hItn&srw and critical care Nursir&g (1994) 10, W-40 0 Longman Group UK Ltd 1994

Does nurse turnover mean nurse wastage in Intensive Care Units

Vanessa Gibson

It has been claimed that the turnover rate of nurses working in Intensive Care Units (ICUs) is higher than in other areas of nursing; very little statistical evidence was found to support this claim. A questionnaire was designed to discover the reasons for nurse turnover among intensive care nurses. 45 nurses who had left the three ICUs of a large teaching hospital took part in the survey providing quantitative and qualitative data. High levels of dissatisfaction were found for career development, pay and clinical regrading, these being the main cause of turnover among the nurses who responded. Other causes were moving to another geographical area and the need for flexible hours. These findings can partly be explained by role conflict.

INTRODUCTION

This study is not so much concerned with turnover figures but with the reasons why skilled nurses leave intensive care nursing and where they go. Turnover of specially trained staff can be expensive for employers in terms of finances, time and training. Uncontrolled turnover can quickly affect the sense of cohesion and morale of a unit. Most nurses want to work with col- leagues they know and trust and turnover undermines familiarity and trust. There are many reasons why turnover occurs, one being the problem of role conflict.

It is beneficial to patients to have a stable and

Vmmssa Gibson RGN, PG, Dip Health and Social Research, CartEd, RNT, Nurse Teacher, ENS 100 Course, Newcastle and Notthumbria College of Health Studies, Newcastle upon Tyne, UK (Requests for offprints to VG) Manuscript accepted 15 October 1993

32

skilled work-force to take care of them; effective communication and collaboration have been identified as key variables influencing morbidity and mortality outcomes in the ICUs (Knaus, Draper 8s Wagner 1986). Analysis of factors that influence nurses to leave may help employers to retain skilled nurses.

The aims of this study were to discover:

1. the reasons why nurses leave the ICUs at one hospital and which factors influenced this decision

2. which factors might have influenced nurses to stay

3. whether factors influencing nurse turnover differ amongst ICUs within the same hospital and why they differ

4. where the nurses go to once they have left 5. whether their ICU skills are wasted in their

present job 6. whether they would consider returning to

ICU nursing.

INTENSIVE AND CRITICAL CARE NURSING 33

The hospital involved is a teaching hospital which has 800 beds and three ICUs. These units are: a general ICU, a cardio-thoracic ICU and a paediatric cardio-thoracic ICU.

As much research in this area has taken place in North America, it would appear useful to have some research undertaken in the UK.

LITERATURE REVIEW

An intensive care unit (ICU) is defined by Barnett and McCann (1988) as:

A place where there is constant observation of a patient on at least a one-to-one nurse/patient ratio, where medical staff are in constant attendance and where there is a multi-discipli- nary approach to total care of a seriously ill patient.

In the last 20 years ICUs have become standard in most general hospitals, requiring more and more trained and skilled staff. Hay 8c Oken (1972) describe the nurses’situation as that of resembling a ‘soldier serving with an elite combat group’.

Turnover can be defined as the percentage of employees who leave their jobs during a year. Turnover can have both positive (Lowery & Jacobsen 1984) and negative affects but mainly seems to be viewed from the negative perspec- tive, especially in terms of cost to employing authorities.

There is evidence to suggest that staff turnover can be detrimental to the quality of patient care. Revans (1964) found that the length of patient stay was increased when staff turnover was high, and Stryker (1981) found that the quality of patient care is likely to deteriorate when staff retention is difficult.

Hoffman (198 1) states that few administrators can cite accurate figures demonstrating a clear recognition of what type of turnover is occurring, how much and where. He goes on to state that measuring turnover appears decep- tively easy and that measures are easily misinter- preted, because the rates are calculated on a macro scale which does not objectively measure

In the UK factors that influenced nurses to leave have been found to be: stress too high; workloads inhibit the care; underfunded resources; bad atmosphere; petty regulations; poor promotion prospects; management style; to widen experience; wanting a new challenge; pregnancy, and hours of work. The factors that might have influenced nurses to stay included; realistic staffing levels; better pay; counselling support for nurses; part-time hours and creche facilities (Waite 1987). The studies relate to nursing personnel generally, but why do nurses leave ICUs?

