Areas of work-life in Spanish hostelry professionals: explanatory power on burnout dimensions.

BACKGROUND: Researchers have studied for decades workplace stress and burnout to identify their relationship to health and wellness. This research has focused on stress levels in people, as well as on environmental and personal factors that contribute to experiencing stress or burnout. In addition to the burnout measurement questionnaires (MBI-GS), Leiter and Maslach designed a model to evaluate the areas of work environment that relate to this construct (Areas of Worklife Scale-AWLS). The goal of the present research was to analyze the psychometric properties of a Spanish translation of the MBI (GS) and the AWLS with a Spanish-speaking population. This work makes a substantial contribution by addressing the need to use validated measures and methods when exploring the positive and negative aspects of organizations. These conditions provide a means to accurately evaluate the impact of interventions aimed to address stress and burnout. METHOD: Cross-sectional study with self-report measures. The sample was comprised of 452 managers and employees (hotels, restaurants, catering) of Aragón (Spain). There were approximately equal numbers of women and men (45,4% vs. 54,6%). The average age of participants was 36.6 years (SD = 10.03). A battery of questionnaires was used: Socio-demographic and work characteristics, Scale of stress and health symptoms, Maslach Burnout Inventory-General Survey (MBI-GS), Areas of Worklife Scale (AWLS). RESULTS: The results showed optimal psychometric properties in both questionnaires, especially in terms of the predictive capacity of the AWLS in each of the MBI-GS dimensions. CONCLUSIONS: The best explained dimension is that of emotional exhaustion. The manageable load variable is the one that most contributes to predicting burnout levels. For future interventions, the results confirm the need to verify the levels of each area of work, in order to focus on the most deteriorated ones.

The protective role of self-efficacy against workplace incivility and burnout in nursing: A time-lagged study.

BACKGROUND: Incivility has negative consequences in the workplace and remains a prevalent issue in nursing. Research has consistently linked incivility to nurse burnout and, in turn, to poor mental health and turnover intentions. To retain high-quality nurses, it is important to understand what factors might protect nurses from the negative effects of workplace mistreatment. PURPOSE: The aim of the study was to investigate the role of relational occupational coping self-efficacy in protecting nurses from workplace incivility and related burnout and turnover intentions. METHODOLOGY: A two-wave national sample of 596 Canadian nurses completed mail surveys both at Time 1 and one year later at Time 2. Structural equation modeling was used to test the hypothesized model. RESULTS: The model showed a good fit, and most of the hypothesized paths were significant. Overall, the results supported the hypothesized protective effect of relational occupational coping self-efficacy against incivility and later burnout, mental health, and turnover intentions. CONCLUSION: Relational occupational coping self-efficacy is an important protective factor against negative work behavior. PRACTICE IMPLICATIONS: Organizations should provide nurses with opportunities to build their coping strategies for managing job demands and difficult interpersonal interactions. Similarly, providing exposure to effective role models and providing meaningful verbal encouragement are other sources of efficacy information for building nurses' relational coping self-efficacy.

New insights into burnout and health care: Strategies for improving civility and alleviating burnout.

What do we know about burnout, and what can we do about it? This article will provide an overview of what has been learned from current research on burnout, and what are the implications of the key themes that have emerged. One theme involves the critical significance of the social environment in health care settings. A second theme is the challenge of how to take what we know, and apply it to what we can do about burnout. What we need are new ideas about potential interventions, and clear evidence of their effectiveness. One example of this perspective addresses burnout by improving the balance of civil, respectful social encounters occurring during a workday. Research has demonstrated that not only can civility be increased at work but that doing so leads to an enduring reduction in burnout among health care providers. Lessons learned from this extensive research form the basis of recommendations for medical education. Specifically, the effectiveness of both the academic content and supervised practice would be enhanced by giving a greater emphasis to the social dynamics of healthcare teams. This perspective can help new physicians in avoiding potential pitfalls and recovering from unavoidable strains.

A multilevel investigation on nursing turnover intention: the cross-level role of leader-member exchange.

