TUGAS RESUME JURNAL MANAJEMEN KEPERAWATAN

DI SUSUN OLEH :

Dewi evita sari

2001048

PROGAM STUDI SARJANA ILMU KEPERAWATAN

UNIVERSITAS MUHAMMADIYAH KLATEN

2023/2023
 RESUME JURNAL CPD

Judul : Economic evaluation of CPD activities for healthcare professionals: A scoping review

Author : Witold Orlik, Giuseppe Aleo, Thomas Kearns, Jonathan Briody, Jane Wray, Paul
Mahon, Mario Gazi, Normela Radoš, Cristina García Vivar, Manuel Lillo Crespo, Catherine
Fitzgerald

Tahun : 2021

Pengembangan profesional berkelanjutan (CPD) sangat penting bagi para profesional

kesehatan untuk memberikan layanan yang berpusat pada manusia yang berkualitas tinggi dan
aman, di tengah sistem kesehatan yang terus berubah di seluruh dunia. CPD dapat membantu
meningkatkan keterampilan dan pengetahuan petugas kesehatan, sehingga mereka dapat
memberikan layanan yang lebih baik dan lebih efektif kepada pasien. Selain itu, CPD juga dapat
membantu petugas kesehatan untuk tetap terkini dengan perkembangan terbaru dalam bidang
kesehatan dan teknologi medis, sehingga mereka dapat memberikan layanan yang lebih inovatif
dan efisien.

Program dan kegiatan CPD dapat membantu mengatasi perencanaan ketenagakerjaan dan
perekrutan petugas kesehatan dengan memberikan pendidikan dan pelatihan yang diperlukan
untuk meningkatkan keterampilan dan pengetahuan petugas kesehatan. Dengan meningkatkan
keterampilan dan pengetahuan petugas kesehatan, program dan kegiatan CPD dapat membantu
meningkatkan kualitas layanan kesehatan yang disediakan oleh petugas kesehatan yang ada,
sehingga mengurangi kebutuhan akan merekrut petugas kesehatan baru. Selain itu, program dan
kegiatan CPD juga dapat membantu meningkatkan retensi petugas kesehatan yang ada dengan
memberikan kesempatan untuk pengembangan karir dan meningkatkan kepuasan kerja.

Disebutkan bahwa pendidikan yang transformatif dan berkualitas tinggi serta

pembelajaran seumur hidup bagi semua petugas layanan kesehatan diperlukan, dan bahwa
pendekatan yang terkoordinasi diperlukan untuk menentukan bagaimana program dan kegiatan
CPD dapat mengatasi perencanaan ketenagakerjaan dan perekrutan dan retensi petugas
kesehatan. Namun, secara umum, strategi untuk meningkatkan pendidikan kesehatan yang
transformatif dan berkualitas tinggi dapat mencakup pengembangan kurikulum yang relevan
dengan kebutuhan pasar tenaga kerja, penggunaan teknologi modern dalam pembelajaran, dan
pengembangan program pelatihan dan pengembangan profesional berkelanjutan yang efektif.
 Penelitian CPD ini dilakukan dengan mengumpulkan bukti-bukti penelitian mengenai
evaluasi ekonomi, perubahan praktik klinis, dan perolehan pengetahuan. Sumber data yang
digunakan dalam penelitian ini meliputi CINAHL, MEDLINE/PubMed, Scopus, Database
Econlit, dan Web of Science. Dalam penelitian CPD, evaluasi ekonomi menjadi fokus utama,
dan mayoritas artikel yang digunakan dalam penelitian ini merupakan evaluasi ekonomi parsial.

Dari 6791 judul yang teridentifikasi, 119 artikel memenuhi kriteria inklusi dan
dimasukkan dalam scoping review ini. Mayoritas artikel merupakan evaluasi ekonomi parsial
terhadap program CPD (n = 70); setengahnya berasal dari Amerika. Studi yang mencakup
berbagai profesi merupakan studi yang paling umum (n = 54), diikuti oleh perawat (n = 34) dan
dokter (n = 23). Hasil pasien adalah hasil yang paling sering dilaporkan (n = 51), diikuti oleh
perubahan dalam praktik klinis (n = 38) dan peningkatan pengetahuan profesional kesehatan (n =
19).

Ada kebutuhan mendesak untuk mendapatkan lebih banyak bukti mengenai evaluasi
ekonomi CPD. Hal ini sangat penting mengingat meningkatnya biaya layanan kesehatan secara
global. Mayoritas studi yang dimasukkan dalam tinjauan ini tidak memberikan informasi rinci
mengenai evaluasi dan banyak yang hanya berfokus pada biaya kegiatan CPD daripada hasilnya.
 RESUME JURNAL JENJANG KARIR

Judul : The Impact of the COVID-19 Pandemic on Future Nursing Career Turnover Intention
Among Nursing Students

Author : Yulan Lin, Zhijian Hu, Mahmoud Danaee, Haridah Alias, Li Ping Wong

Tahun : 2021

Permasalahan kekurangan dan pergantian staf perawat merupakan masalah sumber daya
manusia yang mempengaruhi banyak negara Eropa dan Asia dan mempunyai dampak besar
terhadap kinerja sistem layanan kesehatan nasional di negara-negara tersebut. Kekurangan
perawat yang terus berlanjut menghambat penyampaian pasien berkualitas tinggi perawatan dan
berdampak buruk pada hasil akhir pasien dan kematian. Selama pandemi penyakit menular,
petugas kesehatan adalah sumber daya yang paling berharga di setiap negara. Karena perawat
merupakan mayoritas pekerja layanan kesehatan, mereka mempunyai fungsi yang sangat penting
dalam sistem layanan kesehatan selama wabah penyakit menular akut. Dampak COVID-19
terhadap tenaga perawat sudah sangat terasa di seluruh dunia dan pandemi ini telah
memperburuk kekurangan staf perawat yang sudah kritis. Yang terpenting, pandemi COVID-19
telah mengakibatkan peningkatan beban kerja perawat,17 yang mengakibatkan pada perawat
yang mengalami kelelahan atau tekanan psikologis.

Sering meningkatnya kebutuhan akan perawat dunia yang menghadapi pandemic

COVID- 19, mahasiswa keperawatan merupakan tenaga kerja keperawatan yang penting di masa
depan. Oleh karena itu, penting bagi mahasiswa keperawatan untuk memasuki dunia kerja untuk
mengisi kekurangan tenaga kerja perawat yang serius. Penelitian ini bertujuan untuk mengetahui
persepsi niat berpindah kerja di kalangan mahasiswa keperawatan. Literatur yang ada
menunjukkan bahwa ketakutan akan COVID-19 dan kepuasan hidup merupakan pengaruh
penting terhadap niat berpindah karir. Oleh karena itu, faktor-faktor yang mempengaruhi niat
berpindah, yaitu ketakutan akan COVID-19 dan kepuasan hidup, juga dipelajari. Dalam
penelitian ini kami berhipotesis bahwa tingkat ketakutan yang lebih tinggi terhadap pandemi
COVID-19 dan tingkat kepuasan hidup yang lebih rendah dapat menghasilkan niat berpindah
yang lebih tinggi di kalangan mahasiswa keperawatan.
 Sebanyak 1020 tanggapan lengkap diterima (tingkat respons: 86,2%). Hampir separuh
(49,1%) melaporkan bahwa mereka akan memilih untuk tidak mengikuti kursus keperawatan jika
diberi pilihan, 45,4% sering berpikir untuk tidak terjun ke profesi keperawatan di masa depan,
dan 23,7% akan mempertimbangkan untuk memasuki industri kesehatan yang tidak mempunyai
pendidikan keperawatan kontak dengan pasien. Analisis data survei terbuka mengenai perspektif
mahasiswa tentang bagaimana mendorong mahasiswa keperawatan untuk memasuki dunia kerja
keperawatan mengungkapkan lima tema utama: 1) peran profesional, rasa hormat, dan
pengakuan;
2) upah yang lebih tinggi; 3) mengurangi beban kerja; 4) meningkatkan kesehatan dan
keselamatan kerja; dan 5) peluang kemajuan karir.

