Cost of nursing turnover in a Teaching Hospital *

Objective: To map the sub processes related to turnover of nursing staff and to investigate and measure the nursing turnover cost. Method: This is a descriptive-exploratory study, classified as case study, conducted in a teaching hospital in the southeastern, Brazil, in the period from May to November 2013. The population was composed by the nursing staff, using Nursing Turnover Cost Calculation Methodology. Results: The total cost of turnover was R$314.605,62, and ranged from R$2.221,42 to R$3.073,23 per employee. The costs of pre-hire totaled R$101.004,60 (32,1%), and the hiring process consumed R$92.743,60 (91.8%) The costs of post-hire totaled R$213.601,02 (67,9%), for the sub process decreased productivity, R$199.982,40 (93.6%). Conclusion: The study identified the importance of managing the cost of staff turnover and the financial impact of the cost of the employee termination, which represented three times the average salary of the nursing staff. DESCRIPTORS Nursing, Team; Personnel Turnover; Personnel Administration, Hospital; Costs and Cost Analysis. Cost of nursing turnover in a Teaching Hospital* Custo da rotatividade da equipe de enfermagem em hospital de ensino Costo de la rotatividad del equipo de enfermería en hospital de enseñanza Paula Buck de Oliveira Ruiz1, Marcia Galan Perroca2, Marli de Carvalho Jericó2 How to cite this article: Ruiz PBO, Perroca MG, Jericó MC. Cost of nursing turnover in a Teaching Hospital. Rev Esc Enferm USP. 2016;50(1):101-8. DOI: http://dx.doi.org/10.1590/ S0080-623420160000100014 Corresponding author: Paula Buck de Oliveira Ruiz Praça do Arpoador, 320 CEP 13104-052 – Campinas, SP, Brasil pbuckinha@yahoo.com.br


INTRODUCTION
Nursing Turnover is a global concern, however, its definition and measurement vary according to the authors used (1)(2) .It is defined and presented in literature in different ways, as the fluctuation between the hiring and termination of employees (3) , or just by the number of employees terminated in relation to the number of employees who work at the institution (4) .
The causes of turnover are related to external phenomena (supply and demand in the labor market and economic situation) and internal phenomena (salary policy, types of supervision and organizational conditions) (5) .
There is a lack of consensus regarding the optimal rate of turnover, but what must be considered is that there should not be losses to the harmony of the institution.When this value is null, it demonstrates a stagnation of the institution, and if this rate is high, it leads to losses in productivity (6) .It is considered that an optimal turnover rate would be one in which the institution can retain their quality staff, replacing those with poor performance (3) .
Healthcare organizations spend a lot of money to replace nurses and lose intellectual capital when they quit, showing as a consequence potential productivity losses associated with this turnover (7) .A study conducted in the United States estimated the cost of hiring new nurses, to the institution, at US$856 million per year, ranging from US$1.4 to US$2.1 billion for society.However, this estimate may be low, as they included only the costs associated with the hiring of new nurses (8) .
There are few national (9)(10) and international (2)(3)(4)7) studies exploring the cost of turnover, as well as the use of a standard methodology for the survey of expenditures/investments. InBrazilian literature, it is proposed that the calculation of cost is composed by primary, secondary and tertiary costs.The primary costs are related to the termination of each employee and their replacement by another, secondary costs are related to extra-labor and extra-operational expenditures, and the tertiary costs consist of estimated costs and parallel effects related to turnover (3) .Hiring process studies, training and termination of direct costs of labor showed the time taken by professionals and their monetary value (9)(10) , and also the materials consumed in each step of the process (10) .
Internationally, studies propose different methodologies for calculating cost of turnover.Some use the stages of hiring to calculate the cost of turnover (11) .Other authors estimate the direct and indirect costs based on the management model, which considers hiring, their productivity and termination.This model recognizes characteristics of the patient, nurses and hospital unit involved in the professional productivity (12) .
Nursing Turnover Cost Calculation Methodology (NTCCM) is divided into two categories of cost: pre-hire (recruitment, vacancies and hiring) and post-hire practices (training, decreased productivity of the new employees during their learning curve, and termination) (4) .In other research, similar to NTCCM, five subcategories were used, except for the decreased productivity of the new employees during their learning curve and termination (11) .
Turnover is an international concern due to high cost to health organizations and to affect the work environment in relation to the quality of care and patient/collaborator safety.However, among the turnover studies, the ones related to its cost, due to its complexity, are still little investigated.
In this respect, the objectives of the study were to map the sub processes related to turnover of nursing staff and to measure the cost of turnover of nursing staff.

