Economy can be applied to your health

Retention management in hospitals - working in the field of tension in health care

Summary

This article from the magazine “Gruppe. Interaction. Organization. (GIO) “describes challenges for retention management in hospitals and backs them up with data from an empirical study. The work in a hospital describes a special working environment in which not only the motives of the employees but also the special position of the patient, the organizational form “hospital” significantly differentiate it from other organizations in the economic context. Nevertheless, hospitals also have to face the shortage of skilled workers and the demographic development in Germany. In order to integrate a functioning retention management into a hospital and to prevent the problems, the three areas of tension “profitability”, “interculturality” and “stress” must first be considered. Again and again, these present employees in a hospital with major challenges in their already work-intensive everyday life. Different action concepts could be developed which enable the organization "hospital" to work against the areas of tension and to bind employees to their own company in the long term.

Abstract

This contribution from the journal “Group. Interaction. Organization. (GIO) “describes challenges for retention management in hospitals and backs them up with data from an empirical study. The workplace in a hospital describes a special working environment in which not only the motives of the employees, but also the special position of the patient, the organizational form "hospital" is essentially differentiated from other organizations in the economic context. Nevertheless, hospitals must also face the lack of skilled employees and the demographic development in Germany. In order to integrate a functioning retention management into a hospital and to prevent these problems, the three issues “economic efficiency”, “interculturality” and “stress” must be considered first. These issues pose a constant challenge to employees in a hospital, in their already labor-intensive everyday life. Different concepts of action were developed, which allows the organization “hospital” to work against the three issues and to bind employees in the long term to their own company.

introduction

Working in a hospital is a special job that is not determined by good earning potential or high social standing, but rather, when working as an employee in the medical field, it is, so to speak, a vocation to take care of people in exceptional situations and to take care of them to accept. However, at a time when cost pressures and competitive orientation are finding their way into many areas, it is not possible to refer only to an ideological willingness to help. Rather, employees in a hospital often find themselves walking a tightrope between patient well-being and economic efficiency (Behar et al. 2016). Of course, basic rules of medical ethics ensure that, in case of doubt, the staff should always decide in favor of the patient and against economic interests, but this state of tension brings new challenges for employees in a hospital (Staar and Kempny 2019; Staar et al. 2018). Many other obstacles, such as cultural and linguistic barriers, are also increasingly coming to the medical staff, who increasingly determine the tension in the hospital. Thus, there are three areas of tension in particular in a hospital, which should be part of this article. The first area of ​​conflict is the need to focus more economically. The second area of ​​tension is interculturality in relation to the staff, but also in relation to the patients. The third area of ​​tension considers the medical professionals in a hospital separately and deals with the stress they experience.

In order to position themselves adequately in relation to the areas of tension, hospitals must embark on a process of change in order to minimize or even out the areas of tension (Staar et al. 2018). It is therefore important to take new perspectives and orientations of the organization “hospital”. New concepts for action have to be found for the new challenges with regard to staff, the economic structure and also for patient care. Since the change in the flat rate remuneration for hospitals, personnel-political and economic decisions have to move more and more into the foreground of hospital management. This influences the treatment of patients on the one hand, but also the mission statement and the self-image of the employees in a hospital. For example, it is no longer possible to treat patients regardless of the costs incurred (Behar et al. 2016). The fact that this development does not currently work in all hospitals or that a change has only begun can be seen in the hospitals that do not come into a profitable or cost-neutral zone (Blum et al. 2013). The need for entrepreneurial behavior in hospitals exists and is essential for the organization, the employees and ultimately also for the patients in order to ensure the continued existence of individual hospitals. A change in corporate culture, personnel policy and the economic orientation of the hospital company must therefore take place and should focus particularly on "corporate entrepreneurship" and "retention management" in the hospital and health sector.

