Ten respondents from among those who had completed the survey (n = 20) were interviewed. None of the participants elected to withdraw from the study after having been interviewed. Following analysis, we settled on four themes (see Table 1) connecting directly to our stated objectives.
Table 1
Avoidable factors contributing to churn often reflect intersecting, workplace-specific human resource management issues.
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Unavoidable factors contributing to churn are frequently the result of decisions made by the departing dietitian.
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High churn in select positions can have a disproportionate negative impact on the specific group of patients served by the dietitian(s) in those positions.
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Consequences of churn include lasting impacts on the efficiency of and access to medical nutrition therapy.
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Avoidable factors contributing to churn often reflect intersecting, workplace-specific human resource management issues.
The intersecting workplace-specific human resource management issues we identified included manager support, availability of growth opportunities, burnout and/or heavy workload, tension and/or conflict at work and hours of work. All respondents addressed manager support as a factor contributing to (or preventing) churn; they identified both supportive and unsupportive practices and approaches. Manager characteristics and/or practices identified as contributing to churn included inflexibility; micromanagement, such as “when the manager is too involved and wants to control all of their [a clinical dietitians] activities” (P07); unresponsiveness, and; inattentiveness. Dictatorial management styles were identified as hindering employee retention, while providing autonomy — including the freedom to make mistakes — was associated with reduced turnover.
A trusting relationship between employee and manager was the most frequently mentioned factor positively influencing retention of clinical dietitians with half of respondents describing the importance of trust. As one manager reported: “some of the things dietitians have told me is that…they feel like they know that we’ll go to bat for them, that we will stand for them when it’s difficult” (P07). Five managers felt that their dietitian employees particularly valued their responsiveness in answering questions and in helping them to solve problems they experienced. This included timely action to take clinical dietitians’ problem(s) up as high in the organization as needed to achieve a solution. Managers recognized that staff also appreciated a listening ear, with no expectation of specific action by either manager or dietitian.
Practices associated with employee retention by managers included: providing informal opportunities to “touch base”; exhibiting transparency by clearly outlining expectations and providing rationale for either the status quo or new initiatives; making time for collaborative problem-solving sessions; recognizing dietitian accomplishments and value (individually and collectively); demonstrating empathy during interactions with staff; treating staff equitably, and; providing active support for clinical dietitians to achieve personal and professional goals. Two respondents felt that an understanding of the role of the dietitian, frequently based on personal experience as clinicians in similar roles, was of value in retaining staff. One manager summarized many key points as follows:
“I think a leader needs to let people do their work… on their own and learn on their own from some of their mistakes… it needs to be a safe environment to try new things, to challenge oneself and then people grow. If not, they leave." (P05)
The presence or lack of opportunities for growth, whether expressed as a desire for expanded skills and expertise, for prestige, or for advancement was reported as a factor impacting turnover by nine of ten respondents. Specifically, clinical dietitians desired “to have education that sustains practice” (P01). Managers acknowledged that clinical dietitians often sought “more challenging roles” (P02), sometimes in a particular specialization or area of passion for them. Such specialization may not have been attainable or possible within the employing organization. One manager stated explicitly:
“sometimes I think we all move to other health authorities just because there’s some interesting positions –there’s a potential to specialize in different areas that you couldn’t do here” (P03)
Managers most commonly reported prestige or preference as linked to employment in specific, respected facilities, rather than as associated with an individual program or field of practice. One respondent commented on the popularity among clinical dietitians of working at the largest, acute care hospital and how that had led to smaller, community hospitals losing “some of their dietitians because they want to come here” (P05). Holding a specialized position at this site was associated with additional opportunities for growth, development and recognition.
In the case of pediatrics, one respondent noted that there was a certain cachet to treating children who “will do anything they can to get better” with “parents who will do anything it takes to make their kids better” (P09). She noted that in adult care:
“sometimes the conditions are complex and chronic and sometimes actually coming from choices in the past” – “being told you [the patient or client] have to change things is not always welcome, especially when it’s having to do with food or alcohol or anything like that” (P09)
In relation to advancement, a manager working in a more rural area noted a lack of positions to form a career ladder within their health authority. In smaller health authorities, there may be very limited turnover in the few existing advanced dietitian roles, which makes it infeasible for others to advance in the organization within the span of their career.