Pandemi COVID-19 diperkirakan akan memperburuk penurunan jumlah mahasiswa

keperawatan yang memasuki profesi keperawatan. Penggunaan pertanyaan terbuka yang
mendorong mahasiswa keperawatan untuk memasuki profesi keperawatan sangat kondusif untuk
mengungkap wawasan yang berguna dari peserta penelitian kami. Data yang mendukung temuan
penelitian ini tersedia berdasarkan permintaan dari penulis terkait. Data tidak tersedia untuk
umum karena privasi atau batasan etika. Sebagian besar mahasiswa mungkin akan meninggalkan
profesi keperawatan setelah lulus, dan institusi juga mungkin berisiko membuat mahasiswanya
berhenti dari program keperawatan. Tenaga kerja keperawatan mungkin terus menghadapi
kekurangan karena rendahnya jumlah lulusan keperawatan untuk mengisi kembali angkatan
kerja. Karena mahasiswa keperawatan merupakan sumber penting tenaga kerja keperawatan di
masa depan, maka mengatasi ketakutan dan kesejahteraan mereka sebelum lulus harus menjadi
prioritas. Kepuasan hidup dan reaksi psikologis terhadap pandemi COVID-19 mempengaruhi
persepsi niat berpindah mahasiswa keperawatan dalam penelitian ini dan dapat memandu
institusi pendidikan tinggi untuk secara hati-hati memperhatikan kelompok mahasiswa yang
rentan terhadap niat berpindah.
DOI: 10.1111/medu.14813

REVIEWARTICLE

MEDICALEDUCATIONINREVIEW

Economic evaluation of CPD activities for healthcare

professionals: A scoping review
Witold Orlik1 | Giuseppe Aleo1 | Thomas Kearns1 | Jonathan Briody2 |
Jane Wray3 | Paul Mahon1 | Mario Gazic4 | Normela Radoš4 |
5 6
Cristina García Vivar | Manuel Lillo Crespo | Catherine Fitzgerald1
1
Faculty of Nursing and Midwifery, Royal
College of Surgeons in Ireland, Dublin, Ireland
2
Division of Population Health Sciences, Data
Science Centre, Royal College of Surgeons in
Ireland, Dublin, Ireland Abstract
3
Faculty of Health Sciences, University of Hull, Context: Continuing professional development (CPD) activities for healthcare
Hull, UK professionals are central to the optimisation of patient safety and person-centred care.
4
Croatian Nursing Council, Zagreb, Croatia Although there is some evidence on the economics of healthcare professionals training,
5
Department of Health Sciences, Public very little is known about the costs and benefits of CPD.
University of Navarra, Pamplona, Spain Methods: This study aimed to review the research evidence on economic evaluations of
6
Faculty of Health Sciences, University of CPD activities for healthcare professionals. CINAHL, MEDLINE/PubMed, Scopus, Econlit
Alicante, Alicante, Spain
and Web of Science databases were used to identify articles published between 2010
Correspondence and 2021.
Witold Orlik, Faculty of Nursing and
Results: Of the 6791 titles identified, 119 articles met the inclusion criteria and were
Midwifery, Royal College of Surgeons in Ireland; 123
St Stephen's Green, Dublin 2, D02 YN77, Ireland. included in this scoping review. The majority of articles were partial economic
Email: witoldorlik@rcsi.com
evaluations of CPD programmes (n= 70); half were from the USA. Studies that included
multiple professions were most prevalent (n= 54), followed by nurses (n= 34) and
doctors (n= 23). Patient outcomes were the most commonly reported outcome (n= 51),
followed by change in clinical practice (n= 38) and healthcare professionals' knowledge
gain (n= 19).
Conclusions: There is an urgent call for more evidence regarding the economic
evaluations of CPD. This is particularly important in view of the rising costs of healthcare
globally. The majority of studies included in this review did not provide detailed
information on the evaluations and many focused exclusively on the cost of CPD activities
rather than outcomes.
1 | INTRODUCTION
Continuing professional development (CPD) is
essential for healthcare professionals to deliver high-
quality and safe person-centred care, amidst ever-
changing health systems across the globe. The World
Health Organization (WHO) cited a skilled workforce
as the
cornerstone of a healthy nation and supported the
need to expand transformative, high-quality
education and life-long learning for all healthcare
workers.1 A coordinated approach is needed to
determine how CPD programmes and activities can
address workforce planning and the recruitment and
This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any medium,
provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made.
© 2022 The Authors. Medical Education published by Association for the Study of Medical Education and John Wiley & Sons Ltd.
retention of healthcare workers. This approach
supports strategies to confront the current global
recruitment and retention crisis of healthcare workers
to achieve a quality healthcare system for all people.
Evaluation of CPD activities is an essential part of the
programme measuring whether and to what extent
they improve the delivery of high quality, safe person-
centred care. CPD activities should be able to
demonstrate the sustainability and efficiency of the
programme. While there is limited data on the
economic cost of training health professionals,2,3 very
little is known about the economic cost and cost-
effectiveness of providing CPD to healthcare
professionals.
Economic evaluations can provide useful
information to those making decisions about the
allocation of limited health care resources. In
particular, economic evaluations can be used to
identify interventions that are vital to the health
service (health professionals, organisations and
patients) and those that provide little benefit given
the resources required. The ultimate test of an
economic evaluation is whether it leads to better
decisions in the presence of uncertainty and results in
the more efficient and effective use of limited
healthcare resources.4 There is an important role for
economic evaluations in priority setting in health care
decision-making. This includes assessing the
costeffectiveness of CPD activities for healthcare
professionals. Consequently, an economic evaluation
of CPD activities can be used to maximise the benefits
from health care spending in this area and to contain
costs and manage the needs of the health service.5
Information regarding the economic costs
associated with the various educational methods used
to deliver CPD programmes informs decisions and
choices about CPD activities for healthcare
professionals, healthcare organisations as funders and
educational institutions that provide CPD. Such
knowledge informs the sustainability and efficiency of
CPD activities. These are challenging times for
healthcare delivery with economic constraints and
Med Educ.
workforce shortages. Thus, it is essential that
sustainable and efficient CPD is a fundamental part of
the healthcare service. Despite calls for increased
economic accountability in health professional
education,6,7 economic evaluations of CPD remain a
challenge with a limited number of published studies
in this field.8,9
A review of the literature on the cost-effectiveness
of CPD in health care found a minimal number of
published studies (n = 9).8 It was concluded that more
cost-effectiveness studies were urgently required and
that there was a need for greater attention to ensure
that methods of evaluation and analysis are reported
appropriately. Another recent systematic review
focused on methods and reporting quality of cost
evaluations in health professions education.10 Trends
over time by sampling research reports at 5-year
intervals (2001, 2006, 2011 and 2016) were examined.
Seventy-eight studies were included in the final
review, which included an evaluation of
undergraduate, post-graduate and CPD education. Of
these studies, 36 were categorised as relating to CPD,
five studies in 2001, nine in 2006, 11 in 2011 and 11 in
2016. Findings from this study would indicate that
there has been an increase in published studies in this
field since 2002.8 However, it was found that there
were reporting deficiencies and that appropriate
methods of evaluation and analysis continue to be
lacking.10
 A preliminary search for existing scoping reviews 2.1 | Criteria for selection of articles
and systematic reviews on economic evaluation of
CPD was conducted; none were found. Therefore, this Inclusion and exclusion criteria were developed based
scoping review aims to collate the body of evidence on the aims of the review and research questions.
available on economic evaluations of CPD and identify
gaps in knowledge found in the literature to better
guide future research. 2.1.1 | Inclusion criteria

Studies were included in the review on the following

2 | METHODS basis:

Scoping reviews have become an increasingly popular a. year of publication, from 2010 to 2021;
approach to explore and appraise healthcare research b. studies published in the English language only;
evidence.11 Especially, if the scope of the research is
c. the following healthcare professions were included:
complex and has not been previously investigated.12
Scoping reviews allow for quick identification of (nurses, doctors, allied health professionals,
sources and types of evidence to pinpoint key dentists.).
elements relating to the area of interest.12 It was d. all CPD activities that included
suggested that a scoping review was an appropriate
an education or training
tool to address the review questions. The following
questions were addressed: What is the scale of component.
research evidence on economic evaluations of CPD e. economic evaluations included:
activities for healthcare professionals? Which health
1. Full economic evaluation (FEE) studies—the
professions have been included? What types of
economic evaluations were utilised? Answering these comparative analysis of alternative courses of
core questions will help to map the evidence base and action in terms of both costs (resource use) and
identify areas appropriate for further research or consequences (outcomes, effects). 14 Cost–
systematic review and inform readers on the current
benefit analysis (CBA), cost-effectiveness analysis
state of research on economic evaluations of CPD
activities. (CEA) and cost-utility analysis (CUA). They aimed
to produce measures of incremental resource
For this scoping review, we used the definition of
use, costs and cost-effectiveness.
CPD introduced by the Executive Agency for Health
Consumers, 2013— ‘Systematic maintenance, 2. Partial economic evaluation (PEE) studies—

improvement and continuous acquisition and/or without explicit comparisons between