This article is intended to give the reader an overview of the special features of the hospital corporate context and the various areas of tension. In order to make the findings as practical as possible, two studies were included in this article. The first area of ​​tension, “economic efficiency”, is supported by an interview survey and the third area of ​​tension among medical professionals is supported by a quantitative questionnaire survey. In the following, the individual studies and the theoretical development of the second area of ​​tension “interculturality” will be explained individually. This is followed by the introduction of the concept of "retention management" and practical implications, which result from the three areas of tension and the surveys.

Special feature of medical professions

Before the different areas of tension can be considered in the context of the hospital organization, the specialty of medical professions compared to other professional groups must first be emphasized. The hospital system is a very bureaucratic and strictly organized system (Staar et al. 2014). These rigid and traditional organizational structures, which are recognizable, among other things, in the clear, hierarchical lines in the staff network, are also repeatedly encountered by patients and relatives in the hospital in the form of clear rules and procedural steps. There they can trigger uncertainty and incomprehension in patients (Staar and Kempny 2019). Since the change in case accounting in the hospitals, change processes have inevitably come about, which are not received positively by all employees and all patients. This can lead to conflicts and dissatisfaction due to these processes (Albrecht and Töpfer 2017). One of these changed processes is, for example, the documentation requirement for doctors and nursing staff. The documentation requirement has long been an instrument used in medical treatment (see Bayer 2018). Due to the prevailing motto "What has not been written down, has not been done", doctors and nursing staff not only ensure high-quality treatment, but also protect themselves legally during treatment. An expansion of this documentation can encounter obstacles and contradictions with some medical professionals and with the nursing staff. Due to the already tight schedule of doctors and nursing staff, extensive and precise documentation appears to be a further burden. In the context of the new remuneration system, extensive and precise documentation of the treatment steps and the recording of patient health data means higher or appropriate remuneration (Leiner 2012). With detailed documentation, bills can be significantly higher, as special treatments can also be billed or the patient's health data indicate particularly intensive care (Staar et al. 2018). The documentation requirement exemplifies how new processes and improved methods in medical treatment can mean financial added value for the organization, but at the same time encounter resistance from the workforce.

If you look at different areas in the hospital organization, you not only find different types of training, such as a long academic course or a very practical training, but also different motivational backgrounds, such as reputation, altruism, biological and anatomical interest and financial incentives who accompany the work of the employees in the hospital (Staar et al. 2018).

If one looks at the group of nurses in relation to the choice of occupation, the financial incentives or supposedly good working hours cannot be given here as a serious reason. Rather, nurses act more out of an altruistic, helping motive than can be found in other professional groups (Staar et al. 2018). With relatively low wages, an extremely high workload and high physical strain, these employees do highly qualified work in a hospital.

Another group to be considered for this work are doctors. There is a clear distinction between these in terms of the hierarchical structure. While the interns have very little freedom to make decisions with a comparatively low salary and high workload, chief physicians and senior physicians have a different financial incentive and greater freedom at work. Although these groups of people also have special motives that relate to helping and supportive work with people, the opportunities for advancement and income can also be seen as motives for choosing a career (Staar et al. 2018).

The shortage of skilled workers poses ever greater challenges for hospitals (Schmidt et al. 2012). A high fluctuation and the loss of qualified staff due to demographic change in Germany leads to discontinuities in care, loss of knowledge about processes and procedures in the hospital and thus to disruptions in the working atmosphere and procedures (Ulatowski 2013). The high fluctuation and the age-related loss of staff cannot currently be covered by new trainees, students or young professionals (Schmidt et al. 2012). A similar problem can also be found with general practitioners in rural areas. The immigration of qualified personnel is also not a sufficient option here to cover the shortage in the personnel structure (Ulatowski 2013). In addition, these immigrant experts face further difficulties in employment in the context of health care (Staar and Kempny 2019). In order to counteract this change, hospitals must actively bind qualified staff to their own facilities and also recruit additional staff in order to be able to cover the shortage of skilled workers (Haupt and Bouncken 2014).