METHOD
The research is exploratory and descriptive, classified as case study (12) , with quantitative characteristics.It was conducted in a large teaching hospital (720 beds), located in the Southeast region of Brazil, in the period from May to November 2013.The hospital performs, on average, 46.000 visits per month, it has 5.259 employees, and is a reference to 102 municipalities in the northwestern region of São Paulo State.
The investigated places were 12 inpatient units (six clinics and six surgical), 15 specialized units (nine semi-intensive and intensive care units, two emergency units, two surgical centers, one materials and sterilization center and one hemodialysis unit) and one diagnostic and therapeutic service unit (Endoscopy).The clinics and health units that are not part of the structure of the hospital complex were excluded.The population was composed by members of the nursing staff (nurses, technicians and assistants), except residents.
Data collection was conducted after formal authorization from the hospital, signatures of the Consent Form of participants in accordance with the Research Ethics Committee (nº 96,830/2012).
The calculation of the turnover rate was conducted by means of the equation proposed by Hospital Quality Control (HQC), which considers the number of people who are hired and terminated in the institution (13) .Only the external turnover rates were considered, therefore, internal turnover and reassignments were excluded.

Turnover= n° of employees hired + n° of employess terminated x=100 2 n° of employess per period/month
The methodology used was Nursing Turnover Cost Calculation Methodology (NTCCM), composed by two categories of cost pre-hire and post-hire.This methodology was developed in early 1990s and has been refined for application in Nursing (4) .The pre-hire cost encompasses three subcategories (recruiting applicants for open vacancies, handling vacancies, and hiring new nurses) and post-hire, four (orientation and training of new employees, decreased productivity of new employees during their learning curve, dismissals and terminations).Each subcategory includes relevant costs to its variables.In this investigation, the term "process" was considered in place of the term "category" and "sub-process" for "subcategory".Thus, the mapping of the processes and their consequences (sub-processes and activities) was conducted through interviews with professionals in human resources (HR) and Permanent Education Center (PEC).
The calculation of productivity measurement comprised four steps: Step 1: Preparation of instrument and appropriateness of content -To measure the reduction of productivity of new sub-processes and pre-turnover (termination), using instruments based on the Nursing Interventions Classification (NIC) (14) .Six specialties with mapped interventions have been identified in the literature: emergency unit, adult intensive care, medical and surgical clinics, Operating room, pediatrics, multi-occupancy patient rooms and hemodialysis.For the others, endoscopy, neurology, palliative care unit, semi-intensive care, ICUs (cardiac adult and pediatric, and neonatal) transplant (kidney and bone marrow), and interventions were mapped considering the suggestions of the NIC.In the Materials and Sterilization Center (MSC), the recommended competencies were used by the Brazilian Society of Nursing in the Operating Room (BSNOR) (15) .
Step 2: Validation of instruments -After listing, the interventions were forwarded to an expert opinion on NIC language used.Subsequently, a meeting was held with the nurses and clinic Manager of each area according to the zip code.At this point, representative interventions were selected for the nursing practice in each specialty.
Step 3: Criteria and score definition -three criteria were adopted for assessment, the planning of resource consumption, following the steps of Standard Operating Procedure (SOP) and intervention in a timely manner.The scores of the interventions ranged from zero to four: (0) Intervention was not performed; (1) it does not meet the criteria; (2) it meets a criterion; (3) it meets two criteria; (4) it meets three criteria.
Step 4: The estimated time of the nurse/supervisor for orientation of newly-hired professional.
The implementation of the instrument for measuring the productivity of each employee newly-hired or terminated was performed (after pre-test), with the participation of the manager nurse or unit clinic, nurse of the zip code area and the researcher who did the record in the instrument.
Calculations of costs were performed (table 2) based on the Brazilian currency (R$) and the conversion to dollar was done in September 2015, when R$ 1.00 corresponded to U$3.81 dollars.
The composition for the calculation of costs/employees is shown in chart 1.No productivity cost per employee = total cost/n° hired Decreased productivity of newly hired = percentage difference between performance achieved and estimated (90 days), for 90% of productivity (13) Decreased Productivity Decreased Productivity of the termination = percentage difference between performance achieved and estimated (30 days), for 90% of productivity (13) No productivity cost per employee = total cost/n° terminated *n°-Number The total estimated cost of turnover was obtained by the sum of the pre and post-hire costs.The turnover/employee cost has been calculated by dividing the total costs by the sum of the hired professionals and terminations/month.
It was not considered for the calculation the turnover costs with supplies in hire sub process -R$13.30used in group dynamic, tests and interviews and also the orientation/training -R$93.50-related to the material in the integration period of newly hired professionals.This exclusion was due to the use of remaining office supplies of school kits which are distributed to the employees of the institution.

