1 International Peer Reviewed Journal Nurse Turnover: Implication on Health Care Delivery JOYCE C. BISNAR https://orcid.org/0000-0002-3032-9582 joycealiver@gmail.com Notre Dame University Cotabato City Philippines KATHLEYA GRACE N. PEGARRO https://orcid.org/0000-0002-2997-7929 kathpegarro19@gmail.com Notre Dame University Cotabato City Originality: 100% • Grammar Check: 100% • Plagiarism: 0% ABSTRACT Nurse turnover is a major problem to all health care organizations because of its strong effects on client outcomes, motivation to work, job dissatisfaction and provision of quality patient care. The study aimed to determine the implication/ effects of nurse’s turnover on healthcare delivery. Mixed method and Descriptive research design were employed, and the census was used in the selection of the participants. A validated self- made questionnaire, focus group discussion and key informant interview was utilized to gather the empirical data required. The study revealed that there was a decrease nurse turnover rate in the government hospital and an increase in private hospitals due to low salary, no/ less fringe benefits, poor/no health insurance coverage, better benefits and compensation package offered by other hospitals/countries and lower patient ratio. However, with the increase or decrease in the turnover rate, health care delivery in relation Vol. 34 · October 2018 DOI: https://doi.org/10.7719/jpair.v34i1.626 Print ISSN 2012-3981 Online ISSN 2244-0445 This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License. https://orcid.org/0000-0002-3032-9582 mailto:joycealiver@gmail.com https://orcid.org/0000-0002-2997-7929%20 https://creativecommons.org/licenses/by-nc/4.0/ https://creativecommons.org/licenses/by-nc/4.0/ 2 JPAIR Multidisciplinary Research to the identified five (5) key areas of nurses’ responsibility are still affected due to increased nurse-client ratio, interpersonal relationship, stressful environment and attitudes of the millennial nurses. Further, the majority of the participants are millennials and they outnumbered the generation X and baby boomers who created a generation gap in terms of health care delivery. This shift in attitude poses a great challenge for hospitals to retain millennials because they are growing in numbers and are replacing baby boomers and generation X. Thus, hospitals had to learn, adjust and develop management strategies to accommodate and understand the unique style and attitudes of the millennials for retention. Keywords - Nursing, nurse turnover, push and pull factor, descriptive design, Cotabato City, Philippines. INTRODUCTION While nursing is one of the fastest growing profession (United States Department of Labor, 2018), there is an alarmingly high rate of nurse turnover and shortage. According to Yeates (2010), nurse shortages associated with globalization had hugely increased the hiring, migration, and mobility of nurse in all countries. Reports showed that nurse turnover had increased worldwide to 17.2% in 2015 from 16.4% in 2014 (Solutions, 2016). Additionally, World Health Organization (WHO) estimated a shortage of 4.3 million nurses globally and will continue to worsen with projected deficits of about 57% from 2020 to 2025, Twigg and McCullough (2014). The 2017 RN Survey strongly suggests generous change in the nursing workforce causes the workforce and the progression of baby boomers retirement (AMN healthcare, 2017) resulting to decreased performance in the workplace because skilled nurses and experts are replaced with newbies, and inexperienced (Wieck and Moss, 2015) causing nurse stressed, burned out, job dissatisfaction and turnover (McHugh and Ma, 2014)thus affecting quality healthcare delivery and adverse client outcomes, Texas Health and Human Services (2012). The increasing demand and shortage of nurses pushed developed and high–income countries to do mass hiring of educated and well-trained nurses from low and middle-income countries such as the Philippines which resulted in the depletion of the country’s most experienced and well-qualified nurses, (Dimaya,   McEwen,  Curry, and  Bradley, 2012; Dywili, Bonner, & O’Brien, 2013). Further, push and pull factors such as low salaries, lack of benefits package, high client-nurse ratios, lack of opportunities and professional growth, https://www.ncbi.nlm.nih.gov/pubmed/?term=Dimaya%20RM%5BAuthor%5D&cauthor=true&cauthor_uid=23249411 https://www.ncbi.nlm.nih.gov/pubmed/?term=McEwen%20MK%5BAuthor%5D&cauthor=true&cauthor_uid=23249411 https://www.ncbi.nlm.nih.gov/pubmed/?term=Curry%20LA%5BAuthor%5D&cauthor=true&cauthor_uid=23249411 https://www.ncbi.nlm.nih.gov/pubmed/?term=Bradley%20EH%5BAuthor%5D&cauthor=true&cauthor_uid=23249411 3 International Peer Reviewed Journal and compensation package (Asegid,  Belachew, and  Yimam, 2014, McHugh and Ma, 2014) influenced nurses to leave. Philippine Overseas Employment Administration (POEA) reported that there is an increasing migration of nurses every year from 15,655 in 2012 to 16,444 in 2013 and 19,815 in 2014. (Asian Journal, 2016) Causing a significant problem to all healthcare organizations because of its strong effects to client outcomes, motivation to work, job dissatisfaction, and provision of quality patient care, (Roche, Duffield, Homer, Buchan and Dimitrelis, 2014; Masselink & Lee, 2010). This global phenomenon is an excellent challenge to all healthcare organization and solutions are essential and critical to prevent the worsening of adverse health outcomes. Nurses deliver health care services in many and varied settings armed with competencies they developed from school and workplace guided by the Core Competencies Standards for Nursing Practice (also known as the Key Areas of Nurses Responsibility). This standard requires nurses to utilize their knowledge and judgment to assess clients and family health needs, provide care and support to manage their health. Several studies on the effects of nurse turnover is well discussed and documented, however, it is focused more on its cost to health care system without considering its impact on delivery of health care services in terms of the five (5) critical areas of nurse’s responsibility on safe and quality care, health education, communication, collaboration and