Tension between hospital - business administration and medicine

In addition to the fight for qualified personnel, the financing and economic orientation of the hospital is also a task that management has to face in order to be able to operate in the market over the long term.

The DRG remuneration system was introduced as a result of the cost reform between 2003 and 2014. As a result of the reform, hospitals inevitably changed from cost centers to profit centers. The economic orientation of the houses became essentially more important after the reform. While economic efficiency before the reform meant that all beds in a hospital were occupied and enough patients were treated in the hospital, economic efficiency in the hospital context today means treating patients as efficiently as possible in order to be able to discharge them as quickly as possible (Staar et al. 2018 ). This leads to outpatient treatment for the operations that allow this form of treatment. In addition, there is a high time and cost pressure for the hospitals, increased competition among the hospitals and the need to continuously improve processes and procedures. However, many of the houses are struggling to equalize costs or, at best, to break even. According to figures from the German Hospital Institute (2013), only 12.1% of the hospitals achieve a balanced annual result. 42.2% of the houses end the year with a shortfall and roughly the same amount of hospitals (45.6%) achieve an annual surplus. The consequences of a cost reform are particularly evident here. Some of the hospitals have managed to integrate the economic idea into the hospital in the time since the reform, while other hospitals have not yet managed to organize the hospital operations economically.

This alignment can be quite difficult for two reasons. On the one hand, a rather rigid remuneration system meets a relatively unregulated hospital market. Here there is high competitive pressure in some areas, which some hospitals find difficult to deal with. On the other hand, the idea of ​​economic efficiency in hospitals does not always meet with understanding and goodwill among employees. For example, some employees are unwilling to face the idea of ​​economic efficiency in a hospital, since the original idea of ​​the helping profession does not seem to agree with a business perspective (Staar et al. 2018).

These findings imply that there must be differences between the organizations and also between the employees, as some hospitals operate very successfully on the market and other hospitals do not. Against the background of the special nature of the hospital organization, knowledge of the economic orientation cannot simply be adopted by other forms of organization.

Study design of the interview survey

In order to find out why some hospitals are successful and other hospitals are not working successfully in the market, these questions should be checked with the help of semi-structured expert interviews. On the one hand, the survey should work out intra-individual resources and resistance to economic work in the hospital. In addition, the form of organization should also be considered, which under certain circumstances promotes economic work in some areas or hinders it through certain structures. Finally, it should be found out in which areas economic work is particularly strongly represented and how this distribution can be explained.

In order to generate as much knowledge as possible with a small survey, different employees from different organizations and levels were selected. In the final sample, there were two people from nursing, an assistant doctor, two chief physicians and an administrative director. Through the different people in the survey, different perspectives from different organizations on the economic orientation could be generated and evaluated in connection with the theory. The interviews were evaluated after a detailed transcription based on Mayring. Categories found and formed were then compared with theoretical findings.

Results of the survey

A summary of the theoretical comparison in combination with the results of the interviews with regard to the organizational form can be found in Table 1. The results relating to the individual can be found in Table 2.

When evaluating the interviews, it was found that the employees in a hospital also notice the cost pressure and the need to focus on an economical way of working. However, it was also criticized that the current form of organization does not support a change in orientation in all areas. However, this change is of the utmost relevance. Some differences between hospitals and other companies could be identified. Three points of particular importance appeared here. On the one hand, there is the ethical question that must be asked in relation to entrepreneurial thinking and acting. How far may and can an employee in a hospital think entrepreneurially and from when does this thinking and acting negatively influence the patient. The second specialty are the patients. A clear distinction must be made here between patients and customers, as patients are in an emergency or extreme situation and depend on the help of the staff. The third point is employee motivation. Especially in the nursing professions, altruism and charity seem to be a characteristic motive for work motivation.This motive turns out to be extremely positive in the treatment and care of patients, but at the same time could also represent an obstacle to entrepreneurial thinking and acting. Of course, employees in nursing do not act solely on the basis of this motive. There are additional incentives and motives. However, all interviewees identified this motive as an important motive for nurses.