RESULTS
It was observed that in the period of four months, 38 hospital nursing staff professionals were terminated, as a result of initiatives from the employee or from the institution and 76 professionals were hired (table 1).The turnover rate ranged from 0.84% to 1.06%, the average number of hired professionals ranged from 2.5 to 9.5 and termination from 1.3 to 4.5.The costs relating to post-hire process (Table 3) totaled R$213,601.02,and the sub-process of decreased productivity of the 68 newly hired professional in the trial period was R$199,982.40.The time spent by the nurse supervisor applying orientation to newly hired professionals ranged from R$21,712.72 to R$43,292.33.The total cost of turnover (processes of pre and posthire) was R$314,605.62.The pre-hire costs represented 32.1% and post-hire 67.9% of the total.The turnover/ employee cost ranged from R$2,221.42 to R$ 3,073.23 and the cost of termination/employee was R$5,553.56 to R$16,811.75(Table 4).

DISCUSSION
Turnover of nursing has a big financial impact for healthcare organizations, their rates vary according to the type of institution, private or public (11) .In this study, the turnover rate was lower -MD 0.99% -than those presented in 37 general unsealed hospitals, participants of HQC -MD 2.17% -over the same period (13) .
The global perspective on turnover rates in England is approximately 10% (16) ; ranging from 12 to 21% of a research including ten European countries (11) and are around 20% in Canada (17) .International Classification for annual turnover rates in health organizations relates how low variations 4-12%, moderate 12-21% and high 22-44% (18) .
Turnover is a multifactorial event, there is not a number that defines this ideal rate, since it depends on the individuality of each institution and also the external market (11) .Taking these aspects into consideration, it is expected that the turnover rate does not reach levels that lead to compromised quality, rising costs and patient safety.
The pre-hire related costs totaled 32.1% of the expenses generated in turnover, in which the sub-process vacancies (overtime and temporary contract) was the most present, with 29.5%.An integrative review of literature showed that the cost of vacancies is more costly, regardless of cost methodology (11) .In other researches conducted in the United States, Australia, Canada and New Zealand, this figure reached 68% of direct costs (12) .
A study conducted in the United States, during one year, showed that the values of the direct costs caused by turnover vary widely.In an estimate, it was concluded that for hospitals, the recruitment cost per nurse/month was a total of US$241.67 (4) for nursing staff, in our study it was R$6.28 (US$ 1.76).Regarding the sub-process cost of recruiting/ month, this research showed R$402.48 for the nursing staff, higher value than those found in the national research of the nursing technicians category (R$191.18) (10).Recruitment plays a central role supplying the selection process of the institution with the highest number of candidates and, if inefficient, possibly brings losses for the institution, and high turnover rates (3) .
After recruitment, the selection of candidates takes place, and for that sub-process there was an expense cost/ month of R$1,662.78.A national study found that for the hiring process, this sub-process was the most consumed resource/month, around R$1,138.890 (10) .The proper selection process will bring high productivity to the institution, lower turnover rates, ensuring return on investment applied to this activity.However, the recruitment and selection activities do not end when the candidate is hired, but, after the process of integration and adaptation of the institution (3) .
For the sub-processes of orientation and training, in this investigation, there was an investment/month of R$ 843.65.In a national study, the admission training/month was R$ 268.90 (11) .This sub-process aims to develop favorable attitudes to the institution and meet the information needs for the new institution (19) .Human capital should be well developed and the training becomes a lucrative source because, since it enriches the human heritage in the institution, reducing their time to adapt and the initial turnover (3) .
The greatest burden presented in this study was related to post-hire process -67.9% -and the lower productivity of the newly hired professional was the most expensive, with 63.6%.The scarcity of research related to objective or subjective measure of the productivity of newly hired professionals makes the comparison of data to be done only with international studies, which reported costs for this process up to 64% (11) .Turnover contributes to an increase in the organization's costs, loss of productivity and organizational inefficiency by replacing a skilled employee.The awareness of leaders is diverted and increases the consumption time to monitor the newly hired, expending resources that could be directed to other financial initiatives/policies (4) .
In the present study, we identified that the estimated annual cost of turnover per employee (nursing staff ) will be R$33,116.28(US$ 8,961.93).Recent international studies have shown great variability in their findings, where expenditures per nurse/year are estimated at R$83,820.00(US$ 22,000) and R$335,607.66(US$ 88.086) (4,(11)(12)20) .
When analyzing turnover rates and comparing their costs, it can be seen that the costs are directly proportional to that event.Internationally, researches reported that the rates range from less than 9.49% to a maximum of 250% (11) , while our study presents rates ranging from 0.84% to 1.06%.The costs presented by these studies, whether in American hospitals, in Europe, or only in an institution, range from US$5.8 million/year (20) to US$ 7.9 to 8.5 million/year (4) .Compared to the present study, which showed a lower turnover rate, the total cost was R$314,605.62(US$ 82,790.95) in four-month investigation.Performing an estimated total cost shown in the research for a year, the cost of turnover may reach R$943,816.86(US$ 247,720.96).
Thus, the results found in the literature revealed variability in international studies and lack of data in national research on turnover cost, in terms of concept, professional nursing categorization, measurement and indicators.The research methodologies, data sources, and the cost of calculation and coverage provide just the results of estimated costs.
The case study method is limited in its applicability, but the validity of the results, since studies have shown that when taking infrastructure many results are similar.Another limitation relates to the use, for the first time, at the national level, in an adapted form, the methodology Nursing Turnover Cost Calculation Methodology (NTCCM), and objective measurement of productivity not using the NIC.Still, there is a gap on the scope of the termination sub-process, in which activities related to the medical examination were not investigated, and also the termination of sub-process, with regard to activities related to registration, documentation, attendance at the approval in the Labor Courts.