teamwork, and records management thus this study (Lazarte, 2016). FRAMEWORK Abraham Maslow Hierarchy of Needs (1970) is a motivational theory composed of five classes of human needs depicted as hierarchical levels within a pyramid in ascending order, which ranges from physiologic needs through safety, belonging, and esteem, to self-actualization (Mathes, 1981). In this theory, Maslow argued that lower level needs had to be satisfied before one can move on the higher levels. As each lower-level need is satisfied, the person will aim to go to the next higher demand until it is satisfied. Considering Maslow‘s hierarchy of needs theory in relation to nurses turnover, one can assert that nurses need better salaries, fringe benefits, insurance benefits, recognition, and good interpersonal relationship with the members of the healthcare team for them to achieve self- actualization needs. The implication of this theory to the study is that, if nurse’s needs are met and are satisfied with their work then they will be motivated to stay in the institution/ organization. https://www.hindawi.com/43810642/ https://www.hindawi.com/63419096/ https://www.sciencedirect.com/science/article/pii/S0897189717301234 https://www.sciencedirect.com/science/article/pii/S0897189717301234 4 JPAIR Multidisciplinary Research Another theory in relation to the study is Vroom`s Expectancy Motivation Theory. His theory is based on the belief that an employees’ effort will lead to performance and performance will lead to rewards (Vroom, 1964). The theory emphasizes that employees will perform their best and put more effort into their work equal to what they expect in return such as pay increase, recognition, additional benefits and opportunities for promotion. If employees will not be compensated and personal and professional growth opportunities will not be provided in return for their hard work, they will put little effort and eventually leave their work and look for new opportunities from other organization. Vroom’s expectancy theory can also be associated with Maslow`s hierarchy of needs. Maslow is used to describing which and what particular outcomes individuals can be motivated and Vroom described whether individuals would act based on their experience and expectations. OBJECTIVES OF THE STUDY The following objectives have been framed to guide the research to (1) determine the nurse’s turnover rate for the past five years, (2) determine the push and pull of nurse turnover, (3) determine and analyze the implication of nurse’s turnover on healthcare delivery in terms of (a) Safe and quality nursing care, (b) Health education (c) Communication (d) Collaboration and Teamwork (e) Records management and (4) find out the actions taken by the institutions in addressing the implications of nurse turnover. METHODOLOGY Research Design This study employed a mixed method and descriptive research design as it described, discussed and analyzed the push and pull factor of nurse turnover, its implication on healthcare delivery. Further, the researchers determine the actions and interventions taken by the institution to address the problems on the push and pull factors of nurse and the implication on health care delivery. Research Site The study was conducted in Cotabato Regional and Medical Center and other private Hospitals in Cotabato City such as Notre Dame Hospital and School of Midwifery, Cotabato Puericulture Center and General Hospital Foundation Inc. 5 International Peer Reviewed Journal Cotabato Regional and Medical Center (CRMC) which is the only government- owned Hospital in Cotabato City with 400-bed capacity whose vision and mission is to be the center of excellence thru delivery of quality, affordable, equitable and sustainable specialized health care services in partnership with all stakeholders towards customer satisfaction. It is located in front of Mall of Alnor along Sinsuat Avenue. Notre Dame Hospital and School of Midwifery is a secondary hospital with 100-bed capacity located parallel to Cotabato Regional and Medical Center. It is owned and managed by the Dominican sisters whose vision and mission are to commit to compassionate human resource formation while pursuing effective and efficient healthcare management. While Cotabato Puericulture Center and General Hospital Foundation Inc. were formerly known as Cotabato Puericulture Center and Maternity and Children Hospital Inc.is a semi-private primary hospital with 30-bed capacity and is located at the heart of the city, in front of Cotabato City Plaza. Participants The participants of the study are the 97 senior nurses and supervisors of the General, Obstetrics-Gynecology, and Pediatric- Medicine who have been working from the three (3) identified hospitals for more than two (2) years, 51 of which are from Hospital A, 30 from Hospital B and 16 from Hospital C while Hospital D refused to participate in the study thus they are excluded. The qualitative data was collected from the 23 senior nurses and supervisors through focus group discussion and three chief nurses of the three (3) hospitals through an interview. Sampling Technique Census was used in the selection of the participants. A total of 97 participants including all senior nurses, supervisors and chief nurses who have been working in the three (3) identified hospitals for 2 years or more participated in the study. Fifty-one (51) are from Hospital A, thirty (30) from Hospital B and sixteen (16) from Hospital C. Instrumentation The instruments used for data gathering is a self-made questionnaire checked and validated by experts with a rating of 4.3 out of 5 points score which means very good. The comments or suggestions to improve the paper were incorporated 6 JPAIR Multidisciplinary Research into the instruments. The said questionnaire is composed of three (3) Parts. Part I pertains to the demographic profile of the participants. Part II consisted of the questions that determined the push and pull of nurse turnover and the participants were asked to answer the questions using the following scale: 2-Yes; 1-No. Part III is composed of items that pertain to the implications of nurse turnover on healthcare delivery. The data was collected through interview and focus group discussion of senior nurses, and