alternative interventions in terms of both costs
reinforcement of the life-long knowledge, skills and
(resource use) and consequences (effects). These
competencies of health professionals. It is pivotal to
included cost analyses, cost-description studies
meeting patient, health service delivery and individual
and cost- outcome descriptions.
professional learning needs. The term acknowledges
f. manuscript type: original research studies
not only the wide ranging competencies needed to
published in peerreviewed journals investigating
practice high quality care delivery but also the multi-
CPD activities, with or without a comparison
disciplinary context of patient care’.13
between interventions or activities. All research
studies were included that met the inclusion
criteria, regardless of the study design.
2.1.2 | Exclusion criteria
Students undertaking undergraduate and post-
graduate education, for example, residency training
programmes, bachelor degree, master degree, post-
graduate diploma or PhD were excluded. Conference
abstracts, books, editorials, commentary-style articles
and systematic reviews were excluded from the
study.
2.2 | Search strategy
The scoping review included peer-reviewed primary
research articles that were retrieved from the
following electronic databases: Cumulative Index to
Nursing and Allied Health Literature (CINAHL),
MEDLINE/PubMed, Scopus, Econlit and Web of
Science. Reference lists of reviews found through the
electronic search were checked to ensure that
relevant articles were included. The team used an
iterative process to identify key search terms. The
search terms were kept broad, resulting in many
irrelevant studies having to be eliminated in the study
selection stage. An academic librarian advised on the
most appropriate Medical Subject Headings (MeSH)
terms for the search and how to modify them for the
different databases. The following MeSH terms were
used: health professions (nurse OR doctor OR
physician OR physio), economics (costs and cost
analysis [CA] OR CBA OR cost-effectiveness OR return
on investment) and continuing education
(professional education OR continuing professional
development OR professional development OR staff
development OR continuing education OR continuing
medical education). Based on this exploratory,
scoping phase, the search strings for each database
were finalised. Articles were retrieved from each
database and imported into a reference management
software tool (EndNote).
2.3 | Data extraction
A data-charting table was used to extract the data
from the final selected sources (full text articles
included in the scoping review). The charting of
results was an iterative process whereby the data-
charting table was continuously updated so additional
data could be amended or added. The data-charting
table was piloted by two members of the research
team (WO, CF). Two or three selected sources were
used to trial the data-charting table to ensure all the
relevant results were extracted. The following data
were extracted from the full text articles to be
included in the data-charting table: author(s) names
and journal related details, year of publication, title,
country, population, educational intervention, study
outcomes, outcome categories and economic
evaluation details (see supporting information). The
methodological quality of the studies was not
appraised as the aim of this scoping review was to
provide an overview of the existing evidence on
economic evaluations of CPD activities for healthcare
professionals.15
3 | RESULTS
3.1 | Selection of sources of evidence
As a result of the databases search, 6791 research
records were found. Subsequently, the duplicates
were removed (n = 664) and two authors (WO and CF)
independently screened titles, abstracts and
keywords of the remaining articles (n = 6127) to
exclude those that did not meet the inclusion criteria.
Consequently, 5815 articles were removed, leaving
312 research items to be downloaded as full texts.
Disagreements about study eligibility were discussed
between the two reviewers until consensus was
reached. The reference lists of the included articles
were also reviewed for additional papers; 119 articles
were included in the final review. The process of
study selection was reported using Preferred
Reporting Items for Systematic Reviews and Meta-
Analyses flow chart (Figure 1).
3.2 | Characteristics of sources of evidence
3.2.1 | Year/geographical location
The highest number of studies was for 2011 (n = 18),
followed by 2016 (n = 14) and 2013 (n = 13). The
lowest number of studies was for 2019 (n = 5),
followed by 2014 (n = 6) and 2017, 2018 and 2020
with an equal volume of studies (n = 8). Half of the
included studies were from the USA (n = 59), followed
by UK (n = 19) and Australia (n = 7); see Table 1.
Studies that included multiple professions were most
prevalent (n = 54), followed by nurses (n = 34) and
doctors (n = 23). Other professions (e.g. midwives and
dentists) were represented in the remaining eight
studies (Table 2).
3.2.2 | Studies' outcomes
The outcomes of each study (endpoints resulting from
CPD activities) were categorised into five main
categories: patient outcomes, practice/behaviour
FIGURE 1 Flow chart
demonstrating the study selection
process
change, healthcare professionals' knowledge gain,
education related and healthcare professionals'
personal health and safety (Table 3). Patient
outcomes were the most commonly reported
outcome (n = 51). Within this category, the
subcategory ‘improved clinical outcomes’ was the
most frequently reported (n = 19). Another category
of the study outcomes was practice/behaviour change
(n = 38), and the highest subcategory was medication
management (n = 16). The third, most prevalent
category of outcomes was healthcare professionals
knowledge gain (n = 19).
3.3 | Economic evaluations
3.3.1 | FEEs
Economic evaluations were classified into two main
categories: FEEs and PEEs, Table 4. Among studies
with FEE (n = 50), costeffectiveness studies (n = 35)
were the most prevalent approach to examine the
costs and outcomes of CPD activities, followed by
studies with cost–benefit (n = 8) and cost-
minimisation approaches (n = 6). In CEA studies, costs
are expressed in monetary units, for example, dollars
or euros, whereas benefits are expressed in
nonmonetary, natural units, for example, quality-
adjusted life years (QALYs) or knowledge gain.16 A
study in Malawi on an orthopaedic clinical officer
training programme to improve musculoskeletal care
reported the cost-effectiveness of the programme.17 It
was established that the average cost for each
hospital was US$138.75 (95% CI: US$69.58–207.91)
per one disability-adjusted life year (DALY). In a study
on reducing glycaemic episodes among patients with Sweden 1

type 2 diabetes, it was established that the Diabetes Ireland and UK 1

Management Education Programme for healthcare Multi European (Belgium, England, Netherlands, 1 Poland,
staff was cost-effective when compared with standard Scotland, Spain)

care. A cost of 43 Australian dollars resulted in 1 day North America 64

of glycaemic symptoms avoided.18
USA 59
In cost–benefit analysis studies, both costs and
Canada 4
benefits are expressed in monetary units.16 A study on
the safety of patient handling and its impact on Mexico 1
South America 3
medical staff injuries (n = 55 health professionals;
Argentina 1
USA) reported financial gains obtained after Chile 1
implementing an educational intervention.19 It was Guatemala 1
found there was a cost–benefit of $3.71 for every Asia 5
dollar invested, expressed in reduced injuries for the
Indonesia 1
duration of 30 months after the training.
Correspondingly, a study from Canada on manual Japan 1

handling in long-term care facilities reported financial Saudi Arabia 1

outcomes of the programme.20 It was established that Taiwan 1

the benefits resulting from the training were smaller Multi Asian (Bangladesh, Pakistan, Sri Lanka) 1
(748 431 Canadian dollars) when compared with costs Africa 5
(894 000 Canadian dollars). However, that relatively South Africa 2
modest, incremental cost resulted in the prevention Malawi 1
of additional accidents linked to the manual handling Zambia 1

of patients. Multi African (Burundi, Ethiopia, Kenya, Malawi, 1

Mozambique, Rwanda, Tanzania, Uganda,
Zambia, and Zimbabwe)

Australia 7
3.3.2 | PEEs
Australia 6
Among studies categorised as PEE, the majority Australia and UK 1
applied CA (n = 69). CA studies are characterised by Total 119
information provided for costs TABLE 1 Country and a
number of articles

Number of
articles
Country
Europe 35
exclusively and do not include evidence on financial
UK 19
returns and outcomes.16 Most often, CA's focus is on
France 2
cost-description, cost saving or return on investment.
Spain 2 For example, in a study encouraging patient
Denmark 1 engagement
Profession in more healthy behaviours (n = 1827
N (%)

Finland 1 patients), there TABLE 2Profession profile

Multiple professions 54 (45)
Germany 1
Nurses 34 (29)
Italy 1
Kosovo 1 Doctors 23 (19)

Norway 1 Pharmacists 3 (2)

Poland 1 Midwives 2 (2)

Portugal 1
Dentists 1 (1)
Serbia 1
 Genetic councillors 1 (1) Economic evaluation category N (%)

Podiatrists 1 (1) Cost analysis (PEE) 70 (59)

Total 119 (100) Cost-effectiveness analysis (FEE) 35 (29)

TABLE 3 Categories of the outcomes resulting from Cost–benefit analysis (FEE) 8 (7)
CPD activities Cost-minimization analysis (FEE) 6 (5)

Category N % Cost-utility analysis (FEE) 1 (1)

Abbreviations: FEE, full economic evaluation; PEE, partial economic analysis.
Patient outcomes 51 43
Improved clinical outcomes 19 16
Effectiveness of care 9 8 Correspondingly, a recent study from the UK
Improved life quality 9 8 examining clinical librarian support in critical hospital
Reduced mortality 5 4 care reported monetary benefits expressed in terms
Improved mental health and lifestyle changes 5 4 of return on investment.23 Specifically, the librarian's
help in academic writing, information search,
Reduction in duration of care 2 1.5
referencing and proofreading resulted in financial
Improved patient safety 2 1.5
gains (for every £1 invested, a positive return on
Practice/behaviour change 38 32
investment of £1.18–3.03 was obtained).
Medication management 16 13