CONCLUSION
The study identified the importance of managing the cost of staff turnover and the financial impact of the termination/ employee cost, who represented three times the average salary of the nursing staff.
This study provides the knowledge and mapping of processes and activities involved in turnover, advancing the management of nursing staff costs and innovating in the use of NIC to measure the productivity of newly hired professionals and terminations.More than numerical results, we believe in the need for improvements in personnel policies aimed at retaining nurses, especially in the first year.This study has also contributed to the personal management and productivity analysis of newly hired professionals, as well as the costs involved.

Chart 1 -
Costs Composition of sub-processes.From May to August 2013, São José do Rio Preto, SP, Brazil.Costs Composition Sub-processes Calculating the cost/sub-process Hourly cost of labor = base salary and social charges (20.1%), divided by the monthly working hours Recruitment Recruitment cost per employee = total cost/ n° registered applications Hiring Contract cost per employee = total cost/n° interviews Orientation/Training Training cost = total cost/n° training hours Terminations Termination costs = total cost/n° of terminations Overtime = hourly cost of the Professional category + 100% Vacancies Vacancies per employee cost = total cost/ n° of terminations Orientation time = hourly cost of Professional category (days of the week) Decreased Productivity of nurses

Table 1 -
Distribution of hired and terminated nursing staff, according to Professional category, turnover rate and inpatient units.From May to August 2013 -São José do Rio Preto, SP, Brazil.

Table 2
shows that the costs of the pre-hire process were R$101,004.60,and the sub process vacancies accounted for R$92,743.60(91.8%) and the extra hour of activity ranged from R$13,694.90 to R$32,771.58.

Table 2 -
Distribution of the costs of sub processes related to pre-hire of nursing staff (R$).From May to August 2013, São José do Rio Preto, SP, Brazil.

Table 3 -
Distribution of the costs of sub-processes related to post-hire process of nursing staff (R$).From May to August 2013, São José do Rio Preto, SP, Brazil.

Table 4 -
Distribution of costs related to pre and post-hire processes of the nursing staff (R$).From May to August 2013, São José do Rio Preto, SP, Brazil.