supervisors and Part IV seeks to find out the actions/ interventions taken by the Institution in addressing the push and pull factor of nurses’ turnover and the implication on health care delivery. It is composed of questions which were answered by three chief nurses from the three (3) selected hospitals as key informants. Data Gathering Procedure Initially, a survey was done to determine the number of senior nurses, supervisors and chief nurses of the four (4) hospitals. Upon approval of the study by the university research council, a letter of permission was submitted to Hospitals A, B, C, and D administrators for the conduct of the research and the researcher sought approval from the Research Ethics Board. Once approved, the actual conduct of the study commenced with a letter of permission to the participants stating the purpose and benefits of the study and their right to refuse to participate once they feel that their right is violated. The validated survey questionnaire was distributed and retrieved personally by the researcher considering strict confidentiality and anonymity. The researchers did a one on one interview to the three (3) chief nurses as key informants and focus group discussion to the senior nurses and supervisors. The data gathered was tallied and tabulated. Consultation with the statistician was made for the computation and other statistical treatment needed for the interpretation and analysis of the data collected. Ethical Considerations The participants were informed that their participation was voluntary and was assured that the researcher would maintain the confidentiality and anonymity of the data with the departments and their hospital of affiliation. The result of the research was presented to the university the research panel, validators and public without mentioning the hospital of affiliation instead a letter in the alphabet such as ABC was designated as a representation of each hospital to ensure that confidentiality is practiced and maintained. The chief nurses of the hospital and participants were informed that they would be provided with a copy of the results 7 International Peer Reviewed Journal for their perusal and reference. The researchers obtained an Ethics Clearance from the Ethics Review Committee and signed the informed consent from the participants. Statistical Analysis The quantitative data gathered was tallied, tabulated and treated with descriptive statistics. In depth analysis was done through the formulation of themes and patterns for the qualitative data to validate and expound the quantitative data gathered. Tallying, interpretation, and analysis of the data were done with the help of the statistician. The qualitative data were transcribed, analyzed, and integrated with the quantitative data. RESULTS AND DISCUSSION Findings of this study are presented in a descriptive and tabular form, analyzed and interpreted to answer the research objectives. Data were gathered to determine the push and pull factors of nurse turnover; it’s the implication on health care delivery and the actions or interventions taken by the institution to address the implication of nurse turnover. Nurse Turnover Rate for the Past 5 years Figure 1 and 2 show the nurse turnover rate of the hospitals. Increase in nurse turnover rate is significantly high with hospital B and decreasing in hospital A. Figure 1. Nurse Turnover Rate for the Past 5 years 8 JPAIR Multidisciplinary Research Figure 2. Frequency Distribution of Nurse Turnover per Year Profile of the Participants The profile of the participants includes the age, gender, hospital of affiliation, position, and the number of years working in the hospital. Table 1 presents the demographic profile of the participants. In terms of age, majority or 79. 4 % of them are millennials while only 6.2% are baby boomers and out of the 97 nurse-participants, 67 or 69.1% of them are female while 30 or 30.9% are male. On hospital of affiliation, the majority of them came from Hospital A (52.6%) which is a government hospital, followed by Hospital B (30.9%) and Hospital C (16.5%), both are private hospitals. (79.4%) of the participants are senior nurses while the rest are supervisors (20.6%). In terms of the number of years working in the hospital, the majority of them have been working for at least 3 – 6 years (54.6%) followed by 7 – 9 years of service (9.3%) and those who have been there for 20 years and above (8.2%). Their mean number of years working in the hospital is 7.35 or 7 years. 9 International Peer Reviewed Journal Table 1. Demographic Profile of the Respondents Profile f % Age Millennials( 22-37 years old) 77 79.4 Generation X ( 38-53 years old) 14 14.4 Baby Boomers (54- 72 years old ) 6 6.2 Gender Female 67 69.1 Male 30 30.9 Hospital of Affiliation Hospital A 51 52.6 Hospital B 30 30.9 Hospital C 16 16.5 Position Senior Nurse 77 79.4 Supervisor 20 20.6 Number of Years Working in the Hospital 2 years and below 2 2.1 3 – 6 years 53 54.6 7 – 9 years 9 9.3 10 – 12 years 6 6.2 13 – 15 years 6 6.2 16 – 19 years 4 4.1 20 years and above 8 8.2 Mean No. of Years Working in the Hospital: 7.35 or 7 years Total 97 100.0 Table 2 presents the push and pull factors of nurse turnovers. The participants were made to answer a yes or no questions to determine their reasons for leaving/staying at their current workplace. In terms of the push factors, most of the them stated that low salary (highest of 77.3%), non-competitive fringe benefits (74.2%), no overtime (73.2%), poor/no health insurance coverage (72.2%), and work overload, as well as stressful working environment (69.1%), were their top reasons for leaving their current workplace. While majority answered no to no hazard pay as a push factor (72.2%). 