Does Tailor Different Educational Programs for Different Groups Might Improve Acceptance by Nursing Staff?

Background: Long-term shortages in the nursing workforce and high turnover rates are common in Taiwan medical industry. Little research has investigated the psychological factors associated with retention of nursing staff. However, in practice, religious hospitals often provide education in medicine or the medical humanities to enhance psychological satisfaction. The objective of this study was to explore factors inuencing nursing staff’s retention with their work across different levels of demand. A further objective was to investigate whether medical humanities educations were associated with the retention of nursing staff. Methods: This study used self-administrated questionnaires to survey nurses working in northern areas of Taiwan. The questionnaire design was based on the six levels of Maslow's hierarchy of needs. Participation was voluntary and participants signed informed consent documents. Self-administrated questionnaires were administered by contacting a total of 759 participants; 729 questionnaires were returned (response rate 96.04 %). A logistic regression analysis was used to estimate the impact of seniority of nursing work on nurses reported intention to stay after adjusting for nurse characteristics (gender and age). Results: In the Pearson correlation analysis, nurses’ willingness to stay was moderately correlated with “physical needs”, “safety needs”, “love and belonging needs”, and “esteem needs” (r=0.559, P<0.001; r=0.533, P<0.001; r=0.393, P<0.001; r=0.476, P<0.001, respectively). Furthermore, nurses’ willingness to stay was highly correlated with “self-actualization needs”, “behind self-actualization needs” and “medical humanities education relevant” (r=0.707, P<0.001; r=0.728, P<0.001; r=0.678, P<0.001, respectively). We found that the odds ratio (OR) of retention of nursing staff who worked within 1 year (OR=4.511, P=0.002) and 1-3 years (OR=3.248, P=0.003) was signicantly higher referred to those who worked 5-10 years. Conclusions: With regard to medical humanities education, we recommend adjusting the training as


Background
The shortage of nursing workers is a global phenomenon [1]. As a core aspect of any healthcare system, a su cient number of highly trained and experienced registered practical staff is critical to providing patient-centered healthcare services [2][3]. The HHR literature shows a serious shortage of healthcare workers in many countries around the world, especially in the numbers of doctors and nurses [4][5][6]. In short, nursing is facing a growing shortage of employees around the world and Taiwan is no exception [7,8]. Most medical interventions require the services of doctors, nurses, and other health professionals.
Research shows shortage of healthcare workers may affect health outcomes such as: quality of care, morbidity, and mortality [3-6, 9, 10]. Percentage of registered practical nurse of Taiwan is about 58.4% [11]. Compared to that of Canada as 93.6% and that of USA as 83.2%, percentage of registered practical nurse of Taiwan is obviously low [11]. In addition, nurse turnover rates in Taiwan for 2009-2013 were 16.95%, 17.12%, 18.54%, 19.03% and 16.45%.
Hospitals in Taiwan can be easily divided into three categories. The location of these types of hospitals in their environment, their building structures, number of beds, facilities, and organizational structures may be similar. Due to differences in ownership, the management systems and environmental climates of these hospitals may vary. Hospital management systems are likely to be different across different types of hospitals. Management systems affect employees and need to be considered in terms of their job performance and the quality of work life they provide.
A previous research has shown that nursing is often experienced as work that is time consuming and stressful [12]. Factors such as low job control, high job requirements, and de cits in supportive work relationships are associated with stress [13] and high employee turnover in nurses [14]. Research has shown that nurses report their basic needs as being related to employee job satisfaction [15], overall health [16], and intension to stay. The relationship between leadership styles in healthcare institutions and nurses' work life quality is unclear. It is necessary to understand the relationship between basic needs, the quality of work life in the healthcare profession, and the intension to remain in these professions. In our hospital, humanistic culture operates on the principle of seeking the ideals of truth, beauty, and goodness. Our hypothesis of this study is education based on humanistic culture associated with life quality of practiced nurses. Therefore, we propose a model based on a theory and grounded in empirical observations that might allow researchers to investigate these relationships through a linear regression model.
In this study, the relationships between facets of Maslow's hierarchy of needs were by using the Pearson's correlation test, and the correlation between each facet and any wish is discussed. We also performed simple and multiple regression analysis to investigate the impact of Maslow's hierarchy of needs on the retention of nursing staff in a faith-based hospital in Taiwan.

Research design
This was a cross-sectional quantitative study. The data were collected using a self-report questionnaire consisting of two sections: demographic information and job satisfaction. Demographic data obtained included gender, age, education level, religion, seniority among nursing staff, seniority among hospital staff, and time of any medical or human-related education and training received in the past six months. Anonymous questionnaires were surveyed among clinical nursing staff in general wards, intensive care wards, and oncology wards but excluded in outpatient, emergency, and other ward services to ensure consistency of work content.