AIM: To analyse nursing turnover intention from the unit by using multilevel approach, examining at the individual level, the relationships between job characteristics, job satisfaction and turnover intention, and at the group level the role of leader-member exchange. BACKGROUND: Research on nursing turnover has given little attention to the effects of multilevel factors. METHOD: Aggregated data of 935 nurses nested within 74 teams of four Italian hospitals were collected in 2009 via a self-administered questionnaire. RESULTS: Hierarchical linear modelling showed that job satisfaction mediated the relationship between job characteristics and intention to leave at the individual level. At the unit level, leader-member exchange was directly linked to intention to leave. Furthermore, cross-level interaction revealed that leader-member exchange moderated the relationship between job characteristics and job satisfaction. CONCLUSION: This study supported previous research in single-level turnover studies concerning the key role of job satisfaction, providing evidence that job characteristics are important in creating motivating and satisfying jobs. At the unit-level, leader-member exchange offers an approach to understand the role of unit-specific conditions created by leaders on nurses' workplace wellbeing. IMPLICATIONS FOR NURSING MANAGEMENT: This study showed that it is important for nursing managers to recognise the relevance of implementing management practices that foster healthy workplaces centred on high-quality nurse-supervisor relationships.

Predicting cynicism as a function of trust and civility: a longitudinal analysis.

AIM: The aim of this study was to examine whether participant views of job resources (i.e. trust and civility) towards their co-workers and supervisors were longitudinally predictive of workplace cynicism, an aspect of burnout. BACKGROUND: Cynicism is a significant predictor of intention to quit among nurses. Social supports are hypothesized to protect workers from becoming increasingly cynical. METHOD: Measures of cynicism, and trust and civility in both co-workers and supervisors were part of a survey completed by a sample of 323 Canadian nurses whose responses were matched across two time-points, 1 year apart. RESULTS: Hierarchical multiple linear regression analyses revealed that co-worker civility enhanced the ability of our regression models to predict cynicism by explaining 1.1% of the variance in cynicism. The addition of co-worker trust, supervisor civility and supervisor trust did not enhance the ability of the models to predict cynicism. CONCLUSION: The results indicated the importance of workgroup civility in diminishing workplace cynicism. IMPLICATIONS FOR NURSING MANAGEMENT: Efforts to reduce burnout may be improved by decreasing cynicism through interventions aimed at increasing workgroup civility.

A factor confirmation and convergent validity of the "areas of worklife scale" (AWS) to Spanish translation.

BACKGROUND: Perceived incongruity between the individual and the job on work-life areas such as workload, control, reward, fairness, community and values have implications for the dimensions of burnout syndrome. The "Areas of Work-life Scale" (AWS) is a practical instrument to measure employees´ perceptions of their work environments. AIMS: Validate a Spanish translation of the AWS, and it relationship with Masclach Burnout Inventory dimensions. METHODS: The study was conducted in three medium-sized hospitals and seven rural and urban Primary Care centres (N = 871) in Spain. The "Maslach Burnout Inventory General Survey" (MBI-GS) and AWS were applied. We developed a complete psychometric analysis of its reliability, and validity. RESULTS: Data on the reliability supported a good internal consistency (Cronbach α between .71, and .85). Construct validity was confirmed by a six factor model of the AWS as a good measure of work environments (χ²(352) = 806.21, p < 0.001; χ²/df = 2.29; CFI = 0.935, RMSEA = 0.039); concurrent validity was analysed for its relationship with other measures (opposing dimensions to burnout, and MBI), and each correlation between dimensions and sub-dimensions were statistically significant; as well, predictive validity, by a series of Multiple Regression Analysis examined the resulting patterns of the Confirmatory Factor Analysis (CFA) confirms the relationship between the work-life areas and burnout dimensions. CONCLUSIONS: Leiter and Maslach's AWS has been an important instrument in exploring several work-life factors that contribute to burnout. This scale can now be used to assess the quality of work-life in order to design and assess the need for intervention programs in Spanish-speaking countries.

The roles of unit leadership and nurse-physician collaboration on nursing turnover intention.