The critical care workplace has traditionally been described as turbulent and unpredictable (Hart & Moore 1989), this leading to high turnover rates amongst ICU nurses. In the USA the estimated average annual turnover rate is 23% compared to 50% for intensive care nurses in some places (Searle 1988).

Dear, Weisman, Alexander & Chase (1982) compared job satisfaction and turnover between ICU and non-ICU nurses. ICU nurses were found to be more highly satisfied with work. The strongest determinants of turnover were younger age, lower perceived autonomy and lower eductional level; and ICU nurses were younger and had a lower level of education. It was noted that a turnover rate of 33% amongst ITU nurses compared with 27% for non-ITU nurses could be significant since the consistency and stability of critical care nursing depends on the presence of specially trained nurses. Accord- ing to Kosmoski & Calkin (1988), however, the best predictor of intent to stay was job satisfac- tion, but in contrast to the findings of Dear et al (1988) lower levels of education and less intent to work towards a higher degree contributed to intent to stay on the job.

In summary these studies indicate that nurses leave because of lack of job satisfaction, lack of autonomy, communication and ‘political’ diffi- culties, interactions and relationships, age and level of education but research findings are contradictory.

Theoretical issues the activity of individual nursing units. Role theory appears relevant to the investigation

34 INTENSIVE AND CRITICAL CARE NURSING

and explanation of turnover of staff. Most people fulfil multiple roles in life. Roles are associated with behavioural expectations for what a person ‘should do’. These expectations come from several sources such as expectations associated with established and recognised roles and with a person’s own self-concept. A woman, for instance, may have the role of nurse, wife, mother or daughter, friend, student, member of a club or an association. These multiple roles of one person are often referred to as a role-reper- toire (Heiss 198 1).

It is useful to look at the concept of ‘roles’ when considering nurse turnover as the roles of a nurse are manifold. It is when these roles come into conflict or when the role of nurse conflicts with other roles a person may play in society that turnover may occur.

Results Of 106 questionnaires sent out 45 were returned completed. This is a return rate of 42.5%. From the adult cardio-thoracic unit 22 nurses responded (20.75%), from the children’s cardio- thoracic unit 10 nurses responded (9.43%) and from the general ICU 13 nurses responded (12.26%), total 42.5%. Most nurses were aged between 25-29 (55.5%), 29 (64.4%) were regis- tered nurses, 16 (35.6%) were enrolled nurses. The majority of respondents were female, 43 (95.6%) with only two male respondents (4.4%). 40 nurses (88.9%) had worked full-time while working at the study hospital, while only five (11.1%) worked part-time. Also most nurses worked day shifts, 31 (68.9%), 10 (22.2%) worked night shifts while four (8.9%) worked rotational shifts.

WHY DO NURSES LEAVE? DESIGN AND METHOD

Data were collected by use of a questionnaire. Ideally, a probability sample would have been used, but a true probability sample is hard to come by and a convenience sample was used instead, which limits generalisation of the study findings. The target population was therefore all the nurses who had left ICU nursing at the study hospital between January 1987 and January 1991.

The major ethical issue anticipated was the problem of the personnel department releasing the names and addresses of past employees as these people might object to the release of this information.

In the course of the research other ethical issues emerged. Firstly, in the cover letter respondents were assured of anonymity, however some respondents were identifiable to me as they were ex-colleagues. These people might not have completed the questionnaire if they had realised this. However, some respondents included notes for me thereby revealing their identity. Secondly, some very detailed data cannot be quoted directly as this might risk a break in confidentiality.

The main reason given for leaving was to attend a full-time course. A total of 13 (28.9%) nurses had left to attend nursing or non-nursing courses. Other reasons for leaving included moving to another geographical area; of the eight (17.8%) nurses who left to move to another area six did so because their partners either had jobs or lived in the area moved to. Five ( 11.1%) nurses said they left because of lack of career development. All reasons given for leaving are set out in Table 1 and responses to the factors that influenced that decision are set out in Table 2.

The main factor that influenced nurses’ deci- sions to leave was a lack of career development. 17 nurses (37.8%) gave this reason as an influencing factor. This was also a recurring theme in comments by the respondents. Com- ments such as:

- Lack of ICU courses available for enrolled nurses. The inability for any career develop- ment for enrolled nurses was a major factor in my decision to leave ICU.

- Lack of a structured career that offered bene- fits for the nurse wishing to stay within the clinical area.