Sampling Strategy
The sample was recruited using convenience sampling according to the following method: First, a total of 759 questionnaires were sent to the clinical nursing staff of the Taipei Tzu Chi Hospital. The overall response rate was 97.6 %, providing a total 741 questionnaires that were validly completed and returned.
Second, the questionnaire content was analyzed based on theoretical predictions from Maslow's hierarchy of needs. See Appendix for the complete questionnaire design.

Measures
The content of the questionnaire was discussed with six nursing experts, and the interviewee's (participant's) understanding of the vocabulary was measured. The content of the questionnaire was constructed accordingly to consensus and presented so that participants were asked to respond according to the ve-point Likert scale method (responses ranging from 1 to 5). Three nursing experts will conduct tests of expert validity according to prede ned inspection items such as "clear meaning," "related to the investigation content," and "easy to answer." The content validity index (CVI) values of each item were greater 0.8. There were a few items that were "easy to answer" or "exactly clear", with corresponding CVI values less than 0.8, but the overall impact was small, indicating that the questionnaire had good content validity.

Job satisfaction
In the present study, the job satisfaction scale used items rated on a ve-point Likert scale. It included 10 items related to job satisfaction that were: salary, total weekly working hours, safety in working environment, mutual assistance, acceptability of constructive advice, and learning resources and opportunities for growth. Participants were asked to rate their degree of satisfaction about their jobs on a scale ranging from Strongly Agree (SA); Agree (A); Neutral (N); Disagree (D); Strongly Disagree (SD) which coding 1, 2, 3, 4, 5, respectively. The 10 item job satisfaction scale produced an acceptable level of reliability (Cronbach's α = .889).

Statistical analysis
Pearson correlations were used to assess relationships between all variables in the model. Student's t or Analysis of variance (ANOVA) was used for continuous parametric data to detect the differences among the different groups. Linear regression analysis was used to examine the pattern of the relationships among all variables. Logistic regression analyses were used to investigate the association between the nurses' characteristics and intention to stay the hospital. To assess model t, we examined R-square and the p value of F statistic (<0.05) as t indices. SPSS version 24.0 was used to perform descriptive statistical analysis.

Results
A total of 729 nurses working in different facilities responded to the questionnaire (96.04% response rate). All analysis was performed as two-sided tests with signi cance levels of 0.05.

Nurses' characteristics and their intent to stay
Overall, only 87.8% of nurses indicated that they were likely or very likely to stay in their current job (See Table 1). Analysis showed that the majority of respondents were females (95.6%). Most responding nurses were below 29 years of age (57.9%) and this age group was second least likely to report intention to stay in their current job (86.7%) ( Table 1). A total of 2.7% of responding nurses were educated in graduate school, and this group was least likely to report intention to stay (84.2 %). A total of 27.2% of responding nurses had over than 10 years of overall working experience related to nursing, and this group was the most likely to report intention to stay (91.3 %) except within 1 year of experience working as a nursing. A total of 12.6% of responding nurses had not received medical and human-related education/training in the past six months, and this group was least likely to report an intention to stay (84.4 %).

Bivariate analysis
The correlations between all the levels of Maslow's hierarchy of needs and intension to stay in this study are displayed in Table 2. The analysis found that there is a positive correlation between each level and the intension to stay. Among them, "physiological needs", "safety requirements", "love and subordination needs" and moderate willingness to stay are moderately positively correlated (correlations between 0.30 and 0.50). Further, "self-realization needs", "beyond self-demand" and "medical humanity education relevance" were highly positively correlated (correlation greater than 0.60), and all correlations reached statistically signi cance (p < 0.001). The results of the study show that each level of need and medical humanities education are positively related to nurses' intension to stay at their current jobs. This is consistent with the research hypothesis. The results also show that Maslow's hierarchy of needs and increases in medical humanities education are positively related to the retention nursing employees.
Retention measures should be meeting the needs of each facet will help to retain the bene ts.

Multivariate regression
We constructed a multivariate regression model after controlling for adjusted age, sex, and education level. We found that Maslow's hierarchy of needs had signi cant positive effects on intension to stay. These results are displayed in Table 3 (also adjust covariates). Furthermore, we found self-actualization needs had the most positive in uence on intension to stay after adjusting for covariates. These results support the research hypothesis.