Equipment usage 8 7
3.4 | Synthesis of results
Organisational change 5 4

Improvements in communication
Infectious disease screening
Healthcare professionals knowledge gain
Education related
Efficiency of learning related to modality
Cost reduction in delivery of education
Evaluation of dental examination
Promoting nursing certification
Healthcare professionals personal health and
safety
Manual handling
Nurses wellness
Needle stick injury prevention
Abbreviation: CPD, continuing professional development.
was a training cost reported of £1597 per each of the
27 general practices in Wales (CA–cost description).21
A study on training to prevent bleeding complications
(n = 133 continuing medical education recipients;
USA) reported that based on the sensitivity analysis,
substantial cost savings were estimated for
reoperation bleeding, $2 233 988 (95% confidence
interval [CI], $1 223 901–$3 648 719).22 TABLE 4
Economic evaluation characteristics
1 1
The number of studies per country, professional
1 1 profiles, study outcomes and economic evaluation
19 16 details was divided across three 4-year periods (Table
7 6 5). There is a dominance in the volume of research
4 3 from North America, mainly the USA; however, this is
less explicit for the 2018–2021 period. With regard to
1 1 professional profile, multiple professions are most
1 1 prevalent, followed by nurses and doctors, and this
1 1
pattern is stable across all three time periods
4 3
presented. Regarding the study results, a similar
number of articles with improved patient outcomes
2 1.5 and changes in practice were found for the 2010–
1 1
2013 period. For the 2014–2021 period, the articles
1 1
with improved patient outcomes were more
frequently identified compared with changes in
practice. Regarding the economic characteristics, PEEs
are more common compared with FEEs for the 2010–
2013 period. A similar trend was noticed for the
2014–2021 period, although the difference in terms
of the number of articles is smaller.
4 | DISCUSSION
This review highlights the extent, nature and range of
literature since 2010 on economic evaluations of CPD
activities for healthcare professionals. A significant
finding in this review is the noticeably limited number
of studies conducting an economic evaluation of CPD
in healthcare professionals education. In addition,
there was a decrease rather than an increase in the
number of studies between 2010 and 2021. It is
unknown if the outbreak of the global Covid-19
pandemic in March 2020 contributed to this
decrease.24 The education of healthcare professionals
is an area in which a strategic optimisation of limited
resources is of the utmost importance.25 However, we
find that almost without exception, there is
compelling evidence to suggest an absence of
economic evaluation of programmes of education. A
variety of potential determinants may have
contributed to this modest volume of research. One
possible explanation is that many organisations (e.g.
universities or healthcare organisations) that do
conduct economic evaluations of their educational
activity do this as part of the overall programme
evaluation rather than research.26 Consequently,
those conducting the evaluation may not consider
publishing their findings. More typically, there are
often no mechanisms in educational institutions and
healthcare organisations, which require economic
evaluations of the educational activities.25,27
Furthermore, stakeholders involved in the allocation
of funding for education may not require economic
evaluations to be conducted as part of the
programme evaluation to begin with.28
4.1 | Outcomes
Patient outcomes were the most frequently observed
outcome category, followed by changes in practice or
behaviour of healthcare professionals. These findings
concur with the results from a scoping review on
health professionals' performance and patient
outcomes.29 The authors established that patient
outcomes and changes in healthcare professionals'
behaviour were most frequently identified among 63
knowledge syntheses included in the review.
Concerning the economic evaluations of the studies,
PEEs focusing on the costs of CPD programmes were
most commonly noted. Perhaps a higher number of
identified articles with PEE compared with FEE is due
to a relative ‘convenience’ of focusing exclusively on
costs of CPD rather than linking the costs to the
outcomes. These findings correspond with results
from the systematic review on cost evaluations in
health professions education.10 Only 16 out of 78
studies included in the review applied FEE. Among
studies with FEE, a CEA was the most prevalent
approach used. CPD activities in healthcare often
have an impact on outcomes that are expressed in
non-monetary terms, such as reduced mortality,
QALY, or decreased hospital stay.
There are a number of components of economic
analysis that make it valuable to the broader
education community. Conducting economic
evaluations of educational activities can lead to more
efficient use of educational resources that can reduce
the costs associated with accomplishing
organisational goals, for example, more effective use
of information technology. Economic evaluations can
expand what can be achieved in the presence of
budget constraints and can also ascertain which
investments in education may provide the highest
return. A fundamental characteristic of economic
analysis that makes the work useful to the broader
education community is also the expansiveness of the
possible research context. Economic analysis may
explore educational30–32 and economic
consequences33–35 and also career advancement,35,36
provision of health services37–39 and population
health.40,41 Such analysis may also investigate an array
of patient outcomes, for example, medication
adherence, morbidity, quality of life, emotional well-
being21,36,42 and mortality.43,44 Thus, diversity of scope
in an economic analysis increases the value of such
research by contributing to a more complete
exploration of the education of healthcare
professionals, improving overall understanding in the
field.16
 Years N (%) Years N (%) Years N (%) TABLE 5 Study characteristics
2010–2013 2014–2017 2018–2021 across three 4-year periods
54 (46) 39 (33) 26 (22)
Study characteristic
Region

USA and Canada 30 (25) 22 (18) 11 (9)

Europe 15 (13) 12 (10) 9 (7.5)
Australia 2 (1.5) 1 (1) 3 (2.5)
Africa 2 (1.5) 3 (2.5) 0 (0)
Asia 3 (2.5) 0 (0) 2 (1.5)
Latin America 2 (1.5) 1 (1) 1 (1)
Profession
Multiple
24 (20) 16 (13) 14 (12)

Nurses 15 (13) 11 (9) 8 (7)

Doctors 12 (10) 8 (7) 3 (2.5)

Other 3 (2.5) 4 (3) 1 (1)

Outcome
Patient outcomes 22 (18) 18 (15) 14 (12)
Practice/behaviour change 20 (17) 9 (8) 7 (6)
Knowledge gain 7 (6) 8 (7.5) 2 (1.5)
Other 5 (4) 4 (3) 3 (2.5)
Economic evaluation category

Full economic evaluation 20 (17) 18 (15) 12 (10)

Cost-effectiveness analysis 11 (9) 14 (12) 10 (8)
Cost–benefit analysis 5 (4) 2 (1.5) 1 (1)
Cost-minimisation analysis 4 (3) 1 (1) 1 (1)
Cost-utility analysis 0 (0) 1 (1) 0 (0)
Partial economic evaluation 34 (29) 21 (18) 14 (12)

CA (cost description) 11 (9) 10 (8) 6 (5)

CA (cost saving) 20 (17) 9 (7.5) 6 (5)

CA (return of investment) 3 (2.5) 1 (1) 2 (1.5)

CA (cost consequence) 0 (0) 1 (1) 0 (0)

Abbreviation: CA, cost analysis.
improved patient outcomes and increased knowledge
for healthcare professionals.
4.2 | Strengths and limitations Regarding limitations of the included studies, the
majority provided incomplete information on
An extensive search for articles using five electronic
educational interventions or training. This lack of
databases and an additional manual search allowed
details resulted in the inability to differentiate
for a broad exploration of knowledge resources. As a
between specific types of interventions and link them
result, a relatively high number of included articles
with explicit financial outcomes. There is a need to
were identified which led to a detailed appraisal of
use appropriate methodology to evaluate the
the existing evidence. To the best of the authors'
economic impact of CPD activities. Studies on
knowledge, this is the first scoping review that
economic evaluations of CPD need to capture the key
described the economic impact of CPD programmes
components of the programme including the type of
across a variety of healthcare professions. Main
intervention, the healthcare professionals involved,
beneficiaries of the programmes were patients and
the setting where the intervention occurs, specific
medical personnel as interventions often led to
details of all the resources used and most importantly
a clear identification of the outcomes that the economic evaluations of CPD to support the process
programme hopes to achieve. Finally, the majority of of
the studies were from countries where English is a
primary language. Hence, there may be an over- future evaluation (Box 1).49–51
representation of studies from these countries. The While not the main focus of this review, a
decision to limit the search to research records in consideration of these results within the wider
English language exclusively was based on the academic environment (undergraduate and post-
challenge of translating multiple languages and the graduate education) may provide a broader context
practical challenges of locating and assessing relevant for economic evaluation. In the scholarly setting, such
non-English studies. evaluations are less common. In a systematic review
of economic evaluations of healthcare professions
education, it was reported that only three studies in
4.3 | Implications for future research
an undergraduate context were evaluated using a FEE
compared with two in post-graduate education and
The authors of this review emphasise the importance
11 for CPD activities.10 The higher number of identified
of publishing economic evaluations of educational
studies in CPD evaluated by FEE may reflect an
activities. Such evaluations are important irrespective
assumption that CPD activities more often lead to
of whether they are related to undergraduate, post-
outcomes in a larger context, for example, improved
graduate education or CPD. Economic evaluations can
service provision, patient outcomes or decreased
be applied to estimate ‘value for money’ across a
expenditure on medication. Thus, there may be an
variety of outcomes resulting from education. Thus,
expectation that such outcomes are less likely to be a
such evaluations may escape some of the narrower
result of undergraduate or post-graduate
designations of traditional CPD research, providing
programmes. However, there is unequivocal evidence
the opportunity to conduct research with an
indicating that the global cost of healthcare education
increased scope of context. For example, it is possible
has risen dramatically during prior decades. It was
to study educational outcomes and learning
reported that in the last 60 years, the cost of 4 years
objectives and also professional progression,
of medical education in the USA increased more than
fellowship and residency programmes, financial
sevenfold.53 Moreover, the average debt of graduating
return, service provision, disease prevention, patient
students (75% of the overall student population)
quality of life, morbidity and mortality.45–48 This will
reached 200 000 dollars. As educational costs
result in breadth of perspective deepening research
continue to rise, access is curtailed. There is thus a
understanding of this field.
practical need to increase access to healthcare
It is vital to promote a research culture that fosters education while controlling the rising costs. According
the importance of programme evaluation in the to a WHO report in 2016,54 there was a 7 million
context of health professions education. Economic shortfall regarding staffing needs in healthcare
evaluations are necessary to define success in worldwide in 2013 and by 2030 this
programmes under resource constraints.26 In addition,
applying evaluations in the health system
demonstrates how best to commit resources in order
to maximise educational gains following
intervention.16 A more costly intervention may be
superior when compared with a cheaper alternative
provided it offers substantially more value. Similarly, a
less efficient activity may be recognised as offering
better value as long as savings are significant.16 Per
review of best practice in the literature, we provide
key recommendations for the appropriate conduct of
 Dovepr Lin