10 JPAIR Multidisciplinary Research On the pull factors, most of the nurses stated that better benefits and compensation package (highest of 79.4%), influence from peers and relatives (72.2%), lower nurse-patient ratio (70.1%), chance to upgrade nursing skills (61.9%) and higher salary (60.8%) were their top reasons of staying in their current workplace. Table 2. Push and Pull Factors of Nurse Turnover Push and Pull Factors YES NO Push Factors f % f % 1. Low Salary 75 77.3 22 22.7 2. No Overtime 71 73.2 26 26.8 3. Poor/ No health insurance coverage 70 72.2 27 27.8 4. Work Overload and stressful working environment 67 69.1 30 30.9 5. Slow Promotion 57 58.8 40 41.2 6. Limited opportunities for professional development 60 61.9 37 38.1 7. Non-Competitive Fringe Benefits 72 74.2 25 25.8 8. Socio-economic Situation 62 63.9 35 36.1 9. No Hazard Pay 27 27.8 70 72.2 Pull Factors 1. Higher salary 59 60.8 38 39.2 2. Better benefits and compensation package 77 79.4 20 20.6 3. Lower nurse-patient ratio 68 70.1 29 29.9 4. More options in working hours 54 55.7 43 44.3 5. A chance to upgrade nursing skills 60 61.9 37 38.1 6. Opportunity for the family to migrate 48 49.5 49 50.5 7. Opportunity to travel and learn other cultures 55 56.7 42 43.3 8. Influence from peers and relatives 70 72.2 27 27.8 9. Advanced technology 58 59.8 39 40.2 10. Better socio-political and economic stability 53 54.6 44 45.4 Implications of Nurse Turnover on Health Care Delivery In terms of the safe and quality nursing care, nurse turnovers would result in less time spent to perform bedside care and basic nursing procedures (highest of 67%), lack of focus on the demands or needs of patients and their family 11 International Peer Reviewed Journal members (59.8%) increased risk of nosocomial infections as well as delayed discharges (both at 58.8%) and delayed nurse’s response to clients /watcher’s call as well as increased client’s wait time for diagnostic tests/procedures (both at 57.7%). However, the results reveal that nurse turnover would not result in increased client’s complaints on nursing care provided (53.6%) and less/ no time for nurses to detect complications (51.5%). In terms of health education, nurse turnover would result in inadequate individual client’s health education (highest of 55.7%), less time or no time to provide specific group health education (54.6%) and insufficient time to give health education to clients and family (50.5%). In terms of communication and collaboration, nurse turnovers would result in lack /no time for nurses communicate with the client and members of the family (highest of 61.9%),and problems/ conditions are not addressed in a timely manner as well as inadequate nurse’s education on how client’s and family will take care of their illness or injury (both at 58.8%). In terms of records management, nurse turnovers would result in failure of the nurses to document some important client information as well as less or no time to discuss clients’ condition with members of the health care team (highest both at 59.8%) and mismanagement of nurses of client’s records. However, the results reveal that nurse turnover would not result in increased risk for inaccurate information (53.6%) and poor referral to members of the healthcare team (50.5%). 12 JPAIR Multidisciplinary Research Table 3. The Implication of Nurse Turnover on Health Care Delivery The Implication of Nurse Turnover on Health Care Delivery YES NO Safe and Quality Nursing Care f % f % 1. less time spent to perform bedside care and basic nursing procedures 65 67.0 32 33.0 2. increase/ risks in medication error 55 56.7 42 43.3 3. decrease efficiency and effectiveness of nursing care 51 52.6 46 47.4 4. delayed nurse’s response to clients /watcher’s call 56 57.7 41 42.3 5. increase the client’s complaints on nursing care provided 45 46.4 52 53.6 6. increased risk of nosocomial infections 57 58.8 40 41.2 7. delayed discharges 57 58.8 40 41.2 8. increased client’s wait time for diagnostic tests/procedures 56 57.7 41 42.3 9. lack of focus on the demands or needs of patients and their family members 10. less/ no time for nurses to detect complications 58 47 59.8 48.5 50 39 40.2 51.5 11. increase the incidence of complications and/or adverse events during the hospitalization 55 56.7 42 43.3 Health Education 12. insufficient time to give health education to clients and family 49 50.5 48 49.5 13.. inadequate individual client’s health education 54 55.7 43 44.3 14. less time or no time to provide a specific group health education 53 54.6 44 45.4 15. inadequate nurse’s education on how client’s and the family will take care of their illness or injury 57 58.8 40 41.2 Communication, Teamwork and Collaboration 16. problems/ conditions are not addressed in a timely manner 57 58.8 40 41.2 17. lack /no time for nurses communicate with the client and members of the family 60 61.9 37 38.1 18. increase staff communication problem 49 50.5 49 50.5 19. failure of the nurses to communicate clients condition to significant health team members 56 57.7 41 42.3 20. poor referral to members of the healthcare team 48 49.5 49 50.5 21. less or no time to discuss clients condition with members of the health care team. 58 59.8 39 40.2 Records Management 22. mismanagement of nurses of client’s records 53 54.6 44 45.4 23. failure of the nurses to document some important client information 58 59.8 39 40.2 24. increase risk for inaccurate information 45 46.4 52 53.6 13 International Peer Reviewed Journal QUALITATIVE DATA Table 3 reveals the implication of nurse turnover on health care delivery. The implication of nurse turnover on health care delivery was observed through four domains namely the safe and quality nursing care, health education, communication, teamwork and collaboration and records management. Despite the decreasing nurse turnover rate in hospital A (government hospital), still there occur issues, concerns and problems in health care delivery brought about by the increasing nurse-client ratio which is 1:30-40. However, in Hospital B and C, there was an increasing turnover rate especially in the last two years due to hiring in the government hospital and to look for better directions in their careers and opportunities abroad. Though they have a 1:10 to 1:12 nurse-patient ratio, they still have problems in delivering quality health care brought about by the constant change of nurses from highly experienced to no experience nurses. The most common issues and concerns identified and it’s implication on healthcare delivery discussed during the FGD, Key Informant Interview, Validation and the result of the study revealed that, first, senior nurses and supervisors verbalized 1:12 nurse-patient is not followed, problems such as medication errors, no time for