Discussion
Most of the respondents in this study (64.9%) were less than 29 years of age. This suggests that the majority of the nursing workforce will be challenged within the next decade. One participant is quoted as saying, "We do budgeting for personnel every year, but we don't actually control this from time to time. Our job analysis does not include recruitment." Approval is always required before hiring. This shows the reliance on recruitment budgets and political development [17]. Not all nurse managers organize training after recruitment, which may adversely affect the socialization process of newly hired nurses, and result in poor retention [18]. The results of this study show that several demographic and personal characteristics of nurses are related to their intention to stay in their current job. Speci cally, nurses are less likely to report intent to stay were younger. The fact that age is not signi cantly related to the intention to leave can be attributed to the fact that age and years of experience are parallel; more experienced nurses are usually older. The direct link between years of experience/age and intention to stay is consistent with other studies in the literature. [19,20].
Our ndings suggest that nurse planners, policy makers, and decision makers should implement targeted retention programs designed to retain freshly graduated nurses and inexperienced nurses [21]. The present study's ndings further indicated that the odds ratio of nurses within 1 year work experience were about four fold as likely to indicate intention to stay in their current job as compared to their counterparts with 5~10 years of experience in nursing (Table 4). Such ndings are also in accordance with previously reported studies in the literature [22]. Sociocultural factors associated with the role of experienced workers in society may also play a role in enhancing the job retention of nurses [23]. Older nurses generally also display higher levels of job commitment [24].
The present study also a liated with Maslow's hierarchy of needs, revealed that in uential factors behind the retention of nurses in Taiwan are related to their professional quali cations. This allows administrators and medical practitioners to make informed decisions regarding nursing retention. Many medical institutions seem to follow a standard strategy during recruitment period [25], but not all institutions conduct job analysis before starting recruitment. This may be because most of the interviewing managers are not involved in regular budgeting plans, which can determine effective and su cient analysis of the main weaknesses of the nursing staff.
According to Maslow's hierarchy of needs, physiological needs, security needs, love and subordinate needs (social needs) are also collectively called "de ciency needs." For nursing staff, basic needs such as their physiological and safety needs are not met. This may ultimately lead to the loss of nursing staff. The results of this study showed that the satisfaction of respondents associated with their physiological needs was signi cantly lower than satisfaction associated with other facets. This effect demonstrated that the satisfaction of hospital nursing staff with "working time" and "salary structure" was lower than other facets. Even with the adjustment of salary structure in hospitals and improvements in the work process, salary and working hours are still important issues nurses face today in the workplace. Salary may not be the primary reason for leaving. The sense of achievement from work, positive relationships with partners, and the ethical culture are important factors contributing to retention [26,27]. Satisfaction with love and subordinate needs (social needs) was reported as the highest satisfaction across all dimensions. It is obvious that hospital care workers work in "unit cooperation" and "cooperation with other teams." With regard to Maslow's high-level needs, self-esteem needs and self-ful lling needs are known as advanced "growth demands," and Maslow adds spiritual demand in a later period that is, "beyond selfful lling needs." If people's needs are not being satis ed, this will determine their intention to stay. Although there is no statistical difference between the groups in the "study of medical and human-related education and training hours" in the past six months, the regression coe cient in regression model was signi cant. The promotion of human activities in hospitals should not take a long time.
According to Maslow's hierarchy of needs, the motivation of people to work ultimately to meet various needs, when a job can meet all levels of needs in people, job satisfaction will increase accordingly and willingness to stay at one's current job follows. Nursing staff's feedback regarding clinical work indicates that it meets basic needs (i.e., physiological needs, safety needs, love and belonging needs), further satisfying self-esteem and self-actualization needs, and even high-level needs for spiritual satisfaction. After meeting the various needs, nursing staff will be less likely to resign from their current positions.
Healthcare organizations should be able to provide a variety of resources to meet the needs of their nursing staff at all levels of the medical workplace, and to attract new nursing staff to maintain clinical operations in hospitals and clinics. Based on the theory of Maslow's hierarchy of needs, this study explored the needs of nursing staff and explored the relationship between each demand level and turnover rate. Moreover, a hospital's education and literacy for medicine and the humanities also affects the clinical practice of nursing staff, and their intention to stay.

Conclusions
We believe that to increase retention of nursing staff several provisions could be pursued, which include: providing a regular day shift system, providing solid new basic education and training, cultivating a working environment that values lifelong learning, tailoring a promotion path, strengthening the communication skills of clinical instructors and head nurses, and funding further research investigating ways to improve the retention of nursing staff. In the area of medical humanities education, we recommend adjusting the training as the necessary teaching activities under the o cial procedure are inadequate, adjusting the required hours of medical humanities education, and tailoring different educational programs to different groups (especially for groups of nurses with 3-5 and 5 -10 years of work experience in the case study hospital) in order to make these programs more widely accepted by nursing staff.

Limitations
We were limited to the available data from a faith-based hospital. The present study is conducted at one speci c time, not as a longitudinal research. In addition, nurse employees responded to a questionnaire via self-report. The potential biases from this method can be minimized due to the substantial sample size (729 questionnaires) and high response rate (96.04 %).

Abbreviations
Odds ratio OR

Consent for publication
Not applicable.

Availability of data and material
Datasets used in the analysis are available from the corresponding author on reasonable request.

Competing interests
The authors declare no competing interests with any organization having direct or indirect nancial interest in the subject matter discussed in the manuscript.

Funding
There was no funding support for this study.
Authors' contributions LHC and TTS proposed the research idea, performed the analysis, wrote the results and discussion, and contributed to the literature review. CFW, ANT, RWL, LYY, CMH, WHP and CYC provided clinical suggestions and helped revise the manuscript. IST supported data analysis and prepared the manuscript for submission. All authors read and approved the nal manuscript.
26. Al-Aameri AS: Job satisfaction and organizational commitment for nurses.