AIM: To report a study of the relationship between variables at the group and individual level with nurses' intention to leave their unit. BACKGROUND: Workplaces are collective environments where workers constantly interact with each other. The quality of working relationship employees develop at the unit-level influences both employee outcomes and unit performance by shaping employee attitudes. DESIGN: The study was a cross-sectional design with self-administered questionnaires. METHODS: A questionnaire including measures of leader-member exchange and nurse-physician collaboration analysed at group-level and affective commitment and turnover intention analysed at individual level, was administered individually to 1018 nurses in five Italian hospitals. Data were collected in 2009. RESULTS: A total of 832 nurses (81·7% response rate) completed questionnaires. The results showed that affective commitment at individual level completely mediated the relationship between leader-member exchange at group-level and nursing turnover intention. Furthermore, the cross-level interaction was significant: at individual level, the nurses with high levels of individual affective commitment towards their unit showed low levels of turnover intention and this relationship was stronger when the nurse-physician collaboration at group-level was high. CONCLUSION: This study showed the importance for organizations to implement management practices that promote both high-quality nurse-supervisor and nurse-physician relationships, because they increase nurses' identification with their units. Individual affective commitment is an important quality for retaining a workforce and good nurses' relationship at group-level relationships with both supervisors and physicians are instrumental in developing identification with the work unit. Thus, the quality of relationship among staff members is an important factor in nurses' decision to leave.

The role of aggressions suffered by healthcare workers as predictors of burnout.

AIMS AND OBJECTIVES: To examine the prevalence of aggression against healthcare professionals and to determine the possible impact that violent episodes have on healthcare professionals in terms of loss of enthusiasm and involvement towards work. The objective was to analyse the percentage of occupational assault against professionals' aggression in different types of healthcare services, differentiating between physical and verbal aggression as a possible variable in detecting burnout in doctors and nursing professionals. BACKGROUND: Leiter and Maslach have explored a double process model of burnout not only based on exhaustion by overload, but also based on personal and organisational value conflicts (community, rewards or values). Moreover, Whittington has obtained conclusive results about the possible relationship between violence and burnout in mental health nurses. DESIGN: A retrospective study was performed in three hospitals and 22 primary care centres in Spain (n = 1·826). METHODS: Through different questionnaires, we have explored the relationship between aggression suffered by healthcare workers and burnout. RESULTS: Eleven percent of respondents had been physically assaulted on at least one occasion, whilst 34·4% had suffered threats and intimidation on at least one occasion and 36·6% had been subjected to insults. Both forms of violence, physical and non-physical aggression, showed significant correlations with symptoms of burnout (emotional exhaustion, depersonalisation and inefficacy). CONCLUSIONS: The survey showed evidence of a double process: (1) by which excess workload helps predict burnout, and (2) by which a mismatch in the congruence of values, or interpersonal conflict, contributes in a meaningful way to each of the dimensions of burnout, adding overhead to the process of exhaustion-cynicism-lack of realisation. Relevance to clinical practice. Studies indicate that health professionals are some of the most exposed to disorders steaming from psychosocial risks and a high comorbidity: anxiety, depression, etc. There is a clear need for accurate instruments of evaluation to detect not only the burnout but also the areas that cause it. Professional exhaustion caused by aggression or other factors can reflect a deterioration in the healthcare relationship.

The psychological conditions for employee engagement in organizational change: Test of a change engagement model.

In the contemporary world of work, organizational change is a constant. For change to be successful, employees need to be positive about implementing organizational change. Change engagement reflects the extent to which employees are enthusiastic about change, and willing to actively involve themselves in promoting and supporting ongoing organizational change. Drawing from Kahn's engagement theory, the research aimed to assess the influence of change-related meaningful work, psychological safety, and self-efficacy as psychological preconditions for change engagement. The study also aimed to test the indirect associations of the change-related psychological preconditions with proactive work behavior through change engagement. Survey data from a Prolific sample (N = 297) were analyzed using confirmatory factor analysis and structural equations modeling. In support of the validity of the model, the results showed that change-related self-efficacy, psychological safety, and meaningfulness had significant direct effects on change engagement, explaining 88% of the variance. The change-related psychological conditions also had significant indirect effects on proactive work behavior through change engagement. The findings therefore suggest that employees who exhibit higher levels of change-related self-efficacy, psychological safety, and work meaningfulness are more likely to support and promote organizational change, and to proactively engage in innovative work behavior. In practical terms, organizations that create the psychological conditions for change could significantly improve employee motivation to change and to innovate, which in turn would increase the likelihood of successful organizational change, and improved organizational competitiveness. Study limitations and directions for future research are discussed.

Building empowering work environments that foster civility and organizational trust: testing an intervention.