If you want to use the advantages of entrepreneurial thinking and acting in a hospital, it makes sense to integrate this basic idea into the guiding culture of the organization. This is possible with corporate entrepreneurship. This is a corporate culture that promotes and implements employee innovations. As a result, the hospital organization can adapt to new situations and create added value in the treatment of patients. In order to integrate this entrepreneurial way of thinking and acting in a hospital, three cornerstones are decisive (Fig. 1).

First of all, empowering skills and attitudes play a major role in hospital staff. Personality traits, cognitive, motivational and social aspects influence the person. In addition, conducive conditions such as financial, temporal and instrumental support and a conducive culture encourage employees to think and act entrepreneurially (Kuratko 2015).

Intercultural challenges in the hospital

Against the background of an increasingly international world of work, the "handling of different cultures" in the hospital has an ever increasing influence on the employees and on the patients. Both patients and employees are increasingly coming from different cultures and thus not only bring different cultural backgrounds, but also linguistic challenges into everyday hospital life (Staar and Kempny 2019).

Intercultural challenges in the team

Intercultural teams can benefit from cultural diversity in the team, but there can also be negative effects in a team due to cultural diversity. Both positive and negative effects on team work performance can be found in teams (Guillaume et al. 2013; Stahl et al. 2010; Tang and Wang 2017; van Dick et al. 2008, p. 1466). It is also possible for culturally diverse teams to be more innovative (Roberge and van Dick, 2010, p. 297) and more creative (Lu et al. 2017, p. 1; Roberge and Dick 2010, p. 297; Stahl et al. 2010) work. At the same time, however, effects such as satisfaction in the team or group cohesion can also occur in a team in a positive or negative manner (cf. Stahl et al. 2010). Different effects can therefore be found in culturally diverse teams. These different effects can be explained up to a certain point by various influencing factors in culturally diverse teams.

On the one hand, the organization is responsible for how well intercultural teams functioned. A clear influence of the organizational culture can be found here. In particular, the way the organization is dealt with and openness to intercultural diversity is crucial here, so that teams can perform better and are less likely to be absent from work (Guillaume et al. 2013; Hofhuis et al. 2012, p. 969). In addition to the organizational culture, the manager and their leadership behavior are also important for intercultural teams and can significantly increase team performance (Lu et al. 2017, p. 2; Somech 2006, p. 150). At the team level, the language in the team and the ability to communicate with one another are important in order to prevent conflicts and increase work performance (Stahl et al. 2010; Tenzer et al. 2017, p. 816). Finally, the individual people in the team are also important, as are their dealings with and attitudes towards intercultural diversity (Tang and Wang 2017). In addition to the challenges of interculturality in the team, the interculturality between patients and hospital staff is also an essential point in the area of ​​tension between interculturality in the hospital.

Intercultural challenges between staff and patients

This intercultural diversity in patient-doctor contact can become an area of ​​tension due to different situations. Due to linguistic, value-related or interpretation-related divergence, misunderstandings and problems during treatment can arise between hospital staff and the patients and their relatives (Staar and Kempny 2019). Communication problems due to language or a different description of the symptoms of diseases can represent barriers (Penka et al. 2012). Different understandings of roles between men and women or different views on treatment methods and medication can also lead to conflicts in treatment (Allemann-Ghionda and Bukow 2011; Grützmann et al. 2012; Ilkilic 2008).

These barriers can be broken through and can be targeted by hospitals. On the one hand, the mentoring programs and training units offered can prepare employees for situations and an intercultural understanding of medical treatments can be developed in the overall context of the hospital (Allemann-Ghionda and Hallal 2011). Employees from other cultures can also be trained so that both linguistic and cultural barriers in patient contact occur as rarely as possible. In addition, an essential component of this intercultural patient-employee relationship seems to be the resource of time and the understanding of other cultures (Lindert et al. 2008). At this point, areas of tension for the hospital staff can arise without the support of the organization. Employees in a hospital encounter a high workload and a chronic lack of time on a daily basis. If the employees then face further hurdles, this can lead to an overload at work. This is where the treatment of the patient and the barriers described meet and the workload on the staff continues to increase.