Box 1 Key Recommendations for Best Practice in the Conduct of Economic Evaluations of Health
Professional Educational Activities

Key Recommendations

• Studies on economic evaluations of CPD need to capture the key components of the programme
including: Detailed description of the educational intervention.

(Foo et al. 2019) Healthcare professionals involved.

Setting where the intervention occurs.

Specific details of all the resources used. Detailed reporting of all costs involved in the
intervention. To facilitate the estimation of costs and costeffectiveness consider using a tool
such as: CostOut ® https://www.cbcsecosttoolkit.org52
Clear identification of the outcomes that the programme hopes to achieve.

• Prioritise full economic evaluations over partial economic evaluations (Tolsgaard & Cook, 2017).
• Use a reporting guideline such as the CHEERS 2022 statement which provides guidance on
reporting of health economic studies (Husereau, 2022).
shortfall is expected to reach 18 million. Economic evaluation may help to address this issue by
supporting the provision of higher education and training for healthcare workers that is demonstrably
affordable and effective.

Another concerning observation from the review is the decreasing number of studies conducting
economic evaluations of CPD. This is in contrast with the findings from the systematic review on cost
evaluations of health professionals' education.10 A possible explanation for this discrepancy is that the
review included research articles published between 2001 and 2016, but only 4 years was scrutinised by
the authors (2001. 2006, 2011 and 2016). Hence, the stability or increase in the volume of studies
reported should be treated with caution. Another possible explanation of this difference is that the
review included studies with pre-graduate and post-graduate education in healthcare and CPD, whereas
this review focused exclusively on healthcare professionals' CPD activities. Finally, in the conclusion of
the review, it was emphasised that an overall proportion of studies published in specific years did not
increase.10
The authors of this review emphasise the need to standardise the methods applied in CPD
programmes. It is understood that such a process of standardisation requires time, and researchers
should be encouraged to identify experts with skills and knowledge in economic evaluations, particularly
regarding the design and implementation of CPD programmes. This standardisation is of importance in
times of healthcare expenditure cuts and increasing demand in the prioritised allocation of funds in
healthcare spending (e.g. ageing populations, global demographic growth and the emergence of Covid-
19). Past research evidence supports that need. It was established that health professions education was
characterised by lower levels of economic literacy when compared with the health and biomedical
sciences.10 Specifically, price adjustments in pharmacology, complementary medicine, biomedical

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sciences, health care multinational trials and reproductive medicine were more commonly reported in
comparison with health professions education studies. Analogously, a critical review on the cost-
effectiveness of CPD in healthcare indicated a lack of consistency of evidence related to economic
evaluations (e.g. cost information or detailed economic analyses).8 This deficiency limited interpretation
of the results and hindered the identification of efficient CPD programmes from which patients could
benefit.

5 | CONCLUSIONS AND RECOMMENDATIONS

A critical insight to emerge from this review is the paucity of studies conducting an economic evaluation
of continuing professional development activities and the absence of a uniform methodology where
such studies did take place. The majority of studies included in the review conducted PEE only. The
information on the costs of isolated educational interventions or CPD programmes limits the utility of
the findings. This type of evaluation does not allow for the identification of how the cost of the
intervention may be mirrored in the financial benefits of CPD activities. One of the ways to address this
caveat in knowledge could be to design and introduce research questions that emphasise the
importance of cost–benefit or cost-effectiveness of CPD programmes. Moreover, there is a need to
develop a standardised framework for reporting the economic impact of CPD programmes and activities.
The framework could benefit from implementing knowledge derived from health economics and
education economics. The combination of resources from those two areas of research could help to
improve and extend the study design of CPD programmes. This would enable accurate assessment and
appropriate comparisons pertinent to CPD activities in healthcare. Finally, more research evidence is
needed regarding ‘the value for money’ estimates of CPD activities. It is particularly importance due to
the rising costs of healthcare globally. A substantial number of studies included in the review did not
provide details of the economic evaluations and many reported costs of CPD only.

ACKNOWLEDGEMENTS
We would like to acknowledge the assistance of Mr Paul J Murphy from RCSI library for his assistance
with the search strategy and Ms Aine Halligan, administrative assistant, Faculty of Nursing and
Midwifery, RCSI, for her assistance locating some of the full text articles. Open access funding provided
by IReL. [Correction added on 20 May 2022, after first online publication: IReL funding statement has
been added.]

CONFLICT OF INTEREST
The authors report no conflict of interest.

ETHICS STATEMENT
Ethical approval was not obtained for this study as human subjects were not involved in the scoping
review.
AUTHOR CONTRIBUTIONS
WO wrote-up the manuscript and identified studies to be included in the review, searched literature and
analysed the results and built the review structure and prepared supplementary materials. GA identified

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studies to be included, searched literature and prepared supplementary materials. TK revised the
manuscript, critically evaluated the gathered evidence, interpreted the results and provided expertise
on CPD in healthcare. JB provided expertise on economic evaluations in healthcare and was involved in
the manuscript write-up. JW provided expertise on CPD in healthcare, pointed towards important
avenues of arguments to be included and critically evaluated the material. PM critically evaluated the
gathered evidence, was involved in revision of the initial draft and added important references. MG
critically revised the initial draft and provided expertise in the context of nursing and continuing medical
education, and he was involved in building a structure of arguments presented in the manuscript. NR
was involved in writing the study protocol (study background), searched literature and provided
rationale for the review. CGV provided expertise on CPD in healthcare, pointed towards important
avenues of arguments to be included in the manuscript and critically evaluated the review content. MLC
critically evaluated the manuscript and provided expertise on the topic of CPD in healthcare and its
evaluation and offered novel ideas to the study. CF prepared the study protocol, identified research gaps
to be addressed, analysed the results, co-ordinated work between the authors and was involved in the
manuscript write-up, evaluation, and extraction of the evidence from the databases. All authors give
permission to be accountable for all aspects of the work in ensuring that questions related to the
accuracy or integrity of any part of the work are appropriately investigated and resolved.

DATA AVAILABILITY STATEMENT

The data that support the findings of this study are available in the supporting information of this article.