BACKGROUND: Creating supportive and empowering workplace conditions is important, not only because these conditions are related to improved nurse health and well-being but also because they are important for retaining top performing nurses. The current nursing shortage emphasizes the need to create such conditions. OBJECTIVES: The aim of this study was to examine the impact of a workplace intervention (Civility, Respect, and Engagement in the Workplace [CREW]) on nurses' empowerment, experiences of supervisor and coworker incivility, and trust in nursing management. METHODS: Registered nurses (Time 1, n = 755; Time 2, n = 573) working in 41 units across five hospitals in two provinces completed measures of workplace empowerment, supervisor and coworker incivility, and trust in management before and after a 6-month intervention. Eight units participated in the intervention, and 33 units were control groups. Multilevel modeling was used to test the impact of the intervention. RESULTS: A significant interaction of time by intervention was found for the access to support and resources empowerment structures, total empowerment, supervisor incivility, and trust in management. DISCUSSION: Compared with the control group, nurses who experienced the intervention program reported significant improvements in empowerment, supervisor incivility, and trust in management. Despite methodological challenges experienced in this study, the CREW process appears to be a promising intervention approach to enhance quality of nursing work environments, which may contribute to the retention of the nursing workforce.

The Influence of Change-Related Organizational and Job Resources on Employee Change Engagement.

Employee attitudes to change are key predictors of organizational change success. In this article, change engagement is defined as the extent to which employees are enthusiastic about change, and willing to actively involve themselves in ongoing organizational change. A model is tested showing how change-related organizational resources (e.g., senior leader support for change and organizational change climate) influence change engagement, in part through their influence on change-related job resources. Confirmatory Factor Analysis (CFA) and Structural Equations Modeling (SEM) results yielded good fit to the data in two independent samples: 225 Australian working professionals, and 201 employees from a Prolific sample. As proposed, change-related organizational resources (modeled as a higher order construct) were positively associated with higher order change-related job resources. Change-related job resources were positively associated with change engagement. In contrast to expectations, organizational resources were not directly associated with change engagement. Instead, change-related job resources fully mediated the relationship. Overall, the study provides empirical support for new measures of organizational change resources and employee change engagement. By drawing from well-established models in the change and engagement literatures, the study provides a promising research direction for those interested in further understanding positive employee attitudes to organizational change. Practical implications and future research opportunities are discussed.

Assessment of Workplace Social Encounters: Social Profiles, Burnout, and Engagement.

Employed people (N = 826) completed questionnaires including the Social Encounters Scale that assessed civility, incivility, and intimidation from supervisors, coworkers, and respondents on identical frequency scale. Factor analyses, correlations, and profile analysis addressed the first research question by demonstrating the benefits of assessing various dimensions of workplace social dynamics on a common rating scale. A subsample (N = 275 completed a second survey, confirming consistency over time. To address the second research question a Latent Profile Analysis (LPA) identified five social profiles: Civil, Low Contact, Uncivil Coworkers, Uncivil Supervisor, and Uncivil. These profiles were associated with distinct perceptions of the work environment, addressing the third research question. To address the fourth research question, crosstabulation with a profile structure based on the Maslach Burnout Scale demonstrated close links of workplace social culture with psychological connections with work.

The Effects of the Civility, Respect, and Engagement in the Workplace (CREW) Program on Social Climate and Work Engagement in a Psychiatric Ward in Japan: A Pilot Study.

BACKGROUND: Good social climate and high work engagement are important factors affecting outcomes in healthcare settings. This study observed the effects of a program called Civility, Respect, and Engagement in the Workplace (CREW) on social climate and staff work engagement in a psychiatric ward of a Japanese hospital. METHODS: The program comprised 18 sessions installed over six months, with each session lasting 30-min. Participation in the program was recommended to all staff members at the ward, including nurses, medical doctors, and others, but it was not mandatory. A serial cross-sectional study collected data at four time-points. Nurses (n = 17 to 22), medical doctors (n = 9 to 13), and others (n = 6 to 10) participated in each survey. The analysis of variance was used to evaluate the changes in the following dependent variables, the Essen climate evaluation schema (EssenCES), the CREW civility scale, and the Utrecht work engagement scale (UWES) over time. RESULT: We found no significant effects. The effect size (Cohen's d) for EssenCES was 0.35 from baseline to post-installation for all staff members. Effect sizes for EssenCES for medical doctors and UWES for nurses were 0.79 and 0.56, respectively, from baseline to post-program. CONCLUSIONS: Differences in social climate and work engagement among Japanese healthcare workers between the baseline and post-installation of the CREW program were non-significant.