bedside care, documentation on the care given to clients is lacking, health education is given in passing and nurses are focused on paper works rather than client care. Additionally, the change in the curriculum to K-12 program created a great impact on the development of student nurses’ skills since they are not allowed to give intravenous medications thus affecting their confidence in drug administration when they are hired as staff nurses resulting to medication errors. Second, newly hired nurses are hesitant and afraid to perform basic nursing procedures because the clinical instructors handling them during their student years are not aggressive in letting them perform procedures in their related learning experience (RLE). Third, relationship with co-nurses is affected especially when the nurse is lazy and absents themselves during their scheduled shift. Fourth, millennial nurse’s attitude and values towards work. They always complain of easy fatigability, no/ lack self-confidence to perform procedures such as administration of IV medication, no/ lack decision making, no command and initiative at work, do not provide clients a thorough explanation on the procedures they performed and medications they administer and lack / non provision of tender loving care to clients which created a gap with generation x and baby boomers. As verbalized by the senior nurses and nurse supervisors millennials 14 JPAIR Multidisciplinary Research are not open to comments, suggestions and they hate to be reprimanded. Once reprimanded, they take it personally and decides to leave work. In addition, millennials do not want to stay in one place because they wanted to explore other ventures to satisfy their curiosity. Fifth, the orientation of new nurses and the transfer of areas of assignment without orientation. As suggested by senior nurses, area orientation period should be lengthened to 2 months to ensure that new nurses have learned and developed their skills. Re-orientation should be done, when nurses are transferred to other departments, although they are familiar with the routine activities, nurses need to know and understand that each client have different needs and concerns and each department has its own standard operating procedures to ensure the delivery of quality health care services. Allowing them to adjust to the new environment will boost their morale and confidence in doing their tasks resulting in job satisfaction and good client outcomes. To address the issues and concerns on the errors and committed mistakes, the hospital has policies, guidelines and hospital protocols to hand to prevent its occurrence and recurrence. The private hospitals (B and C) motivate nurses to stay in the hospital by developing a good interpersonal relationship with the nurses, giving them more options in terms of duty scheduling, increasing their salaries and enhancing their benefits. If they cannot stay long, they are encouraged to finish their contract before they leave and in return, they are given a certificate of employment and recommendation to work in other hospitals or abroad. While nursing continues to be one of the fastest growing professions, there is an alarmingly high rate of nurse turnover and the increasing demand of nurses by other institutions and countries is brought about by aging nursing workforce and many baby boomers are nearing retirement (Haddad and Butler, 2018). In this present study, the result revealed that most of the participants are millennials or between the age of 22 to 37 years, have worked in the hospital for 3 to 6 years and they outnumbered the generation X and baby boomers who have worked for more than 15 years. Auerbach, Buerhaus, and Staiger (2017) presented that the baby-boomer registered nurses (RNs), the largest segment of the RN workforce from 1981 to 2012, are now retiring and the millennials who are entering the nurse workforce has double the rate of the boomer, however, they rarely intend to stay with one employer for their entire career or possibly even more than a few years, Costanza, Badger, Fraser, Severt and Gade (2012). As agreed by Kovner, Brewer, Fatehi & Jun (2014) about 17.5% of new nurses leave their first job within one year of starting their careers. https://www.healthaffairs.org/author/Auerbach%2C+David+I https://www.healthaffairs.org/author/Buerhaus%2C+Peter+I https://www.healthaffairs.org/author/Staiger%2C+Douglas+O 15 International Peer Reviewed Journal On nurse turnover, there was an increased rate in private hospitals and a decrease in government hospitals in the last three years. In contrast to these find- ings, Chien and Yick (2016) stated that nurse turnover rate in private hospitals are low or decrease because nurses are moderately stressed and satisfied with their work environment and relationships. However, during the focus group discus- sion and key informant interview the participants verbalized that nurses in pri- vate hospitals experienced almost the same stress with those working in govern- ment brought about by the constant changing of nurses. Nurses who are still on the stage of learning and developing their skills are obliged to mentor the newly hired nurses since experts and seasoned nurses left the hospitals. The difference in salary and fringe benefits are the most common noticeable reasons why nurses go and not stress. Although work overload and the stressful environment is one of the top five push factors of nurse turnover, its impact is not as high as that of low salary and no/fewer fringe benefits. As agreed by Lorenzo, Galvez‐Tan, Icamina, & Javier (2013) push factors in- clude low salary, no overtime or hazard pay, poor health insurance coverage, work overload or the stressful working environment. Additionally, the World Health Organization (2017) stated that nurses sought better wages, improved working conditions and the higher standard of living not present in their native countries. However, it has been observed that there is a different idea on the result of the push and pulls factor. Lower salary is the number one push factor while a higher wage is the fifth pull factor. Nevertheless, still, it is one of the five identified fac- tors of `nurse turnover. Nurse turnover as mentioned is a significant