ORCID
Witold Orlikhttps://orcid.org/0000-0002-9405-5357
Giuseppe Aleohttps://orcid.org/0000-0002-1306-3364
Cristina García Vivarhttps://orcid.org/0000-0002-6022-559X

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of Education, Teachers College, Columbia University. 2015. Retrieved from: https://www.cbcsecosttoolkit.org
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1016/S0140-6736(16)32235-8

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Risk Management and Healthcare Policy
Open Access Full Text Article
The Impact of the COVID-19 Pandemic
on Future
Nursing Career Turnover Intention
Among Nursing Students
Yulan Lin1
Zhijian Hu1
Mahmoud Danaee2
Haridah Alias2
Li Ping Wong 1,2
1
Department of Epidemiology and
Health
Statistics, School of Public Health,
Fujian
Medical University, Fuzhou, 350122,
Fujian Province, People’s Republic of
China; 2Centre for Epidemiology and
Evidence-Based Practice, Department
of
Social and Preventive Medicine,
Faculty of
Medicine, University of Malaya 50603,
Kuala Lumpur, Malaysia
Risk Management and Healthcare Policy 2021:14
21
Lin
Dovepress
open access to scientific and medical research
ORIGINALRESEARCH
Introduction: A shortage of nurses has been a major global concern, particularly during
pandemics. Nursing students turning away from the nursing profession upon graduation may
exacerbate nursing workforce shortfalls. The main objective of this study was to assess
perceived occupational turnover intention among nursing students and associated factors (fear
of COVID-19 and life satisfaction). Students were also asked to provide suggestions that could
enhance their intention to join the nursing profession.
Methods: An online survey was sent to all registered undergraduate nursing students at Fujian
Medical University, China. The partial least squares structural equation model (PLS- SEM) was
used to investigate key factors influencing turnover intention.
Results: A total of 1020 complete responses were received (response rate: 86.2%). Nearly
half (49.1%) reported that they would choose not to be on a nursing course if given a choice,
45.4% often think of not going into the nursing profession in the future, and 23.7% would
consider entering a healthcare industry that has zero contact with patients. The total turnover
intention score range was 3 to 15, and the mean ± standard deviation (SD) was 9.2 (SD ± 2.5).
PLS-SEM path analysis revealed that fear of COVID-19 (β = 0.226, p < 0.001) had a positive
effect on
turnover intention. Satisfaction with life (β = −0.212, p < 0.001) had a negative effect on
turnover intention. Analysis of open-ended survey data on students’ perspectives on how to
encourage nursing students to enter the nursing workforce revealed five central themes: 1)
professional role, respect, and recognition; 2) higher wages; 3) reduce workload; 4) enhance
occupational health and safety; and 5) career advancement opportunities.
Conclusion: Factors influencing turnover intention and suggestions to reduce students’
apprehension towards joining the nursing profession found in this study should be seriously
taken into consideration in initiatives to address the nurse shortages.
Keywords: Chinese nursing students, fear of COVID-19, psychological reactions, life
satisfaction, turnover intention
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Introduction a general assessment of emotions and attitudes about an individual’s life at a
certain point.11 Greater life satisfaction is associated with greater career
The issues of nursing staff satisfaction, motivation, and commitment.12 Well-being in healthcare workers
shortages and turnover are and undergraduate students has been found to have a positive relationship
human resource problems with optimism, resilience in facing challenges, and a stronger belief in one’s
affecting many European and ability to handle stress.13
Asian countries having a huge
The novel coronavirus (COVID-19) epidemic first broke out in Wuhan,
impact on the performance of
China, in December 2019. It is now a major public health emergency
the national healthcare
worldwide, because it has spread quickly and caused extensive infections. As
systems of those countries.1,2
of 28 March 2021, over 126 million SARS-CoV-2 cases and 2.7 million deaths
Continued nurse shortages
have been reported by the World Health Organization (WHO).14 According to
hinder the delivery of high-
the WHO, as of July 2020, over 1.4 million infections of COVID-19 have been
quality patient care and have a
reported among healthcare workers, which accounts for 10% of global
detrimental
infections.15 During an infectious disease pandemic, healthcare workers are
Correspondence: Yulan Lin; Li Ping Wong impact on patient outcomes and mortality. The nursing shortage situation in
Tel +86-591-2286-2023; +60-379675778 China constitutes a considerable concern.5 In China, the shortage of nurses
has Email yulanlin@fjmu.edu.cn;
wonglp@ummc.edu.my increased the workload, stress, and burnout of the remaining nurses.6 Nurse

Risk Management and Healthcare Policy 2021:14 3605–3615 3605

Received: 31 May 2021 © 2021 Lin et al. This work is published and licensed by Dove Medical Press Limited. The full terms of this license are available at https://www.dovepress.com/terms.php
Accepted: 30 July 2021 and incorporate the Creative Commons Attribution – Non Commercial (unported, v3.0) License (http://creativecommons.org/licenses/by-nc/3.0/). By accessing the work you
hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed. For Published:
27 August 2021 permission for commercial use of this work, please see paragraphs 4.2 and 5 of our Terms
(https://www.dovepress.com/terms.php).
3,4
every country’s most valued resource. As nurses constitute the majority of
turnover is a serious problem
healthcare workers, they have a tremendously important function in
that has been the subject of
healthcare systems during outbreaks of acute infectious diseases. The impact
intensive research in China.7
of COVID-19 on the nursing workforce has been pronounced across the world
High annual turnover rates
and the pandemic has exacerbated the already critical shortage of nursing
range from 20% to 45% of
staff.16 Most importantly, the COVID-19 pandemic has resulted in an
hospital nursing care workers
enhanced nursing workload,17 resulting in nurses suffering burnout or
in China has been reported.8
psychological distress.18 Furthermore, nurses face a substantial risk of SARS-
More recently, a systematic CoV-2 infection because they are on the frontline in the fight against COVID-
review reported a high 19.
prevalence of depressive
symptoms among Chinese A high prevalence of SARS-CoV-2 infection has been reported among
nurses, with an increasing healthcare workers from the UK and the Netherlands.19 In China, as of 26
trend associated with a March 2020, out of 50,006 COVID-19 cases in Wuhan, 2457 (nearly 5%) were
shortage of nursing resources healthcare workers, of whom 17 died.20 Of note, half of the infected
resulting in heavy workloads.9 healthcare workers were nurses.20 A recent study reported that the COVID-19
Apart from a heavy workload, pandemic has instilled tremendous fear among frontline nurses in China, and
well-being and life satisfaction nursing students who will soon become nurses have similarly expressed
are also important influencing heightened anxiety.21
factors affecting nurses’ As the need for nurses continues to increase with the world facing the
decision to stay in the nursing COVID-19 pandemic, nursing students are an important future nursing
profession.10 Life satisfaction is workforce. An increasing loss of Chinese nurses after graduation was
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reported in China prior to
the pandemic.22 Hence, it is
important that nursing
students enter the
workforce to fill the serious
nursing workforce
shortage. Much research
has been conducted into
the turnover intention of
nurses in the workforce,
but little is known about
the turnover intentions and
career orientations of
nursing students after the
COVID-19 pandemic in
China. Therefore, this study
aimed to determine
perceived occupational
turnover intention among
nursing students. The
existing literature indicates
that fear of COVID-19 and
life satisfaction are
important influences of
career turnover intention.
Hence, factors influencing
turnover intention, namely
fear of COVID-19 and life
satisfaction, were also
studied. In this study we
hypothesized that higher
levels of fear of the COVID-
19 pandemic and lower
levels of life satisfaction
may result in higher
turnover intention among
nursing students.
It is also important to
gather opinions from
nursing students about
other external factors that
influence turnover
intention. Therefore, the
second objective of this
Risk Management and Healthcare Policy 2021:14
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Lin
study was to capture students’ opinions on these factors to obtain a
greater understanding of the barriers or facilitators influencing their
intention to join the nursing profession. The findings of this study may
contribute to the understanding of nursing students’ career intentions in
the era of the COVID-19 pandemic and provide useful insights for nursing
programmes or government authorities to prevent depletion of the
nursing workforce.
Method
Study Participants
The participants were all undergraduate nursing students enrolled in
Fujian Medical University, Fuzhou, China. The survey was administered
online. A convenience sampling method was used for the data collection.
The link to the online self-report questionnaire was sent to all registered
nursing students. Data collection was conducted between 24 September
2020 and 10 October 2020. In the current study, the estimated sample
size was derived from the online Raosoft sample size calculator.23 The
sample size was calculated based on a response rate of 50%, a confidence
interval of 99%, a margin of error of 5%, and a total of the university
nursing student population of 1183. Accordingly, the total sample size
required for the study was calculated to be 426. The sample size was
multiplied by the predicted design effect of two to account for the use of
convenience sampling and an online survey.24 Hence, the minimum survey
sample size was set to 852 (426 × 2) participants.
Measures
Fear of COVID-19 Scale
The fear of COVID-19 scale assessed the students’ psychological reactions
to the COVID-19 pandemic. They were asked about their level of fear in
relation to being in a nursing career during the COVID-19 pandemic. To
date, there is no established measurement for assessing fear of COVID-19
in nurses or other healthcare workers, hence the questionnaire used was
self-developed. A five- item unidimensional scale was answered by
nursing students using a 4-point Likert scale which ranged from 0 (not at
all afraid) to 3 (very afraid). The composite score ranged from 0 to 15,
with a higher score indicating a greater fear of COVID-19.
Satisfaction with Life Scale
Students’ satisfaction with their current life was measured using the five-
item Satisfaction with Life Scale (SWLS).25 Students answered each item
on the scale using a seven- point Likert scale ranging from 1 (strongly
disagree) to 7 (strongly agree). The summation of complete item
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responses yielded a total choose again, I would choose not to be in the nursing course”.
raw score ranging from 5
to 35. The scores were The last question in this survey was an open-ended question, to which the
classified as extremely students responded in their own words with suggestions to alleviate
satisfied (31–35), satisfied students’ apprehension about joining the nursing profession.
(26–30), slightly satisfied
(21–25), neutral (20), Data Analysis
slightly dissatisfied (15–
19), dissatisfied (10–14), Univariable and multivariable logistic regression analyses were performed to
and extremely dissatisfied investigate the demographic factors influencing fear of COVID-19 and
(5–9).25 The mean satisfaction with life. In the multivariable logistic regression analyses, all
Cronbach’s alpha of the variables found to have a statistically significant association (two-tailed, p<
SWLS across various 0.05) in the univariate analyses were entered into the model via the forced-
samples was 0.78 with entry method.28 Odds ratios (ORs), 95% confidence intervals (95% CIs) and p-
95% values were calculated for each independent variable. The Hosmer-
confidence intervals (95% Lemeshow goodness-of-fit test was used to measure the model fit.29
CI) ranging from 0.766 to Partial least squares structural equation modelling (PLS-SEM) was used to
quantify the contributing factors (socio-demographics, fear of COVID-19, and
0.807.26
satisfaction with life) of turnover intention. As the students’ age and grade
are equivalent assessments, only the students’ age was included in the
Turnover Intention Scale
model. A bootstrapping approach was used to evaluate the significance of the
Perceived turnover
associations in the proposed model. This technique assesses not only the
intention was measured
reliability of the dataset but also the statistical significance of the coefficients
using a modified version of
and the error of the estimated path coefficients.30 The bootstrapped
the turnover intention
significance calculation was conducted using SmartPLS version 3.2.8
assessment scale by
(SmartPLS GmbH).31 In the model, turnover intention, fear of COVID-19, and
Camman, Fichman, Jenkins
satisfaction with life were considered as reflective constructs and all other
and Klesh (1979),27 using a
independent variables were a single-item construct. Prior to running the path
three-item scale with a
model, the convergent and discriminant validity of all the measurements
five-point Likert format
were assessed. To assess reliability, we utilized internal consistency using
ranging from 1 (strongly
Cronbach’s alpha coefficient (α) with composite reliability (CR). Discriminant
disagree) to 5 (strongly
validity was evaluated using the heterotrait-monotrait (HTMT) ratio. The
agree). The total score
qualitative data generated by open- ended questions were analysed using
ranged from 3 to 15, with a
deductive qualitative content analysis.32,33
higher score indicating
greater turnover intention.
Turnover intention was
assessed by the item “I
often think of not going
into the nursing profession
in the future”, “It is very
possible that I will look for
a career in the healthcare
industry that has zero
contact with patients in
the future”, and “If I could
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Table 1 Characteristics of the Study Population and Factors Associated with Fear of COVID-19 and Satisfaction with Life (N=1020)