Value Conflict, Lack of Rewards, and Sense of Community as Psychosocial Risk Factors of Burnout in Communication Professionals (Press, Radio, and Television).

Journalists are at particular risk of work-related stress and burnout. The objective of this study is to describe and analyze the principal factors involved in the appearance of burnout in communication professionals, as well as the possible interactions between them and with self-reported health, and to observe whether the variables involved are the same in different types of environments. To achieve this objective, 292 participants answered the following measurement instruments: Demographic and labor datasheet; Maslach Burnout Inventory (MBI General survey); Areas of Worklife Scale (AWS); and General Health Questionnaire (GHQ -12). The results were the following: Emotional Exhaustion (EE) shows direct correlation and statistical significance with the other two burnout dimensions, Depersonalization (DP) and Personal Accomplishment (PA), also with health perception variables and inverse and statistical significance with the workload, control, rewards, community, fairness, and values. A multiple linear regression model shows workload and values as inverse EE predictors, which confirms a burnout process in which EE contributes as the main dimension in DP and is shown to be a precursor of PA, itself. When comparing different types of media, journalists who work in institutional press offices presented significantly lower scores in PA and higher in control, rewards, community, justice, and values. Therefore, further research should be carried out in order to analyze the protective role of these variables regarding PA and burnout.

Generational differences in distress, attitudes and incivility among nurses.

AIMS: The first research objective was to replicate the finding of Leiter et al. [(2008)Journal of Nursing Management, 16, 100-109.] of Generation X nurses (n=338) reporting higher levels of distress than Baby Boomer nurses (n=139). The second objective was to test whether Generation X nurses reported more negative social environments at work than did Baby Boomer nurses. BACKGROUND: Negative social environments can influence the quality of work and the experience of distress for nurses. Generational differences in the experience of distress and collegiality have implications for the establishment of healthy workplaces, recruitment and retention. METHODS: A questionnaire survey of nurses was organized by generation. Analyses of variance contrasted the scores on burnout, turnover intention, physical symptoms, supervisor incivility, coworker incivility and team civility. RESULTS: The results confirmed the hypotheses of Generation X nurses reporting more negative experiences than did Baby Boomer nurses on all measures. CONCLUSIONS: The negative quality of social encounters at work contributes to nurses' experience of distress and suggest conflicts of values with the dominant culture of their workplaces. IMPLICATIONS FOR NURSING MANAGEMENT: Proactive initiatives to enhance the quality of collegiality can contribute to retention strategies. Building collegiality across generations can be especially useful.

When respect deteriorates: incivility as a moderator of the stressor-strain relationship among hospital workers.

AIM: To test whether incivility at work exacerbates the relationship between stressors and strain for hospital workers. BACKGROUND: A climate of incivility and disrespect among colleagues was expected to heighten the impact of work stressors on the mental and physical health of care providers. METHODS: Members of 17 care-providing units from five hospital systems in Canada completed surveys, before and after a civility intervention (eight intervention vs. nine comparison units). Analyses tested whether (1) incivility moderated the stressor-strain relationship at baseline (n=478), and (2) the stressor-strain relationship decreased for the intervention units relative to comparison units 6 months later (n=361). RESULTS: (1) Pre-intervention, individuals reporting more incivility on their unit showed a stronger stressor-strain relationship. (2) The negative relationship between work overload and mental health was mitigated among intervention group staff 6 months after the introduction of a colleague-based civility programme. CONCLUSIONS: Besides being a stressor itself, incivility exacerbates the relationship between existing job role stressors and strain among health care workers. IMPLICATIONS FOR NURSING MANAGEMENT: Colleague civility and respect have an important ripple effect of buffering inevitable work stressors, helping health care providers respond to stress with greater health and resiliency.

Job Demand-Control-Support Latent Profiles and Their Relationships with Interpersonal Stressors, Job Burnout, and Intrinsic Work Motivation.