Stress in medical professionals

Due to various influencing factors such as working hours, extreme situations, areas of tension such as economic efficiency and / or cultural barriers that affect medical professionals in hospitals, but also medical professionals in other organizational contexts, the burden of stressors in the workplace continues to increase (Rasch et al. 2017).

According to this, doctors suffer more and more from stress and the consequences of stress. Due to long working hours of sometimes more than 80 hours and stress from severe fates (e.g. in oncology), more and more doctors consider themselves at risk of burnout (Bergner 2010).

In a study by occupational physicians, the Goethe University Frankfurt am Main found that more than half of all doctors working in hospitals suffer from stress that is harmful to health (Bauer and Groneberg 2013). The nationwide study by the authors Jan Bauer and David Groneberg included the results of over 2000 questionnaires. The result shows a stress prevalence for assistant doctors of 63.8%, for specialists of 54.3%, for senior physicians 46.0% and for chief physicians 24.6%. The decreasing perception of stress with increasing, hierarchical position is clearly recognizable. There seems to be a connection with the existing scope for decision-making and the perception of stress (Bauer and Groneberg 2013). Greater scope for decision-making therefore leads to a lower feeling of stress. While assistant doctors are more externally determined with regard to the workflow and duty roster, chief physicians in particular can organize their own work more independently. Not only the freedom to make decisions are central aspects in the development of stress. Similar to many other professional groups, it is also evident among doctors that support through social contacts is very important (Zwack 2015). A study among 220 doctors from the research institute "esanum" showed that doctors obviously feel considerably stressed as a result of conflicts with colleagues (Hamberger 2013). According to this study, conflicts in the workplace are the main cause of stress and have a major influence on the perception of stress. In addition, competitive thinking and the urge for perfection in the special hospital work environment also play a role in relation to the stress level of medical professionals.

If colleagues do not support workloads and collegiality is lost, the pressure from high workloads can become a decisive stressor. Conversely, social support from superiors and colleagues leads to relief (Keller et al. 2010b). The high work intensity can be seen as one reason for the stress among doctors (Bergner 2010).

Bauer and Groneberg (2013) see the higher proportion of weekend shifts, night shifts and overtime as an additional stress factor, especially for the young doctors. The high workload can lead to the feeling that you can no longer meet your own requirements because many activities have to be done at the same time.

Keller et al. (2010a) subdivide the stressors affecting medical practice into several subcategories. These include B. administrative tasks and documentation requirements, a high work intensity with few opportunities to break, additional burdens from lectures, a high time and deadline pressure and also a lack of personnel. According to Bergner (2010), direct doctor-patient contact is not perceived as stress, but factors such as lack of time, time pressure, restrictions on freedom of occupation by law, fear of legal proceedings or reports, lack of collegiality, lack of security of employment and financial insecurity.

Zwack (2015) shows in a study other stressors for doctors. The main subjective stressors include administrative tasks, bureaucracy and financial security.

The National Association of Statutory Health Insurance Physicians also draws attention to the high time burden doctors face due to bureaucratic effort. A resident doctor spends an average of 26% of his working time with bureaucracy, even with a clinic doctor it is more than two hours a day (Flintrop and Korzilius 2012). The doctor lacks this time for doctor-patient contact, i.e. for the actual medical activity for which he was trained. This results in a dissatisfaction of the doctors, since they have to deal with largely unrelated activities, but also dissatisfaction with the patient, who is given the impression that the doctor has little time. “In the medical profession, starting motives and everyday work are often far apart” (Zwack 2015, p. 18).