problem by all healthcare or- ganization because of its adverse effects on quality healthcare delivery and client outcomes. What is unique in this study is, it emphasizes and focuses more on the impact of nurse turnover on the five (5) of the eleven (11) critical areas of nurse’s responsibilities rather than the operational costs as other researches and studies did. The five key areas of responsibilities identified are safe and quality nursing care, health education, communication, teamwork and collaboration, and records management. On safe and quality nursing care, the study revealed that nurse turnover resulted in less time spent to perform bedside care and necessary nursing proce- dures, lack of focus on the demands or needs of clients and their family members, delayed discharges, delayed nurse’s response to clients/watcher’s call, increased client’s wait time for diagnostic tests/procedures and is agreed upon by the chief nurses, supervisors and senior nurses during interview, focus group discussion. 16 JPAIR Multidisciplinary Research Further, the interview revealed that staff nurses commonly committed medica- tion errors in contrast to the result of the survey as the least problem for safe and quality care. Bolandianbafghi, Salimi, Rassouli, Faraji, and Sarebanhassanbadin (2017) accounted for medication Errors to stress, nurse’s burnout, and job dis- satisfaction as a result of understaffing caused by the increase in nurse turnover. Health education is essential in nursing for it will help improve the health status of individual client and their family, especially in a culturally diverse com- munity such as Cotabato City. Unfortunately, nurse turnover resulted in inad- equate nurse’s education on how clients and family will take care of their illness or injury, insufficient and insufficient time to give health education to individual client and their family. These findings of the study are agreed and validated by supervisors and senior nurses that ward nurses lack/no time to explain the im- portance of nursing procedures performed. Although they feed client with little information, it is not enough for clients to understand considering the cultural diversity in the place. As Raingruber (2013) cited health education are activi- ties that seek to inform individual client on the nature and causes of health and illness, and it motivates them to accept behavioral change by influencing their values, attitudes, and beliefs. Nevertheless, it did not materialize in the present study. Relative to health education, communication is an essential factor for the success of the outcome of individualized client care. According to Kourkouta and Papathanasiou (2014) and Vertino (2014), communication plays an essen- tial role throughout the client’s healthcare experience, and great responsibility falls on nurses. They must be able to relay information especially during periods of intense stress. The problem in communication was seen in the present study, nurses recognized the importance of communication but due to increased work- load, they lack or no time to communicate with the clients and their family and less or no time to discuss client’s condition thus problems are not appropriately addressed. Increase staff communication problem was also mentioned during the focus group discussion and validation, although it is the least identified prob- lem in the survey. This problem is due to the attitude of the millennials such as they are lazy to perform the task given to them because they quickly get tired, stressed and burnout, no/ lack decision making, and initiative at work thus af- fecting quality client care and satisfaction. Institute for Healthcare Communica- tion (2011) and Nacioglu (2016) stated that the client’s perception of the quality healthcare they received is highly dependent on the quality of interaction with the healthcare team. 17 International Peer Reviewed Journal Collaboration and teamwork are noticeable in all hospitals. Participants ver- balized that they seldom experienced problems regarding communication and referral to other healthcare team members thus it is the least problem identified in the survey. The healthcare team members are cooperatively working together, using the proper referral system to formulate and carry out plans for client care, (O’Daniel and Rosenstein, 2011). As observed majority of local healthcare providers in the Philippines are still using the paper-based records, which poses challenges for nurses because it does not only affect their primary function to client care but also their ability to man- age their task/work efficiently (Wood, 2015) With increased workload brought about by nurse-client ratio, nurses fail to document some vital client information and mismanaged client’s records. According to Luthuli and Kalusopa (2017), Medical record mismanagement can result in delays in delivering necessary medi- cal treatment and incorrect diagnosis. Although problem on misdiagnosis due to records mismanagement was not experienced, still the hospitals are taking significant steps to prevent its occurrence. The hospitals motivated them through salary increase though it is not that competitive with other institution, developing a good interpersonal relationship, enhancing nurses’ benefits and more options regarding duty schedule to retain nurses. The responses of the participants are agreed upon by that, improving the work environment for nurses makes it easier for hospitals to reduce turnover and retain them because a negative work environment may lead to job dissatisfaction and nurse’s burnout which may have an adverse effect on client outcomes. Addi- tionally, it may also result in more turnover as departments become understaffed and more nurses will experience burnout (Nantsupawat, Kunaviktikul, Nantsu- pawat, Wichaikhum, Thienthong, & Poghosyan, 2017 and Kerfoot, 2015). More importantly, the hospital shifted from practical nursing to modified primary nursing. This is done to enhance quality individualized client care. In cases of errors, issues, and problems, it is easy for the nurse manager to identify who is held accountable. According to Thompson (2018) the primary nurse de- signs a complete care plan for every client under his care, thus the