Notes: *p<0.05, **p<0.01, ***p<0.001. aHosmer–Lemeshow test, chi-square: 2.666, p-value: 0.954; Nagelkerke R2: 0.049. bHosmer–Lemeshow test, chi-square: 6.819, p-
value: 0.338; Nagelkerke R2: 0.063. †Responses for extremely satisfied/satisfied/slightly satisfied/neutral. ‡Responses for slightly dissatisfied/dissatisfied/extremely
dissatisfied.
years. The majority of the participants were female (85.5%), originated from
rural areas (69.1%) and had an average monthly family income of CNY4000-
Results 9999. The complete details of students’ characteristics are presented in Table
1.
A total of 1020 out of a total
sample of 1183 nursing
registered nursing students
completed the survey between
24 September 2020 and 10
October 2020, producing a
response rate of 86.2%. The
mean (±SD) age of the
participants was 19.9 (±1.5)

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Figure 1 shows the
responses for fear of being in
nursing career during the
COVID-19 pandemic. Nearly
70% reported being very
afraid/moderately afraid of
infecting family members,
followed by fear of losing life.
The mean (±SD) for the total
physical prevention barriers
score was 6.3 (±3.1). The
median was 6.0 (interquartile
range [IQR], 5.0 to 9.0). The
mean fear scores were
categorised as a score of 7–15
Figure 1 Proportion of “very afraid/moderately afraid” responses for fear of COVID-19 items (N=1020).
or 0–6, based on the median
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Lin
split; as such, a total of 510 (50.0%; 95% CI: 46.9 to 53.1) were categorised as
having a score of 7–10. As shown in Table 1, those of an older age, females,
those originating from rural areas, and those with higher grades reported a
higher fear of COVID-19. Finding from the multivariate analysis revealed that
students from grade 3 (OR=2.13, 95% CI: 1.30–3.49) and grade 4 (OR=1.72,
95% CI: 1.02–2.95) reported a higher fear than did those from grade 1.
Female students reported higher fear scores than males (OR=1.59, 95% CI:
1.10–2.28), and participants originating from rural areas reported higher fear
scores than those from urban areas (OR=1.40, 95% CI: 1.06–1.84).
As shown in Figure 2, nearly two-thirds (62.4%) responded “strongly
agree/agree/slightly agree/neutral” concerning their level of satisfaction
with their lives at the current moment and slightly over half (55.3%) said
that their life was close to their ideal. Overall, the proportion of “strongly
agree/agree/slightly agree/neutral” responses was very low for all the
five SWLS items. The highest proportion (29.7%) was for the slightly
dissatisfied group (score 15–19), followed by 26.4% for slightly
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Figure 2 Proportion of “strongly agree/agree/slightly agree/neutral” responses for satisfaction items and total satisfaction with life score (N=1020).

Figure 3 Proportion of responses of “extremely agree/slightly agree” responses for turnover items (N=1020).

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satisfied (score 21–25). The mean (±SD) for the SWLS
was 18.7 (±5.9). The median was 19 (IQR: 15.0 to
23.0). As shown in Table 1, significantly higher
satisfaction with life scores were reported among
younger age participants and those living in urban
areas. In the multivariable analysis, average family
income was the strongest predictor of higher SWLS.
Participants with an average family monthly income of
CNY 10,000 and above had a 2.13 higher odds (95% CI:
1.44–3.16) of higher SWLS than those with an income
below CNY4000. Participants aged 16–19 years old
reported 1.55 higher odds (95% CI: 1.03– 2.32) of
higher SWLS than those aged 22–23 years.
Participants residing in urban areas also reported 1.33
Table 2 Convergent Validity and Reliability of Constructs

Construct Item Loading Cronbach’s Composite Average Variance

Alpha Reliability (CR) Extracted (AVE)

Fear of COVID-19 Fear 1 0.857 0.828 0.873 0.587

Fear 2 0.873
Fear 3 0.743
Fear 4 0.502
Fear 5 0.797

Satisfaction with life Satis1 0.810 0.862 0.896 0.632

Satis2 0.716
Satis3 0.839
Satis3 0.793
Satis5 0.813

Turnover intention Turnover1 0.847 0.697 0.833 0.625

Turnover2 0.708
Turnover3 0.810

higher odds (95% CI: 1.00–1.76) of SWLS than those in

rural areas.

The proportion of responses to turnover

intention is shown in Figure 3. The vast majority
responded “extremely agree/slightly agree” that
they would choose not to be on the nursing course
if given a choice (49.1%), often think of not going
into the nursing profession in the future (45.4%),
and are considering the possibility of venturing into
a healthcare industry that has zero contact with
patients (23.7%). The mean (±SD) for the turnover
score was 9.2 (±2.5). The median was 9 (IQR: 8.0 to
11.0).

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Table 2 shows the convergent validity and indicated that this model explained 10.1% of the total

Figure 4 Partial least squares structural equation model (PLS-SEM) of factors influencing turnover intention.
reliability of the constructs. The results of the variance in turnover intention.
measurement model indicated that all indicators had
In the last section of the survey, 71 responses
an acceptable outer loading (above 0.5), with a CR
to the open-ended questions were received.
value over 0.7 and average variance extracted (AVE)
Analysis of the open- ended survey data revealed
above 0.5. The variance inflation factors (VIFs) for all
five central themes in the responses: 1)
indicators were below 2.5, implying that all indicators
professional role, respect, and recognition; 2)
belonging to these three constructs were adequately
higher wages; 3) reduced workload; 4) enhanced
independent. The results of the discriminant validity
occupational health, and safety; and 5) career
analysis using the HTMT ratio of correlations method
advancement opportunities. Selected quotes from
also showed that all HTMT values were lower than the
the participants are shown in Table 3.
most restrictive threshold (0.85) proposed by Kline
(2011),34 implying adequate discriminant validity. The
Discussion
hypothesised associations between demographics,
fear of COVID-19, satisfaction with life, and turnover The COVID-19 pandemic has signified the importance
intention are shown in Figure 4. The model showed of an adequate nursing workforce in the healthcare
that fear of COVID-19 (β=0.226, p<0.001) had a system during an infectious disease crisis. This study
positive effect on turnover intention. Satisfaction with investigated perceived turnover intention among
life (β= −0.212, p<0.001) had a negative effect on nursing students to identify potential shortages of the
turnover intention. The results for adjusted R2 nursing workforce and to enable planning strategies