INTENSlVEAND~:RITI<:AL~:ARENURSIN~~ 35

Table 1

Reasons given for leaving

Moving area Lack of career development Disillusionment To attend nursing course To attend a non-nursing course To attend a conversion course Another ITU job Another nursing job Another non-nursing job To work abroad Children Clinical regrading Needed more flexible hours Personal Too stressful

Total

n %

8

1

17.8 5

2.2

11.1 3

1

6.7

2.2

7 15.5 1

1

2.2

2.2

5 11.1 2

1

4.4

2.2

4 8.9

45

1

100

2.2 2 4.4 3 6.7

- Trouble attending study days and obtaining full or partial study leave. No continuous update in-service training or staff interest groups.

- Once completing the initial 3 months in-ser- vice training to the unit there was little or no relevant continuing education, not even lectures!

pay as an influencing factor while eight nurses

Other major influencing factors included pay and clinical regrading. Nine nurses (20%) cited

(17.8%) cited clinical regrading as a factor. Clinical regrading seemed a very emotive issue producing strong reactions from the respondents. Comments by nurses included:

were common and were not exclusive to one - The clinical regrading was and still is an utter unit. Nurses from all three units frequently mess and a joke on nurses and their skills. commented on this factor. Considering I and many other SENs (State

Lack of career development seemed to be a Enrolled Nurse) did exactly the same job as a particular problem to nurses who did not hold a RGN (Registered General Nurse) - a start specialist qualification in ICU nursing. Examples would have been the same recognition and of some comments include: PAY!

- Little opportunity to get on an ICU course. No active staff nurse development pro- grammes.

- Promotion is only possible with post-basic courses but the courses are not easily available.

- No further career prospects in children’s ICU as I had no post-basic certificate - lower grade because of this.

- Received a grade D despite holding ENB 249 course and regularly mentoring students - I left sooner than planned due to poor grade and definite lack of career development opportunities and lack of support from nurs- ing management regarding this.

- I would like to return to an ICU area but with the poor grade available in the ICUs at present

- I left to further my career by doing the RSCN (Registered Sick Children’s Nurse) course as there was no future in paediatrics for me.

Table 2

Factors influencing decision to leave n % One nurse seemed to sum up the feelings of the rest with the comment:

Lack of career develooment 17 37.8 Management style ’ Relationships with people at work Pay

8 17.8 7 15.6 9 20.0 7 15.6 7 15.6 4 8.9 2 4.4

- but frankly one is a bit of a non-entity without a post-basic qualification.

Only nine (20%) nurses had a qualification specifically relevant to ICU when working there while five (11.1%) had gained an ICU qualifica- tion since leaving. 17 (37.8%) nurses said they held other professional qualifications when working at the hospital but these seem not to have been acknowledged when working in ICU. Comments included:

Effects of work on lifestyle/family Shifts/hours of work Patient care Conflict with other health care

professionals Clinical regrading Inadequate staffing levels Nature of work Stress Changes to the National Health Ser Internal rotation

8 17.8 1 2.2

i 8.7 6.7 vice 2 4.4

3 6.7

NB Respondents could cite more than one reason

36 INTENSIVE AND CRITICAL CARE NURSING

I don’t feel the responsibilities undertaken by - I thoroughly enjoyed my time on ICU. I left staff are being recognised by the regrading solely because I was getting married and system. moving to a new area.

- Whilst the grading system went some way - I would have stayed longer if I had not had to toward remedying the problem, it doesn’t move with my husband. allow the flexibility to change direction within the clinical spectrum. Other nurses would not have stayed no matter

what incentives were on offer. Comments from these nurses included:

FACTORS THAT MAY HAVE INFLUENCED NURSES TO STAY

Few nurses chose the factors listed in the ques- tionnaire which were taken from the study by Waite (1989). The factors and the responses are listed in Table 3.

Table 3

Factors that may have influenced n % nurses to stav

Better pay 7 15.6 Support group for nurses 4 8.9 More flexible hours 5 11.1 Creche facilities 4 8.9 Better staffing levels 0 0 More support from management 5 11.1 Internal rotation 2 4.3 Other factors 5 11.1

- I could not have stayed for any reason.

- After my decision was made none of the above would have been able to influence me.

- None, I was determined to leave. - No, I had decided to work abroad when I

qualified.

It seems that the incentives used in the ques- tionnaire would only have influenced a minority of the nurses to stay, and it is not possible to say what percentage of nurses would have stayed if all the incentives had been offered.