Eight respondents identified burnout and heavy workload as contributors to turnover. One manager reported “workload that’s not congruent with the amount of hours that are expected” (P01). As a result, staff can experience “extreme stress or distress coming to work” as there “is not enough time to finish their work” (P04). Two managers noted that uneven workload distribution across positions contributed to turnover.
Tension and conflict were noted as factors integral to turnover by seven respondents. Three referred to conflict within the profession, five to interprofessional conflict and two to conflicts in relation to undervaluation of the clinical dietitian role. Conflicts among clinical dietitians can result from having to share “very small cramped” (P06) workspace. Such conflicts can be particularly damaging as “they [clinical dietitians] are supposed to share their workload, cover for each other” and “work cooperatively” (P06). For some returning to the dietetic department could help them to “escape” from a hypercritical environment – “like the gossiping and whatever goes on on the unit” (P03). This manager suspected that:
this “kind of escape…helps people to be able to stay longer in their positions and have less turnover because…they have support from their coworkers to not get sucked into that kind of attitude” (P03).
Interprofessional conflict was often closely tied to undervaluing the role of the clinical dietitian. Problems can arise when “other care providers” try “to do the work of the dietitian” or are not “willing to accept the dietitian as the nutrition professional” (P07). One manager commented on the current climate, where “everyone thinks they can do the nutrition component” (P07) and how this can leave clinical dietitians feeling frustrated. Another manager noted that in the past, on their eating disorders unit, a lack of trust had developed when the clinical dietitian:
“would make a recommendation, leave the unit, go see another patient…come back the next day and their recommendation would not be followed. Something else would have been suggested either by the nurse or pharmacy, physician, whatever, so they—it got to a point where they felt discouraged…why am I trying so hard when I have such a heavy caseload to do my assessments and all those recommendations when as soon as I turn, somebody goes in and changes it and they don’t even let me know they disagree, they just go ahead and change it.” (P09)
Four managers attributed some turnover to the full-time equivalence of available positions, with some clinical dietitians expressing a desire for part-time and others for full-time. One manager noted that the “part-time positions don’t seem to turn over quite as much” and that “once they [clinical dietitians] have a child they tend to want to come back part-time.” In her experience, part-time positions were coveted by staff but not desired by the organization which had recently merged many part-time positions to form full-time positions (P01).
In contrast, a manager of clinical dietitians in rural areas reported seeing higher turnover in part-time positions, attributing this, at least in part, to the employee-paid expense and time associated with travel to and from work sites. A preference for full-time was echoed by an additional two managers, who both noted that clinical dietitians began in part-time positions and remained only until a full-time position became available.
Unavoidable factors contributing to churn are frequently the result of decisions made by the departing dietitian.
The unavoidable factor contributing to churn we noted as resulting, most often, from a decision (or series of decision) made by a departing dietitian included events relating to life-stage and geographical concerns. Life-stage was noted by seven managers as a reason for turnover. It is well known that dietetics is a female dominated profession and many clinical dietitians are in the “the time of their lives that they want to start a family” (P04). Employees will also leave positions “because their family is moving” (P05) or “their husband gets transferred” (P07). Retirement was also considered an unavoidable reason for turnover. In some instances the health authority can be blindsided by how much a retiring clinical dietitian actually did. One manager described a recent retirement this way: “when they were trying to package her responsibilities they didn’t even know all the jobs she did and some didn’t get done and there was risk” (P06). In some health authorities, most new hires were relocating to a more rural part of Canada where they may experience isolation. This respondent explained that if “people are here without any family or any of their friends, sometimes that is kind of the issue of why they moved away” (P03). In other cases, it may be that the geographical coverage area is too large:
“When you give a dietitian too much space to try and cover it is hard for them to make meaningful connections in all of those communities…” and “until you have someone who actually wants to be in that community, who is from that community, who’s got a partner that lives in that community [laughs]…you have lots of turnover in that community.” (P07)
High churn in select positions can have a disproportionate negative impact on the specific group of patients served by the dietitian(s) in those positions.