The constant handling of extreme situations, such as dying patients and the suffering of them or their relatives, can represent a further stressor for medical professionals due to the high emotional challenges. Bergner also sees a heavy burden on doctors when they are constantly confronted with the suffering of others (Bergner 2010). Furthermore, he emphasizes the lack of recognition, time pressure, financial pressure and "frequent disruptions or interruptions in actual activity" (Bergner 2010, p. 79) as stressors.

He classifies a lack of information as moderately stressful. B. on new legal regulations and also considers the lack of collegial togetherness and tension in relation to the patient as possible stress-triggering factors.

Excursus: demand control model

Karasek (1979) described the so-called “requirement control model”. This model looks at the connections between high psychological work demands and stress.

The psychological work requirements include the scope of work (quantitative), the quality of work, the organization of work (time pressure, interruptions, etc.) but also social components such as the relationship to employees and superiors (Friedel and Orfeld 2002).

According to Karasek (1979), high work demands cause stress when there is little leeway with regard to one's own decisions.

The "control" refers to different factors. On the one hand, it concerns the option of using and exhausting your own skills and thus being able to develop yourself further. In addition, the type of scope for decision-making, for example with regard to innovations, creativity or work design, is also important (Friedel and Orfeld 2002).

If high work demands are coupled with high scope for decision-making, this tends not to trigger stress, but rather promotes motivation (Karasek 1979). The increased requirement is seen as a positive challenge. It becomes the engine of further action. However, it should not be ignored that the requirements should not exceed the individual talent potential. Otherwise the challenge can easily become overwhelming.

Against the background of the demand control model, the recommendations for action are to be developed and evaluated in the further course of the work.

Study design and implementation

In order to ascertain the physicians' perception of stress and to be able to place them in the context of the areas of tension, it was decided to conduct a quantitative survey among physicians. A total of 63 resident doctors from the Duisburg district could be won over for such a survey. Most of the questionnaire was carried out at a conference in paper form; other medical professionals could be encouraged to participate in the individual practices.

On the one hand, the survey should determine which stress-inducing factors influence resident doctors. On the other hand, it should be checked to what extent the participants in the present sample show resilience and what influences they were shaped by. The overriding goal is to generate recommendations for action to build and maintain resilience.

The questionnaire comprised 11 scales and 76 items. The focus of attention was on the scales on the following topics: social support from colleagues (ISAK ‑ K, Keller et al. 2010b), positive thinking (SCI, Satow 2012), active stress management (SCI, Satow 2012), alcohol and cigarette consumption ( SCI, Satow 2012), social support (SCI, Satow 2012), recreational behavior (Jurkat 2010), appreciation, administrative activities, stress symptoms (SCI, Satow 2012) and resilience (Leppert et al. 2008).

The reliability testing with the help of Cronbach's alpha showed sufficient or satisfactory values ​​for all scales. For the positive thinking scale α = 0.802, for the social support scale α = 0.871, for alcohol and cigarette consumption α = 0.716, for the scale for active stress management α = 0.817, for social support from colleagues α = 0.644, for the scale for appreciation α = 0.642, on the administrative activities scale α = 0.695 and on the stress symptoms scale α = 0.905 and resilience α = 0.947. This enabled the scales to be used for further evaluation.

Excursus: resilience

In psychology, the term resilience describes the ability to deal with crisis situations or persistent external stress. The focus here is on resistance to such impairments and stresses. A higher resilience leads to a lower feeling of stress (Scharenhorst 2008). It is therefore a matter of the phenomenon of psychological resilience.

The American Psychological Association (Comas-Diaz et al. 2018) names a few other factors that are associated with resilience. The ability to design realistic plans and implement them is a factor in resilience. This also includes a positive view of yourself and a healthy self-confidence in your own abilities and strengths. In addition, the ability to communicate and solve problems play an essential role. All of these factors can be learned and developed by individuals (Comas-Diaz et al. 2018).