DO FACTORS DIFFER AMONGST THE UNITS?

NB Respondents were able to tick more than one

Better pay was the factor most cited as likely to influence nurses to stay but only seven (15.6%) nurses chose this. This again raised the issue of clinical regrading. Comments included:

- I would have stayed in the cardio-thoracic unit if an E had been offered on wards or ICU.

- I must add that my decision to leave was based purely on my ability to adequately provide for my family. If I had not been the primary wage earner or alternatively I had been single then my decision would more than likely have been different.

The most striking difference between the units was the mean length of employment, these were:

Adult cardio-thoracic unit 18.86 months Paediatric cardio-thoracic unit 12.40 months General ICU 29.46 months

The overall mean length of employment was 20.5 months with the minimum being 3 months and the maximum being 72 months. A one-way analysis of variance was carried out on the length of employment figures and was found to be statistically significant, P = 0.034. There was no statistically significant difference in the length of employment of part-time nurses and full-time nurses.

Some nurses, mostly those that were moving Differences between units in factors that because of their partner, had enjoyed working caused turnover were investigated. Lack of on ICU and might not have left if it had not been career development was the factor most cited. for their partners. However these nurses could This factor was cited by nurses from each of the not have stayed regardless of incentives. Com- units, 17 (37.8%) in total. Broken down into the ments from these nurses included: individual units 11 (24.4%) nurses from the

INTENSIVE AND CRITICAL CARE NURSING 37

adult cardio-thoracic unit cited lack of career development while 4 (8.9%) nurses cited this from the paediatric unit and only 2 (4.4%) from the general ICU.

While nurses on the cardio-thoracic unit cited lack of career development most as a reason for leaving, nurses on the general ICU cited the effects of work on lifestyle and family. Seven (15.6%) nurses cited this reason in total, five (11.1%) from the general ICU and two (4.4%) from the adult cardio-thoracic unit.

WHAT HAPPENS TO NURSES AFTER THEY HAVE LEFT?

On the question of where nurses went once they had left, 43 (95.6%) nurses were still working and 42 (93.3%) were still working as nurses. The biggest number of these, 13 (28.9%), continued to work in intensive care nursing. It is also interesting to note that 38 (84.4%) were still working in the National Health Service (NHS). Specialities in which nurses were currently employed can be seen Table 4.

Intensive care nursing requires nurses to gain and perform a number of practical skills. The skills and the number of nurses who still use them are listed in Table 5.

Although these skills will be practised mainly in an ICU setting they can be very useful in other hospital settings as the following comments illustrate:

TaMe4 Speddtk in whkh nurses are currently employed

Speciality n % intensive care Attending a course Accident and emergency Surgery Medicine High dependency Bank or agency Community Renal Non-nursing Paediatric Not answered Total

13 3 1 5 1 2 2 2

45

28.9 6.7 2.2

11.1 2.2 4.4 4.4 4.4 4.4 2.2

13.3 15.6

100

Table 5

ITU skills still being used n % Endotracheel suctioning 20 44.4 Administering IV drugs 24 53.3 Taking blood samples 21 46.7 Nursing ventilated patients 22 48.9 Haemodynamic invasive monitoring 23 51.1 Performing dialysis techniques 13 28.8 Other 10 22.2

NB Respondents could tick more than one

- I enjoyed my time on intensive care, it pro- vided me with experience, skills and confi- dence that I use in my present job and will make a lasting effect on my future.

- I thoroughly enjoyed my time on ICU and learnt a great deal, however I prefer nursing children on a ward.

- On a positive note, I will never feel afraid of a nursing (medical) emergency - ICU work makes you self-sufficient.

It seems that the nurses found the experience of working in ICU beneficial. They acquired confidence and practical skills which they were able to utilise in their present jobs. 36 (80%) nurses stated they would consider returning or had returned to ICU nursing.

It is impossible to generalise from these results as the research only covered one hospital in one location over a period of 4 years. The results may also be biased because to a certain extent the sample was self-selected, it was also impossible to compare respondents with non-respondents in terms of age, grade length of service etc, as the personnel office did not keep these details.

