Abstract
Context
The impact of the COVID-19 pandemic on nurses was unprecedented with high volumes of critically ill patients. This strain on direct care nurses included an increased workload, long hours, separation from family, potential exposure and patient death. These factors impacted nurses’ psychological well-being and led to increased reports of nurses intending to leave their jobs. This rapid systematic review and meta-analysis aimed to synthesise the literature of rate of nurses’ intent to leave their job from the psychological impact during COVID-19.
Methods
The Preferred Reporting Items for Systematic Reviews and Meta-Analyses criteria were used to identify, screen, determine eligibility and include studies that provided the rate of nurses’ intent to leave during COVID-19. The Mixed Methods Appraisal Tool (MMAT) was used to appraise methodological quality. Ten studies were scored on five domains and studies were not excluded based on quality. The Cochran Q statistic and the I2 was calculated. These statistics estimate the proportion of variability between differences in the studies rather than by error. A funnel plot confirmed by Egger’s regression to assess for publication bias was presented.
Findings
A total of 10 quantitative, cross-sectional studies were included with sample sizes ranging from 59 to 2301 nurses representing 7 countries around the world. Seven studies measured nurse intent to leave by binary data, two studies used ordinal measures and one measured turnover intention. Using the MMAT, the risk of bias across the five domains ranged from low to high with only one study receiving low bias scores for two domains. In the meta-analysis, the calculated Cochran Q was 188.9 (p<0.0001) indicating large variation across studies, rather than within subjects in the study. The I2 was 95.2 indicating heterogeneity of findings confirmed by the funnel plot of the 10 studies. There was no publication bias as indicated by the Egger’s regression of 0.566 and the p value of 0.586.
Independent variables that were tested on intent to leave included redeployment, long working hours, workload, a negative practice environment, moral distress, stress, burnout, exposure and issues with patient’s quality and safety.
Among the 10 studies, 8 teams found statistically significant relationships between these independent variables and intent to leave. For the two studies that did not find significant relationships, the relative weight of the contribution to the pooled result was only 18.5%. Therefore, the random effect model estimated that the overall nurse intent to leave was 31.7% (95% CI: 25% to 39%).
Commentary
Ulupınar and Erden conducted a rapid systematic review and meta-analysis. The methods employed were strong; however, each study included small sample sizes, diverse populations (ie, nurse managers, practitioners) and specialties (ie, intensive care, emergency room) limiting generalisability. None of the studies scored low risk for bias from all five domains of the MMAT and studies were not excluded on methodological quality. Indeed, the article rated with the lowest risk of bias did not find a statistically significant effect between anxiety and intent to leave. These studies were likely the only available evidence on intent to leave at the time.
One-third of nurses intend to leave their jobs because of the COVID-19 pandemic. It is well documented that mental problems, sleep disturbances, anxiety, moral distress and depression are higher among nurses. Additionally, burnout coupled with physical exhaustion from the increased workload of caring for COVID-19 patients confirms the one-third intent exacerbating a nursing workforce shortage.
The authors synthesise the evidence on strategies to retain nurses including increasing competencies in caring for COVID-19 patients, ensuring personal protective equipment (PPE) and providing psychological support. Additional interventions include strengthening communication between management and clinical nurses, implementing innovative staffing models such as tiered nursing or flex shifts, providing areas for nurses to recuperate and ensuring warehouses of PPE. The psychological impact of the pandemic resulted in the nurse’s intent to leave. However, nurses also exhibited post-traumatic growth from a sense of duty to their patients that demonstrated the ability to adapt, be innovative and provide high, quality patient care during this time that also needs to be researched.
Acknowledgments
The authors of this commentary would like to acknowledge the Center for COVID-19 Response and Pandemic Preparedness at Rutgers University that funded their research on intent to leave.