Bergner addresses aspects that lead to an increase in resilience. He names four essential aspects in relation to the professional group of doctors. Resilience can therefore be strengthened through a lasting interest in one's own job, a strong self-confidence, the knowledge and acceptance of one's own limits and the importance of one's own role as a medical practitioner ascribed to oneself (Bergner 2010).

Study results

In this study, a multiple regression was calculated to identify the effects of social support from colleagues, positive thinking, active stress management, alcohol and cigarette consumption, social support, recreational behavior, appreciation, administrative activities, and stress symptoms on resilience. It turned out that not all effects were suitable for predicting resilience.

The first multiple regression model was calculated to predict resilience using the variables administrative activities, appreciation, and alcohol and cigarette consumption. A significant regression equation could be found (F (3.59) = 6.457, p <0.005), with an R.2 of 0.247. The second multiple regression model was also run to calculate resilience using the previous variables. However, the variable social support was also included here. A significant regression equation (F (4.58) = 5.903, p <0.000), with an R2 of 0.289 can be found.Although the predictive power is increased by the variable social support, the second model must be viewed critically, as there are higher correlations between the variable social support and the other three variables.

Resilience could to a certain extent be described in this study by 4 variables. The variables social support, administrative activities, appreciation and alcohol and cigarette consumption therefore have an impact on the resilience of medical professionals. However, measures for the other variables should also be worked out in the following, as these should nevertheless be included according to theory.

Derived measures

The area of ​​“stress and workload” also clearly shows a large area of ​​tension, which doctors and medical staff in a hospital stress. Measures to increase resilience can be found in individual areas, which can then help the employees in a hospital to build up a resistance to stressful situations (Tab. 3).

Retention Management in the Hospital

Three major areas of tension could be identified which influence employees in a hospital and which can influence motivation, job satisfaction as well as mental and physical health. While the area of ​​tension "entrepreneurial thinking and acting" is more an area that puts corporate management and corporate success in the foreground, the area of ​​tension "intercultural challenges" is a challenge that has a direct impact on patient-employee- Relationship or who has teamwork. While one can evade the field of tension of economic efficiency up to a certain point, this is not possible with the field of tension of intercultural challenges. In addition to these two more global areas of tension in the hospital organization, there is another area of ​​tension called “stress”, which in this article deals particularly with doctors. However, it must be taken into account here that the other occupational groups are also significantly under stress (Rasch et al. 2017).

The subject of stress is initially a very individual and personal challenge that every employee in a hospital has to face. However, it should always be taken into account that the employees' feeling of stress is also the responsibility of the organization, as resources can be made available here.

Against the background of these areas of tension, the shortage of skilled workers and the foreseeable exacerbation of this problem, the question of a possibility not only to reduce the areas of tension to the greatest possible but also to bind the employees to the company in the long term and to support them to motivate work. This is to be described below from the perspective of retention management.

Retention management

Companies that integrate retention management into the organization try to perceive the individual needs and wishes of the employees and to encourage and confirm the employees. In this way, the companies hope that employees will retain their long-term commitment to the company and remain with the company (Ulatowski 2013). The advantages of retention management are then not only noticeable for the company, but also for the employees.

For employees, successful retention management can lead to job satisfaction, commitment and a solid social identity. This results in various effects, such as an increased sense of belonging, more security, orientation and social support for one another. Effects for a company can include falling fluctuation rates, an increase in employee performance, a larger pool of staff, fewer absenteeism and the retention of knowledge in the company (Klaiber 2016).

Retention management includes factors that can influence these effects. First of all, the already mentioned factors of job satisfaction, commitment and social identity are essential. These factors also influence each other and can therefore reinforce each other (Ulatowski 2013).

In addition, other factors have an impact on employees that can strengthen or weaken their loyalty to the company. Organizational factors and working conditions have an influence here. While these factors can be adjusted to the employees by a hospital up to a certain point, factors from the labor market and life factors of the employees can be influenced far less (Kanning 2017).