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to alleviate the nurse turnover rate. This study
investigated psychological reactions to the COVID-19
pandemic and life satisfaction, which are two
important components that can affect career
retention and turnover intention.
In this study, the median score for fear of COVID-19
near the midpoint implies that the nursing students
who participated in the study had a moderate level of
fear about being in a nursing career during the COVID-
19 pandemic. Nursing students in this study expressed
Table 3 Five Central Themes and Respective Illustrative Quotes
Themes Quotes
Lin
With regard to life satisfaction, the current study
showed that the overall level of nursing students’
satisfaction with life was moderate. Nursing students
from urban residences have higher life satisfaction
than those from rural areas. A decline in satisfaction
along with an increase in age was observed, and life
satisfaction increased with an increase in family
income. Our findings of the association between
demographic, socio-economic, and life satisfaction
using the SWLS of this study were similar to findings
reported in college students and adults populations.37–

Professional role, respect, and
recognition
Social status of nurses is low, we do not get the respect we deserve, low salary, and bad treatment at
work.
Should improve social status and social identity of nurses.
Improve social status and patients’ respect for nurses.
Improve the public’s respect for the nurse.
Improve and providing fair treatment to nurses.

Higher wages Policy or strategies to protect nurses’ basic rights, such as increase income and rest time
Increase the salary

Reduce workload Reduce night-shift time, reduce workload.

Career satisfaction and nurses’ welfare.

Enhance occupational health and safety Enhance strategies to protect nurses’ basic rights, such as safety.
Pay more attention to nurses’ personal protection and safety issues.
The hospital needs to prepare enough personnel and protective equipment

Career advancement opportunities I hope the government could pay attention to nursing career development, to secure nurses’ career
happiness.
Improve nurses’ career development, provide more opportunities

heightened fear of the risk of infecting family 41

members and fear of death, which was similarly
reported in a recent survey of frontline nurses in
China. The high susceptibility, severity, and fatality of
COVID-19 intensified anxiety and fear in most
frontline nurses in Wuhan, China; many reported
facing enormous mental turmoil.18 In our study,
nursing students of an older age and with higher
grades exhibited a higher level of fear of COVID- 19.
Like prior studies,35,36 this study found that females
demonstrated lower psychological resilience than
males. It is important to note that male participants
were under- represented in this study; therefore
further studies are needed to confirm the gender
disparities in psychological resilience.
In this study, nearly half reported that they would
not choose to be on the nursing course and thought of
not going into the nursing profession in the future.
Furthermore, based on a score range of 3–15, and a
median score of 9, the findings imply that the nursing
students who participated in this study scored an
average turnover intention. As such, the findings may
imply a potential loss of approximately half of nursing
students entering the workforce. Additionally, this
study indicate the possibility of nursing students
leaving the nursing programme before their residency
to pursue other options. Considering the current
shortage of nursing staff in China, our findings indicate
that the country may be on the verge of a critical

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nursing shortage in the coming years. Recruitment
and retention strategies are urgently required to
prevent this shortage from reaching a crisis point for
healthcare services.
The results of the PLS-SEM analysis shed light
on the importance of psychological reactions to
the COVID-19 pandemic and life satisfaction in
turnover intention. Our study found that a higher
level of fear of COVID-19 was strongly associated
with nursing students’ perceived occupational
turnover intention. Likewise, a recent study
performed in another Asian country reported that
fear of COVID-19 had a significant positive
influence on professional turnover intention in
nurses.35 Therefore, addressing the fear of COVID-
19 may enhance the intention of students to join
the nursing workforce in the future. Improvements
in institutional mental health support for nursing
students to address their fear of COVID-19, such as
provision of counselling and accurate information
about COVID-19, are essential to reduce fear. It is
expected that poor life satisfaction will result in
high turnover intention, as shown in previous
findings on nurses.42,43
The use of an open-ended question
encouraging nursing students to enter the nursing
profession was conducive to uncovering useful
insights from our study participants. Firstly, the
responses indicated the need to improve
recognition and respect from society and within
the organisation, as reported in other studies.44,45
In China, a lack of respect and recognition for
nurses’ work from patients and their families, as
well as the organisation, has been reported to
influence nurses’ intentions to leave their
profession.46 These findings imply that it is
essential to enhance inter-professional respect
between nurses and other health professionals in
medical practice settings. Occupational violence
against nurses from patients and their relatives
should be prevented. There is also a need to
improve the understanding of society about the
prestige of the nursing profession to increase the
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Lin
respect for and visibility of nurses in society.
Responses from our study participants should also
encourage the government authorities to look into
the heavy workload of nurses, long working hours,
and low salaries of nurses, which are also common
challenges surrounding the nursing profession
worldwide.47 Our study participants also called for
the safeguarding of nurses from workplace-
induced injuries and illnesses. Particularly in the
age of COVID-19, high COVID-19 infection rates
and lives lost among nurses in China warrant
effective measures from the authorities to protect
healthcare workers. During the early phase of the
pandemic, a high risk of infection was reported for
healthcare workers in China due48to a shortage of
personal protective equipment. Lastly, the
current lack of career advancement opportunities
among nurses in China warrants serious attention.
Opportunities for career development have been
found to be a factor in nurse retention in the
workforce in many countries around the world,49
as well as in a study conducted in China.50
Therefore, the provision of a good career
orientation with many opportunities for
professional growth is needed.
Limitations
The findings of this study should be interpreted
cautiously owing to some limitations. First, the use
of a cross-sectional study design precluded the
evaluation of the causality among the
relationships investigated in this study. Second,
self- reported data were subject to socially
desirable responses. Third, the occupational
turnover intention does not necessarily result in
actual intention. The last limitation in the
sampling method, which involved recruiting
participants from only one medical school in the
Fujian province. The findings of this study may not
be generalisable to the nursing student population
in China as a whole. Despite these limitations, the
sample was large, with diverse demographic
backgrounds, and the study had the advantage of
a high response rate. Furthermore, our results are
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much in accordance with many similar studies on
turnover intention in nursing careers conducted in
China, as well as across the globe.
Conclusions
The COVID-19 pandemic is anticipated to exacerbate
the decline in nursing students entering the nursing
profession. A considerable proportion may turn away
from the nursing profession upon graduation, and
institutions may also be at risk of students quitting the
nursing programme. The nursing workforce may
continue to face shortages due to the low number of
nursing graduates to replenish the workforce. Existing
nurses may be likely to continue experiencing burnout
and dissatisfaction, potentially leading to reduced
patient care resulting in higher patient mortality. An
important highlight of this study is the significant
influence of fear of COVID-19 and life satisfaction on
nursing students’ turnover intention. As nursing
students are an important source of the future
nursing workforce, addressing their fears and well-
being before they graduate should be a priority. Life
satisfaction and psychological reactions to the COVID-
19 pandemic influenced nursing students’ perceived
turnover intention in this study and can guide higher
education institutions to carefully attend to groups of
students vulnerable to turnover intention. Tackling
turnover intention in the academic institutions would
encourage nursing students to join the nursing
profession in the future. Psychological approaches to
mental illness, interventions relating to COVID-19 and
career motivational talks at the institutional level are
highly recommended to rejuvenate and sustain the
nursing workforce.
Data Sharing Statement
The data that support the findings of this study are
available upon request from the corresponding
author. The data are not publicly available due to
privacy or ethical restrictions.
Risk Management and Healthcare Policy 2021:14
32
Lin
Ethics Approval and Informed Consent
This study was approved by the Biomedical Research
Ethics
Committee of the Fujian Medical University, Fuzhou,
China (Approval: FJMU 2020 NO.1). This study was
conducted in accordance with the principles of the
Declaration of Helsinki.
The study participants were informed as to the
purpose of the study, and that informed consent
included consent to have anonymized responses
published. It was also noted in the survey form that
consent was implied upon completion of the
questionnaire. All responses were collected and
analysed without identifiers.
Acknowledgments
We would like to thank all participants involved in this
study.
Author Contributions
All authors made a significant contribution to the
work reported, whether that is in the conception,
study design, execution, acquisition of data, analysis
and interpretation, or in all these areas; took part in
drafting, revising or critically reviewing the article;
gave final approval of the version to be published;
have agreed on the journal to which the article has
been submitted; and agree to be accountable for all
aspects of the work.
Funding
This study was supported by the Pilot Project of the
Fujian
Provincial Department of Science and Technology (No.
2020Y0005). The funders had no role in the study
design, data collection and analysis, decision to
publish, or preparation of the manuscript.
https://doi.org/10.2147/RMHP.S322764
DovePress
 Dovepr
Disclosure
The authors declare that the research was conducted
in the absence of any commercial or financial
relationships that could be construed as a potential
conflict of interest.
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