IHP 600 Module 6 Milestone Two Example

Milestone Two: Why Nurses Leave Summit Valley, a Root Cause Analysis

[Student Name]

Southern New Hampshire University

IHP 600: Social and Organizational Issues in Healthcare

Module Six Milestone Two

[Instructor Name]

[Date]

The organization, setting and figures below are a composite written as a model document. No real employer, client, colleague or patient is described.

Milestone Two: Why Nurses Leave Summit Valley, a Root Cause Analysis

Milestone One established that 187 registered nurses left Summit Valley Medical Center last year, with the heaviest losses among first-year nurses and on medical-surgical units. This milestone asks why. It combines exit interviews, survey results, unit staffing data and interviews with four nurse managers, organizes the causes using a recognized model and ranks them so that the recommendations in Milestone Three target what matters most.

The Analytic Framework

Demerouti et al. (2001) proposed the job demands-resources model, which holds that every job has demands, the physical, psychological and organizational aspects that require sustained effort, and resources, the aspects that help people achieve goals, reduce the cost of demands or support growth. In their study, high demands were linked mainly to exhaustion, while a lack of resources was linked mainly to disengagement. The model suits this analysis because it points to two different kinds of fixes: reducing demands and adding resources.

Evidence Gathered

Four sources informed the analysis: 97 coded exit interviews; the staff survey, answered by 612 nursing staff; staffing and turnover records for nine inpatient units; and structured interviews with four nurse managers. A cause-and-effect diagram was drafted with six managers and charge nurses and then tested against the data, so that causes remained in the analysis only if at least two sources supported them.

Demand: Patient Load

The strongest pattern in the unit data is between average patients per nurse on day shift and annual turnover. The three units averaging 6.5 or more patients per nurse lost between 29% and 34% of their nurses; the three averaging under 5 lost between 12% and 16%. Acuity is also rising, with the share of medical-surgical patients requiring frequent reassessment up by about a fifth in three years. Sixty-one of 97 departing nurses named workload.

Table 1. Day-Shift Patient Load and Turnover by Unit Group

Note. Composite data for nine inpatient units over one fiscal year.

Demand: Overtime and Schedules

Mandatory overtime rose 34% in two years, and on higher-load units nurses reported being held over an average of twice a month. Schedules are posted two weeks ahead and changed often, making childcare and school difficult. Night shift nurses reported the least predictability and left at higher rates.

Missing Resource: Break Relief and Support

No unit has a dedicated break relief nurse, so breaks depend on colleagues covering one another's patients on top of their own. Survey respondents on higher-load units reported missing a meal break on more than half their shifts. Nursing assistants are frequently pulled to sit with confused patients, removing another source of help.

Missing Resource: Precepting for New Nurses

New graduates receive eight weeks of orientation with a preceptor who carries a full assignment of their own. Managers described preceptors as exhausted and new nurses as left alone within weeks. Of the 49 first-year nurses who left, 31 cited feeling unprepared or unsupported. There is no structured program after orientation ends, the period when many new nurses find the transition hardest.

Missing Resource: Control and Voice

Nurses have no input into assignments or schedules, and survey results showed only 33% of medical-surgical nurses believe leaders act on feedback. Maslach and Leiter (2016) identify control and fairness among the areas of work life where mismatches feed burnout; exit interviews at Summit Valley echoed both, with nurses describing assignments made without regard to acuity and agency colleagues paid more for identical work.

What Is Not a Primary Cause

Pay was named as the main reason by only 18 of 97 departing nurses, and Summit Valley's base rates sit within 3% of the regional median. Pay matters, and targeted adjustments for night shift may be warranted, but the evidence does not support pay as the root cause. Similarly, relocation and retirement accounted for 22 departures, which the hospital cannot readily prevent.

What the Managers Added

The four manager interviews explained how these causes feel from the middle of the organization. Each manager described spending the first hour of most shifts rebuilding a schedule after call-outs, leaving little time to round on staff or follow up on concerns. Two said they had stopped escalating staffing problems because requests for float nurses were routinely denied. All four named the same wish: authority to approve break relief or an extra nurse on high-acuity days without a lengthy approval chain. Their accounts suggest that the lack of voice nurses report is partly inherited from managers who themselves lack control over resources.

Ranking the Causes

A Pareto table ranks causes by how often departing nurses named them as a primary or secondary reason. Workload, unsupported transition, lack of voice and schedule instability together account for most of the cited reasons, and all four are within the hospital's control.

Table 2. Causes Cited in 97 Exit Interviews

Note. Nurses could name up to two reasons; 210 citations in total.

Why the Causes Must Be Tackled Together

The causes interact. Heavy loads leave no one free to relieve breaks or precept properly, which makes new nurses leave, which raises loads further. Brand et al. (2017) reviewed whole-system approaches to health care worker well-being, meaning interventions that act at several levels of an organization at once, and concluded that such approaches showed promise for improving staff health and well-being, although the evidence base was still limited. Addressing only one cause, such as adding a residency without easing loads, is likely to leave the cycle intact.

Limitations

Exit interviews capture stated reasons, which may differ from underlying ones. The unit comparison shows association, not proof that load causes turnover, since high-load units may differ in other ways such as leadership. The author's role as a manager may have influenced what managers and charge nurses shared.

Conclusion

Turnover at Summit Valley is driven mainly by high demands, especially patient load and unstable schedules, and by missing resources, especially break relief, structured support for new nurses and a voice in decisions. These causes are interconnected and largely within the hospital's control. Milestone Three will design responses aimed at each.

References

Brand, S. L., Thompson Coon, J., Fleming, L. E., Carroll, L., Bethel, A., & Wyatt, K. (2017). Whole-system approaches to improving the health and wellbeing of healthcare workers: A systematic review. PLOS ONE, 12(12), Article e0188418. https://doi.org/10.1371/journal.pone.0188418

Demerouti, E., Bakker, A. B., Nachreiner, F., & Schaufeli, W. B. (2001). The job demands-resources model of burnout. Journal of Applied Psychology, 86(3), 499-512. https://doi.org/10.1037/0021-9010.86.3.499

Maslach, C., & Leiter, M. P. (2016). Understanding the burnout experience: Recent research and its implications for psychiatry. World Psychiatry, 15(2), 103-111. https://doi.org/10.1002/wps.20311