In the Job Demand-Control-Support (JDCS) model, the combination of job demands, job control, and social support was hypothesized to lead to eight different constellations of job types. According to the model, these constellations are linked to wellbeing/health and learning outcomes. In the last three decades, these constellations of job types have been investigated by adopting a variable-centered perspective. However, latent profile analyses (LPA) enable a person-centered approach and empirically capture constellations of job types. In the present study, we used LPA to empirically identify distinct profiles of JDCS among Italian healthcare workers. Furthermore, we investigated the role of social stressors (workplace relationships and coworkers' incivility) as antecedents of these profiles and the association of these profiles with job burnout and work motivation. Results from LPA (n = 1671) revealed four profiles: Isolated Prisoner, Participatory Leader, Moderate Strain, and Low Strain. Negative relationships at work and coworkers' incivility increased the chances of being included in both Isolated prisoner and Participatory Leader profiles. Finally, the Isolated Prisoner and Moderate Strain profiles showed the highest levels of emotional exhaustion and cynicism and the lower levels of intrinsic work motivation. This study extends previous JDCS research, highlighting that researchers should consider empirically identified profiles rather than theoretically defined subgroups. Implications for stress theory, future research, and practice are discussed.

Occupational risk perception, safety training, and injury prevention: testing a model in the Italian printing industry.

This study examined occupational risk perception in relation to safety training and injuries. In a printing industry, 350 workers from 6 departments completed a survey. Data analysis showed significant differences in risk perceptions among departments. Differences in risk perception reflected the type of work and the injury incidents in the departments. A structural equation analysis confirmed a model of risk perception on the basis of employees' evaluation of the prevalence and lethalness of hazards as well as the control over hazards they gain from training. The number of injuries sustained was positively related to the perception of risk exposure and negatively related to evaluations about the safety training. The results highlight the importance of training interventions in increasing workers' adoption of safety procedures and prevention of injuries.

Demands, values, and burnout: relevance for physicians.

OBJECTIVE: T o explore the interaction between workload and values congruence (personal values with health care system values) in the context of burnout and physician engagement and to explore the relative importance of these factors by sex, given the distinct work patterns of male and female physicians. DESIGN: National mailed survey. SETTING: Canada. PARTICIPANTS: A random sample of 8100 Canadian physicians (response rate 40%, N = 3213); 2536 responses (from physicians working more than 35 hours per week) were analyzed. MAIN OUTCOME MEASURES: Levels of burnout, values congruence, and workload, by sex, measured by the Maslach Burnout Inventory-General Scale and the Areas of Worklife Scale. RESULTS: Results showed a moderate level of burnout among Canadian physicians, with relatively positive scores on exhaustion, average scores on cynicism, and mildly negative scores on professional efficacy. A series of multiple regression analyses confirmed parallel main effect contributions from manageable workload and values congruence. Both workload and values congruence predicted exhaustion and cynicism for men and women (P = .001). Only values congruence provided a significant prediction of professional efficacy for both men and women (P = .001) These predictors interacted for women on all 3 aspects of burnout (exhaustion, cynicism, and diminished efficacy). Howevever, overall levels of the burnout indicators departed only modestly from normative levels. CONCLUSION: W orkload and values congruence make distinct contributions to physician burnout. Work overload contributes to predicting exhaustion and cynicism; professional values crises contribute to predicting exhaustion, cynicism, and low professional efficacy. The interaction of values and workload for women in particular has implications for the distinct work-life patterns of male and female physicians. Specifically, the congruence of individual values with values inherent in the health care system appeared to be of greater consequence for women than for men.

Nurse turnover: the mediating role of burnout.

AIM: This study tested whether the mediation model of burnout could predict nurses' turnover intentions. BACKGROUND: A better understanding of what factors support a commitment to a nursing career could inform both policies and workplace practices. The mediation model of burnout provides a way of linking the quality of a nurse's worklife to various outcomes, such as turnover. METHOD: Data on areas of worklife, burnout, and turnover intentions were collected by surveying 667 Canadian nurses in the Atlantic Provinces. RESULTS: The findings supported the mediation model of burnout, in which areas of worklife predicted burnout, which in turn predicted turnover intentions. Cynicism was the key burnout dimension for turnover, and the most critical areas of worklife were value conflicts and inadequate rewards. CONCLUSIONS: The results of this study provide some new insights into how the intention of nurses to leave their job is related to particular aspects of their worklife and to burnout. IMPLICATIONS FOR NURSING MANAGEMENT: These results suggest what may be the most appropriate areas to target for interventions to reduce the risk of nurses exiting early from their chosen career.