills, and stress management [
43]. In addition, the relational practices—e.g., providing support and constructive feedback—of formal healthcare supervisors which are associated with a lower level of employee turnover intention [
10,
12] may also help to foster stronger teamwork climate perceptions. Our results suggest that relational qualities of frontline leaders become particularly important when other aspects of the context, such as perceptions of mindful organizing, are low. Healthcare institutions should focus on recruiting and retaining individuals possessing relational competencies into supervisory leadership roles. In settings where supervisory support for safety is lagging, attention can be directed to a small but growing evidence base that suggests leadership for quality and safety can be built as part of the interventions to improve care [
44]. Organizations and health systems are encouraged to view leadership for safety as a modifiable element that can be fostered rather than a fixed aspect of context that is either present or absent [
45].
Conclusion
Healthcare systems around the world are facing employee shortages and high levels of turnover. This problem is especially pronounced in certain healthcare professions such as nursing [
4]. The results of the current study lend support to this assertion as nursing and clerical staff had significantly higher turnover intentions compared to the allied health staff. Hence, it is prudent to implement staff retention strategies tailored towards healthcare professions that are more likely to exhibit high turnover intentions. Past research also suggests that increasing recruitment and pay are only short-term solutions while interventions that improve the quality of employees’ work life are more effective long-term solutions to reduce turnover [
1]. Indeed, the results of this study show that good perceptions of teamwork significantly lower nursing, allied health, and clerical staff intentions to leave their job. Moreover, when frontline staff perceive poor mindful organizing, a supportive supervisor that prioritizes safety can significantly reduce employees’ turnover intentions. This finding is particularly noteworthy as it highlights the underexplored but important compensatory effect that supportive leadership can have when other aspects of the work context are negative. Together, these results highlight that interventions that improve the quality of teamwork and build/foster supportive supervisory leadership have the potential to lower nursing, allied health, and clerical staff intentions to leave and consequently reduce their actual turnover in the long run.
Acknowledgements
We wish to thank Dr. Dennis Raphael, Dr. Whitney Berta, and Dr. Mary Fox for their contributions as members of the Oral Defense Committee for SZ’s PhD dissertation. Most importantly, we wish to acknowledge and thank those in the hospital where this study took place including senior leaders for their continuous support, the frontline managers on each of the study units for facilitating access to their units, and all of the staff who generously agreed to participate in this study.
Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (
http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (
http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.