All respondents indicated that churn had clear negative impacts on clients and patients. These negative impacts were more notable in situations where churn resulted in gaps in service (during which time there was no dietitian coverage for a particular unit or community). Commonly noted issues impacting on clients and patients included: delayed nutrition care, in particular delays triggered by lengthened waitlists and cancelled clinics; prolonged hospital stays, which may have resulted from delayed discharge planning and/or malnutrition, and; less skilled nutrition care while inexperienced clinical dietitians built experience. These impacts were notable even when there was no gap in service as new clinical dietitians were “usually less efficient at first so there’s still fewer people getting seen or it takes longer to get to them” (P03). A risk of delaying dietitian-provided nutrition care, particularly in outpatient settings, is that:
“when people are waiting a long time to see a dietitian…I believe that they will search out different forms of information and there is a whole pile of it that is not a very high quality in the public sphere, and I think that people may or may not engage in seeing a dietitian if they have to wait too long” (P06).
Importantly, patients or clients with time-sensitive issues/concerns, such as prenatal clients, bear the greater risk when nutrition care is delayed.
Several respondents indicated that “patients have seen lots of different people [clinical dietitians] and they feel that there’s a lack of continuity” (P01). One respondent, speaking to practice in the long-term residential care setting indicated that “residents develop relationships with the staff because” they “provide care to people through an extended time period” and that there may be “some frustration on the part of patients that they have to catch people up to what their history has been” (P08)
Some of the impacts of turnover were gap-specific, meaning that they occurred only when there was a vacancy in the position while awaiting a replacement dietitian. Gaps in service were not always the result of failed searches for new staff; “there is often gap in service between the time a person leaves to the time a new person can come in” (P02). In rural areas candidates could “take the better part of a month” before they were able to report to work (P03). Rural communities could also experience long stretches without access to a clinical dietitian – in one respondents’ observation, communities “get used to not using the dietitian and then…when we do get a dietitian back in that position, they [the clinical dietitian] have to rebuild the trust and the whole practice that the previous dietitian had” (P07).
Consequences of churn include lasting impacts on the efficiency of and access to medical nutrition therapy.
According to respondents’, lasting impacts on the efficiency of and access to medical nutrition therapy resulted from corollary strain following turnover, churn-triggered tension and conflict, and nutrition department-specific costs of turnover. Ultimately, burnout and high workload were identified as both a trigger and consequence of turnover. All managers indicated that there was corollary strain related to turnover which impacted on their own workload and job quality, while nine identified similar effects on remaining team members (including clinical dietitians). A common sentiment was that managers were “constantly recruiting new staff” (P01). Recruitment and hiring were “quite a process…from getting approvals and getting job postings to interviewing” (P02), training and orientation. These tasks took “time away from actually leading practice, addressing practice issues and looking at…expanding programs, securing funding…making proposals to advocate for the profession” (P04). This undone work was seen as leading to the perpetuation of circumstances where coverage of particular units or programs remained insufficient to meet the nutrition needs of clients and patients.
Various impacts on the team were reported to result from having to pick “up the slack for people that have gone on” (P02) and/or from the increased workload associated with training new staff. New staff may not receive high quality, comprehensive training if the dietitian providing their training is struggling with a heavy workload and burnout. Staffing changes can create a “domino effect” (P09) where multiple people shift positions as a result of the first turnover event. One manager noted how the team must adapt when there is turnover and learn to “trust the new person coming in” (P09); churn can “decrease trust from the unit level in our department because we aren’t able to meet the demands of the unit” (P10).
Three managers commented on team dysfunction that could result from churn. In rural locations, frequent turnover in what may be the only position serving the community can result in loss of “the trust of the community”(P07) so that the clinical dietitian is no longer sought out to participate in client-care or program development because community members begin to think: If the dietitian is only going to be here “a couple of months…why would we bring her [or him]into these conversations” (P07)? This can result in the loss of “opportunities to make a difference in the community” (P07). In other cases, it may be that non-dietitian staff step in to fill the void during recruitment and orientation post-dietitian turnover and then have difficulty stepping back once the new clinical dietitian is practice-ready (P09).
Three managers also called attention to the high cost of turnover. One noted how when turnover is high she has “to train more” (P01), which drains her budget for dietitian relief. As a result, remaining clinical dietitians may no longer have had access to workload relief or back-fill when needed.