Workload, nurse turnover, and patient mortality: Test of a hospital-level moderated mediation model

Abstract

Background Hospitals are often tasked with improving patient care while simultaneously increasing operational efficiency. Although efficiency may be gained by maintaining higher patient volume per nurse (higher workload), high-quality patient care requires low levels of nurse turnover, which might be adversely affected by an increase in workload. Purpose Drawing upon job demands–resources theory, we hypothesized that hospital-level workload will predict nurse turnover and that nurse turnover will predict patient mortality, and that registered nurse hiring rates and human resource management practices will moderate (buffer) the positive relationship between nurse workload and nurse turnover, whereas quality care structures will moderate (buffer) the positive relationship between nurse turnover and patient mortality. Methods We tested this model utilizing multiple sources of time-lagged data collected from a sample of 156 hospitals in the United States. Results Our findings suggest that (a) nurse workload is associated with higher nurse turnover, (b) nurse turnover is positively associated with patient mortality, (c) nurse staffing buffers the workload–turnover relationship as a first-stage moderator, and (d) quality care structures act as a second-stage moderator that mitigates the effects of turnover on mortality. Conclusions/Practice Implications The reduction of nurse turnover and patient mortality requires investments in adequate levels of nurse staffing and implementation of quality care structures.