DISCUSSION

Nurses entering intensive care nursing can gain a lot ofjob satisfaction. Intensive care units have a high nurse/patient ratio and nurses develop new skills and advanced knowledge in areas such as physiology. This all leads to a feeling of job satisfaction initially. However, as a nurse becomes more experienced she may look to fulfil other roles. She may wish to learn and practise

38 INTENSIVEANDCRITICALCARENURSING

ward management skills or formally extend her personal knowledge through study days, confer- ences and courses. It seemed that the nurses in this sample were unable to do this while they stayed on the ICUs. Some complained of not being able to attend study days while others felt it necessary to leave in order to attend a full-time course. Others left to take up a ward-based job where they would get the opportunity to learn and practise management skills. The following comments illustrate this point:

- After qualifying as an RSCN I wanted to gain management experience. I intend to return to paediatric intensive care later in my career.

. . . too specialised I feel I would lose other skills.

. . . felt ready for promotion which I felt would take some time to obtain at this hospital.

- I wanted to stay in ICU but felt that cardio was too specialised and had limited opportunities for promotion.

Nurses also complained that it was impossible to gain promotion within ICU without an ICU course certificate. Experienced nurses in this situation may find themselves looking for other avenues in order to fulfil themselves.

Dear et al (1982) found that the strongest determinants of turnover were younger age and lower level of education. The results appear to support this finding as 25 (55.6%) of the sample were aged between 25-29. Only nine (20%) held an ICU qualification while working in the units and 13 (28.9%) left in order to attend a full-time course. At present a lot of pressure is put upon nurses by the profession to keep up-to-date. Ways of doing this are through education on full-time courses, conferences, study days and journals. If employers are unwilling to let nurses have study leave during working time then turnover may be the result.

While nurses on the adult cardio-thoracic unit most often cited lack of career development as a factor for leaving, those on the general ICU cited effects on lifestyle and family. These nurses felt unable to cope with their dual roles as nurse and mother as the following comments illustrate:

- I left to find employment with more flexibility to fit in with family commitments.

- Before I had my family working full time on GITU posed no problems at all. Following going part-time to 2 nights a week this affected my family due to lack of sleep and night duty not suiting me.

- If it had been possible to share a 37 h week with another nurse this would have been ideal for me, also creche facilities to look after my 2-year-old son.

One reason these nurses found it difficult to cope with a career and a family may have been the irregular hours nurses work. Usually nurses work a different combination of shifts each week. These irregular shifts make it more difft- cult to plan child care, especially if the nurse’s partner does not have a ‘9-to-5’job. Some of the nurses in the study would have benefited from more flexible hours and creche facilities.

Pay and clinical regrading are inextricably linked because higher grade means higher salary. The aim of clinical regrading was to reward nurses for their specialist knowledge and to keep experienced nurses within the clinical area. Nurses on ICU felt that clinical regrading had been unfair. They could see other nurses doing the same job as themselves but getting paid more for it. They also felt annoyed for not being rewarded for the responsibilities of look- ing after extremely sick people. This can be illustrated by the following comments:

- Dissatisfaction with being graded ‘C’ because of the responsibility we were expected to have.

- I don’t feel the responsibilities undertaken by staff are being recognised by the regrading system.

Nurses could often get an equivalent or better grade on the ward where they did not have the responsibility of such sick patients. Why, then, stay in ICU?

The views of these nurses regarding which grade they should have been awarded are, however, subjective. Grades were awarded against a list of criteria and not arbitrarily. However, this does not stop individuals feeling dissatisfied about their grades. Possibly these

INTENSIVE AND CRITIGALCARE NURSING 39

nurses were not just dissatisfied because a lower grade meant a lower salary but because it also affected their self-esteem and reflected the esteem in which employers held them. Ashworth (1989) states that:

- The grade given to each nurse is perceived as an indication of the value put on the work done and the person doing it as well as having financial implications.

In the literature reviewed Saleh, Lee & Prien (1965) and Porters & Steers (1973) found a significant relationship between low pay and poor promotional opportunities and increased turnover. In contrast McCloskey (1974) found nurses preferred psychological rewards rather than financial ones. In this study poor career development and pay were reasons given for turnover. However, if the nurses had been given a higher grade this might have encouraged them to stay because of the increased salary and because of the increased esteem that grade carried.