nurse is respon- sible, and there no ambiguity about that is accountable for the client’s care plans. However, Thompson (2018) stated that when hospitals try to implement primary care nursing system without the necessary resources, they may not be able to meet their expectations especially if the primary care nurse is given re- sponsibility to a specific client and could not focus due to scheduling issues and nurse-client ratio, this will compromise the therapeutic relationship with their 18 JPAIR Multidisciplinary Research client. Due to the lack of workforce to do primary nursing, the hospitals in the study modified the primary nursing by integrating and combining primary nurs- ing along with practical nursing. Nurses are assigned to specific clients to perform all necessary nursing procedures except for vital signs taking and monitoring, measuring intake and output and documentation because it is done by nursing aids and charge nurses respectively. CONCLUSIONS The findings of the study revealed that nurse turnover is continuously increasing in private hospitals which are brought about by low salary, no/less fringe benefits, poor / no health insurance coverage, no overtime pay, better opportunities and compensation package offered by other hospitals and lower nurse-client ratio as validated in the qualitative data gathered. Further, the study found out that most of the participants are millennial which resulted in generation gap with seasoned nurses thus affecting healthcare delivery. This shift in attitude poses an excellent challenge for hospitals to retain millennials because they are growing in numbers and are replacing baby boomers and generation X. Based on the result of the study, the researchers therefore conclude that increased or decreased nurse turnover dramatically affects health care delivery in terms of safe and quality nursing care, health education, communication, teamwork and collaboration and records management which is brought about by nurse-patient ratio, stressful environment, interpersonal relationships, nurses attitude and experiences specifically of the millennials, school where they graduated and their foundation during their school days. Thus, it is essential for hospitals to learn, adjust and develop their management strategies to accommodate and understand the unique style and attitudes of the millennials to retain them and prepare them from novice to expert TRANSLATIONAL RESEARCH The result of the study could be utilized or used as a reference for international publications and other forms of information dissemination such as articles, journals or newsletters. The persons or group of people who are significant in the success in healthcare delivery might look into the result of the study and review their policies that may address their problems regarding health care delivery, 19 International Peer Reviewed Journal strengthen and enhance existing systems that are most useful to improve better and quality client outcomes. LITERATURE CITED AMN healthcare, (2017). Viewpoints on Leadership, Nursing shortages, and their Profession. Retrieved from https://goo.gl/JgZGq7 Asegid, A., Belachew, T., &Yimam, E. (2014). Factors influencing job satisfaction and anticipated turnover among nurses in Sidama zone public health facilities, South Ethiopia.  Nursing research and practice,  2014. Retrieved from http:// dx.doi.org/10.1155/2014/909768 Asian Journal, (2016). More Filipino nurses seen working overseas. LA Asian Journal. The Filipino-American Community Newspaper. Weekend Edition. Volume 26. No.49,4 Sections,34 pages. Retrieved from https://goo.gl/DctCPf Auerbach, D. I., Buerhaus, P. I., & Staiger, D. O. (2017). Millennials almost twice as likely to be registered nurses as baby boomers were. Health Affairs, 36(10), 1804-1807. https://doi.org/10.1377/hlthaff.2017.0386 Bolandianbafghi, S., Salimi, T., Rassouli, M., Faraji, R., &Sarebanhassanabadi, M. (2017). Correlation between medication errors with job satisfaction and fatigue of nurses. Electronic physician, 9(8), 5142. Retrieved from doi:  10.19082/5142 Costanza, D. P., Badger, J. M., Fraser, R. L., Severt, J. B., &Gade, P. A. (2012). Generational differences in work-related attitudes: A meta-analysis.  Journal of Business and Psychology, 27(4), 375-394. Retrieved from DOI https://doi. org/10.1007/s10869-012-9259-4 Dimaya, R. M., McEwen, M. K., Curry, L. A., & Bradley, E. H. (2012). Managing health worker migration: a qualitative study of the Philippine response to nurse brain drain. Human resources for health, 10(1), 47. Retrieved from https://doi. org/10.1186/1478-4491-10-47 Dywili, S., Bonner, A. N. N., & O’BRIEN, L. O. U. I. S. E. (2013). Why do nurses migrate?–a review of recent literature.  Journal of nursing management,  21(3), 511-520. Retrieved from https://doi.org/10.1111/j.1365-2834.2011.01318.x http://dx.doi.org/10.1155/2014/909768 http://dx.doi.org/10.1155/2014/909768 https://dx.doi.org/10.19082%2F5142 https://doi.org/10.1186/1478-4491-10-47 https://doi.org/10.1186/1478-4491-10-47 https://doi.org/10.1111/j.1365-2834.2011.01318.x 20 JPAIR Multidisciplinary Research Chien, W. T., & Yick, S. Y. (2016). An investigation of nurses’ job satisfaction in a private hospital and its correlates. The open nursing journal, 10, 99. Retrieved from doi:  10.2174/1874434601610010099 Roche, M. A., Duffield, C. M., Homer, C., Buchan, J., &Dimitrelis, S. (2015). The rate and cost of nurse turnover in Australia.  Collegian,  22(4), 353-358. Retrieved from https://doi.org/10.1016/j.colegn.2014.05.002 Haddad, L., and Butler, T. (2018).Nursing, Shortage. National Center for Biotechnology Information,  U.S. National Library of Medicine. Retrieved fromhttps://www.ncbi.nlm.nih.gov/books/NBK493175/ Institute for Healthcare Communication, (2011). Impact of Communication in Healthcare. Retrieved from https://healthcarecomm.org/about-us/impact-of- communication-in-healthcare/ Kerfoot, K. (2015). Four measures that are key to retaining nurses.  Hospital and Health Networks, 5-6. Retrieved from https://goo.gl/aV3UyK Kourkouta, L., &Papathanasiou, I. V. (2014). Communication in nursing practice.  Material socio-medica,  26(1), 65. Retrieved from doi:    10.5455/ msm.2014.26.65-67 Kovner, C. T., Brewer, C. S., Fatehi, F., & Jun, J. (2014). What does nurse turnover rate mean and what is the rate?. Policy, Politics, & Nursing Practice, 15(3-4), 64- 71. Retrieved from https://doi.org/10.1177/1527154414547953 Lazarte, F. C. (2016). Core Competencies of Beginning Staff Nurses: A Basis for Staff Development Training Program. Journal of Advanced Management Science Vol, 4(2). Retrieved from doi: 10.12720/joams.4.2.98-105 Lorenzo, F. M. E., Galvez‐Tan, J., Icamina, K., & Javier, L. (2007). Nurse migration from a source country perspective: Philippine country case study. Health services research, 42(3p2), 1406-1418. Retrieved from https://doi.org/10.1111/j.1475- 6773.2007.00716.x Luthuli, L. P., &Kalusopa, T. (2017). The management of medical records in the context of service delivery in the public sector in KwaZulu-Natal, South https://dx.doi.org/10.2174%2F1874434601610010099 https://doi.org/10.1016/j.colegn.2014.05.002 https://www.ncbi.nlm.nih.gov/ https://www.ncbi.nlm.nih.gov/ https://www.nlm.nih.gov/ https://dx.doi.org/10.5455%2Fmsm.2014.26.65-67 https://dx.doi.org/10.5455%2Fmsm.2014.26.65-67 https://doi.org/10.1177%2F1527154414547953 https://doi.org/10.1111/j.1475-6773.2007.00716.x https://doi.org/10.1111/j.1475-6773.2007.00716.x 21 International Peer Reviewed Journal Africa: the case of Ngwelezana hospital. South African Journal of Libraries and Information Science,  83(2), 1-11. Retrieved from http://sajlis.journals.ac.za doi:10.7553/83-2-1679 Masselink, L. E., & Lee, S. Y. D. (2010). Nurses, Inc.: expansion and commercialization of nursing education in the Philippines.  Social Science & Medicine,  71(1), 166-172. Retrieved from https://doi.org/10.1016/j. socscimed.2009.11.043 Mathes, E. W. (1981). Maslow’s hierarchy of needs as a guide for living.  Journal of Humanistic Psychology,  21(4), 69-72. Retrieved from https://doi. org/10.1177/002216788102100406 McHugh, M. D., & Ma, C. (2014). Wage, work environment, and staffing: effects on nurse outcomes. Policy, Politics, & Nursing Practice, 15(3-4), 72-80. Retrieved from https://doi.org/10.1177/1527154414546868 Nacioglu, A. (2016). As a critical behavior to improve quality and patient safety in health care: speaking up!. Safety in Health, 2(1), 10. Retrieved from https://doi. org/10.1186/s40886-016-0021-x Nantsupawat, A., Kunaviktikul, W., Nantsupawat, R., Wichaikhum, O. A., Thienthong, H., & Poghosyan, L. (2017). Effects of nurse work environment on job dissatisfaction, burnout, intention to leave.  International nursing review, 64(1), 91-98. Retrieved from https://doi.org/10.1111/inr.12342  Solutions, N. N. (2016). National healthcare retention & RN staffing report. Re- trieved from https://scholar.google.com.ph/scholar?hl=en&as_sdt=0%2C5& q=Nursing+Solutions+Inc.+%282016%29.+2016+National+Healthcare+Rete ntion+%26+RN+Staffing++Report&btnG= O’Daniel, M., & Rosenstein, A. H. (2008). Professional communication and team collaboration. Retrieved from https://goo.gl/NaEX21 Philippine Overseas Employment Administration, (2010). Retrieved from http:// www.poea.gov.ph/html/statistics.html https://doi.org/10.1016/j.socscimed.2009.11.043 https://doi.org/10.1016/j.socscimed.2009.11.043 https://doi.org/10.1177%2F002216788102100406 https://doi.org/10.1177%2F002216788102100406 https://doi.org/10.1177%2F1527154414546868 https://doi.org/10.1186/s40886-016-0021-x https://doi.org/10.1186/s40886-016-0021-x https://doi.org/10.1111/inr.12342 https://scholar.google.com.ph/scholar?hl=en&as_sdt=0%2C5&q=Nursing+Solutions+Inc.+%282016%29.+2016+National+Healthcare+Retention+%26+RN+Staffing++Report&btnG https://scholar.google.com.ph/scholar?hl=en&as_sdt=0%2C5&q=Nursing+Solutions+Inc.+%282016%29.+2016+National+Healthcare+Retention+%26+RN+Staffing++Report&btnG https://scholar.google.com.ph/scholar?hl=en&as_sdt=0%2C5&q=Nursing+Solutions+Inc.+%282016%29.+2016+National+Healthcare+Retention+%26+RN+Staffing++Report&btnG http://www.poea.gov.ph/html/statistics.html http://www.poea.gov.ph/html/statistics.html 22 JPAIR Multidisciplinary Research Raingruber, B. (2013). Contemporary Health Promotion in Nursing Practice, SecondEdition, Includes Navigate 2 Advantage Access. Jones & Bartlett Learning. Retrieved from http://www.jblearning.com/catalog/9781284094749/ Texas Health and Human Services, (2018). Texas Center for Nursing Workforce Studies (TCNWS). Retrieved from http://www.dshs.texas.gov/chs/cnws/. Thompson, Scott. (n.d.). Role of the Primary Nurse. Work - Chron.com. Retrieved from http://work.chron.com/role-primary-nurse-15191.html Twigg, D., & McCullough, K. (2014). Nurse retention: a review of strategies to create and enhance positive practice environments in clinical settings.  International journal of nursing studies,  51(1), 85-92. Retrieved from https://doi. org/10.1016/j.ijnurstu.2013.05.015 Vertino, K. A. (2014). Effective interpersonal communication: A practical guide to improve your life.  OJIN: The Online Journal of Issues in Nursing,  19(3), 1-6. Retrieved from DOI: 10.3912/OJIN.Vol19No03Man01 United States Department of Labor, (2018). Fastest Growing Occupations.Bureau of Labor Statistics. Retrieved from https://www.bls.gov/ooh/fastest-growing.htm Vroom, V. H. (1964). Work and motivation. New york: John willey & sons. Inc. VroomWork and Motivation1964. Retrieved from https://goo.gl/sM7cz8 World Health Organization, (2017). From Brain Drain to Brain Gain Migration of Nursing and Midwifery Workforce in the State of Kerala. INDIA COUNTRY CASE STUDY: KERALA. Retrieved from https://goo.gl/MLrYVj Wieck, L., & Moss, K. D. (2015).  Managing the Intergenerational Nursing Team. HCPro. Retrieved from https://goo.gl/L68BC2 Wood, C. (2017). The importance of good record-keeping for nurses. Nursing Times. Retrieved from https://goo.gl/xdybC4 Yeates, N. (2010). The globalization of nurse migration: Policy issues and responses.  International Labour Review,  149(4), 423-440. Retrieved from https://doi.org/10.1111/j.1564-913X.2010.00096.x http://www.jblearning.com/catalog/9781284094749/ http://www.dshs.texas.gov/chs/cnws/ http://work.chron.com/role-primary-nurse-15191.html https://doi.org/10.1016/j.ijnurstu.2013.05.015 https://doi.org/10.1016/j.ijnurstu.2013.05.015 https://www.bls.gov/ooh/fastest-growing.htm https://goo.gl/sM7cz8 https://doi.org/10.1111/j.1564-913X.2010.00096.x