A striking difference between the units was the mean length of employment. The general ICU retained its staff the longest with a mean length of employment of 29.46 months. The mean lengths of employment on the adult and paediatric cardio-thoracic units were 18.86 and 12.46 months respectively. One reason the length of employment differs may be the nature of the work on the different units. The general ICU takes adults with a wide range of conditions. This has the effect of stimulating new interest in the nursing staff. Both the adult and paediatric cardio-thoracic units mainly take patients having elective heart and chest surgery. While this is very interesting initially it may become very routine after a while because of lack of fresh stimuli. The work on these two units is very specialised and the nurses in the sample have commented on this. Possibly the paediatric unit has the shortest mean length of employment because the nurses find it stressful looking after such sick children. Another possibility is the lack of career development on the cardio-thoracic units. The nurses may find career development more difficult because of the need for a specialist course.

These results are not unique. Waite (1987) also found that pay, promotion prospects and creche facilities influenced nurses to leave. He stated that:

- All of these are things which health authority employers, in theory at least, are in a position to rectify.

To some extent the factors indicated by respondents could have been rectified. Experi- enced nurses with post-basic course certificates could have been given a higher grade. More study leave could have been allocated and cre- che facilities could have been created. These measures all have financial implications for the employing authority. Hospitals have a limited budget and priorities as far as patients are concerned must be met. Even if the nurses had been given higher grades and unlimited study leave it is still possible the turnover would have occurred.

CONCLUSION

Role conflict can only partly explain why nurses leave, as nurses in this study left because of lack of career development and perceived poor grades. The incentives listed above would not have induced nurses to stay, it is possible higher grades might have been an incentive to stay.

Although the nurses in this study had left intensive care nursing at this particular hospital, 38 (84.4%) continued to work for the NHS and 13 (28.9%) continued to work in an ICU. These nurses may be lost to the study hospital but not to the NHS as a whole. Some clinical areas would have acquired some knowledgeable and skilled nurses. Nurse turnover does not necessarily mean nurse wastage if viewed by the NHS as a whole.

Implications for future research As stated earlier it is impossible to generalise from this research but it may be that although nurses are not leaving the NHS they are leaving ICUs in order to get better grades elsewhere.

40 INTENSIVEANDCRITICALCARENURSING

This research could be repeated to ascertain if this is the trend in other hospitals and other Health Authorities.

References

Ashworth P 1989 Clinical grading - de-grading or an opportunity? Intensive Care Nursing 5( 1): l-3

Bar&t D, McCann P 1988 Staffing for intensive care or theraov. Nursinn Times 84(25): 46-48

Dear M: Weisman?, Alexander C, Chase G 1982 The effect of the intensive care nursing role on job satisfaction and turnover. Heart and Lung 1 l(6): 56&565

Hart S, Moore M 1989 The relationship among organisational climate variables and nurse stability in critical care units. Journal of Professional Nursing 5(3): 124-131

Hay D, Oken D 1972 The psychological stresses of intensive care unit nursing. Psychosomatic Medicine 34(2): 109-l 18

Heiss J 1981 Social roles. In: Rosenberg M, Turner R H (eds) Social Psychology: Sociological Perspectives. Basic Books, New York

Hoffman P 1981 Accurate measurement of nursing turnover: the first step in its reduction. Journal of Nursing Admin 11: 37-39

Knaus W, Draper E, Wagner D 1986 An evaluation of outcome from intensive care in major medical centres. Annals International Medicine 104: 4 I O-4 18

Kosmoski K A, Calkin J D 1988 Critical care nurses intent to stay in their positions. Research in Nursing and Health 9: 3-10

Lowery B, Jacobsen B 1984 On the consequences of overturning turnover: a study of performance and turnover. Nursing Research 33(6): 363-367

McCloskey J 1974 Influence of rewards and incentives on staff nurse turnover rate. Nursing Research 23(3): 239-247

Porters L W, Steers R M 1973 Organisation work and personal factors in employee turnover and absenteeism. Psychological Bulletin 10: 151-176

Revans R W 1964 Standards for morale: cause and effects in hospitals. Oxford University Press, London

Saleh S D, Lee R J, Prien E P 1965 Why nurses leave jobs. An analysis of female turnover. Personnel Administration 28: 25-28

Searle L D 1988 The extent of the nursing shortage in critical care. Heart and Lung 17 (6, 1): 25A-29A

Stryker R 1981 How to reduce employee turnover in nursing homes and other health care organisations. C Thomas, Illinois

Waite R 1987 Waste not, want not. Nursing Times 83(27): 24-27