Nurses are an integral part of any healthcare facility or organization. Many factors are attributed to the issue of nurse retention and why nurses leave one job for another. Issues could include burnout, difficult work environments, low salaries, lack of management support, lack of decision making, few development opportunities, or difficult physicians. Nurses are in high demand and the nursing shortage will continue to grow at an alarming rate. Retaining competent, qualified nurses will be a challenge each organization will face. Nurse retention is not a new problem and the factors that lead to the issue is not new. Issues such as patient safety, patient satisfaction, and good quality nursing care directly relates to nursing retention issues. Creating a good working environment for nurses will decrease the turnover rate and will help in recruiting new nurses. Having job satisfaction is important in everyone’s overall well-being. Nursing leadership and managers have the burden and responsibility of promoting a good working environment and protection for the patients and the nursing staff as well. Nurse retention issues can affect an organization on many levels with high turnover rates, costly new employee training, patient safety risks, and overall low staff morale.
Significance of Issue
Few nurses are hired by an employer and stay with them until retirement. The profession of nursing has so many different areas of focus that nurses have many opportunities to change practice settings as often as they choose.
There are an estimated 3,328,771 registered nurses in the United States (Total number of professionally active nurses, 2018). By the year 2022, 1.05 million new jobs for nurses are expected due to growth and replacement needs (Snavely, 2016). It is not enough for organizations to simply hire nurses without having adequate retention strategies. There is a huge economic impact to an organization for a nursing turnover rate. RN turnover rates are 17.2% with 24.2% of hospitals reporting a vacancy rate of 10% or greater (Snavely, 2016). According to Snavely (2016), “The average cost of turnover for a bedside RN ranges from $36,900 to $57,300 resulting in the average hospital losing $4.9 to $7.6 million” (p. 100). The importance of retaining nurses for any organization becomes critical and substantial. Recruiting new nurses requires money spent on advertising, marketing strategies, and new hire training.
Nurse retention is important in ensuring good patient care. Foster (2017) states:
A positive practice environment supports nursing excellence and strives to ensure the health, safety, and personal wellbeing of staff as well as patients. Unhealthy practice environments and a poor organizational climate have a serious negative impact on the recruitment and retention of nurses (p. 251).
Retaining nurses and providing a good work environment can affect patient safety and patient satisfaction. When staffing levels are not where they should be, patient safety can be compromised. When a unit experiences a nursing shortage due to retention issues, the effects can be felt on many levels. The impact can be significant on the nurses having to pick up extra patients, working conditions can deteriorate, the quality of nursing is also influenced. Leaders have a responsibility to help improve the quality of the workplace which helps in retaining skilled nurses (Brunetto, et al., 2013). Not only is the cost of nurse turnover a consideration, there are hidden implications such as patient mortality, medication errors, and increased infection rates, (Brunetto, et al., 2013). Patient care can also be impacted by how much time nurses can spend collaborating with team members, with the patients, and the ability to detect complications early (Brunetto, et al., 2013).
Forces Influencing the Issue
Nurse retention has many influencing factors for leaders. Addressing problems that are related to the retention issues is important. Factors that can lead to nurse retention issues can be leadership problems, the work demand, burnout, lack of job satisfaction, a poor work environment, and a lack of support. A cross-sectional secondary data analysis of 500 licensed nurses in Illinois and North Carolina was sent surveys to examine work-related factors and intent to leave the current position. Han, Trinkoff, & Gurses (2015) examined the results and concluded that “nurses who were dissatisfied with their job reported significantly higher psychological demands and lower autonomy than nurses who were satisfied’ (p. 3224). Han, Trinkoff, & Gurses (2015) also concluded “Nurses were significantly less satisfied with their jobs when they worked longer hours with inadequate breaks or sick days and had lack of support from peers and supervisors” (p. 3224). Supportive leadership has a professional responsibility to promote working environments that protect, nurture, and empower staff. According to Chan, Tam, Lung, Wong, and Chau (2013), “Nurse managers should act with supportive leadership styles to improve the working environment, which can positively affect job satisfaction and hence retention rates (p. 611).
A cross-sectional correlational design study of 415 registered nurses from 10 pediatric intensive care units was conducted to examine the effects of healthy work environments on RN turnovers. From this study, Blake, Leach, Robbins, Pike, & Needleman (2013) concluded, “Nursing leadership was found as the most important factor related to low intent to leave and turnover in PICU nurses” (p. 366). Leadership is a critical component for optimizing the work environment and increasing retention of the nurses (Blake, Leach, Robbins, Pike, & Needleman, 2013). The study also showed that the more years of experience a nurse had, the less likely they would leave their job (Blake, Leach, Robbins, Pike, & Needleman, 2013). When seniority increases, nurses are less likely to leave their job. Communication and collaboration were not predictive of a nurse’s intent to leave, but better patient outcomes were found when communication, collaboration, and leadership were present (Blake, Leach, Robbins, Pike, & Needleman, 2013).
An analysis of panel data, conducted by a retrospective two-stage panel design, was chosen to study by Kutney-Lee, Wu, Sloane, & Aiken. This study used data collected from registered nurses in Pennsylvania hospitals in 1999 and 2006, to determine burnout, intent to leave current position, job dissatisfaction, and to classify the quality of a nurse’s work environments (Kutney-Lee, Wu, Sloane, & Aiken, 2013). Outcomes of the survey were compared from the 1999 survey and the 2006 survey of the nurse work environment. The results of the study found that improvements in nurse work environments are associated with decreased rates of nurse burnout, intent to leave, and job dissatisfaction (Kutney-Lee, Wu, Sloane, & Aiken, 2013). According to Kutney-Lee, Wu, Sloane, & Aiken (2013), “Hospitals that improved their nurse work environments witnessed favorable changes in these outcomes over time, while unfavorable changes were found in hospitals where the work environment declined” (p. 199). Nurse staffing levels were significantly associated with the change in rates of burnout. When staffing levels improved, 4% of the nurses had a decrease in burnout (Kutney-Lee, Wu, Sloane, & Aiken, 2013). Investing in nurse work environments may prove to be critically important, cost efficient, and improve the quality of patient care (Kutney-Lee, Wu, Sloane, & Aiken, 2013).
Summary of Evidence
The studies presented clearly show that the major factors that contribute to nurse retention are effective leadership, the work environment, and adequate staffing levels. Improving the work environment can decrease the stress and the overall wellbeing of staff. The strengths of the articles were the results seemed to show the same results for the top drivers regardless of what methods of study were used. The weaknesses of the studies may not have looked at all aspects of why nurses choose to leave a company. Ethical issues could be a factor if an organization engages in practices that go against nursing ethics. More unit specific research would be beneficial to explore the differences with the different nurse/patient ratios. Individual coping skills could also play a role in a nurse’s decision to leave a position. Some nurses thrive on the adrenaline rushed fast pacing units and some nurses do better in the lower stressed areas. Some studies also failed to list the actual amount of the turnover rates.
The nurse retention issue can pose ethical issues. When a unit is not fully staffed it can pose not only increased stress, but can impact good patient care. Ulrich et al. (2013) states, “Without sufficient staffing it is difficult to meet the ethical standards of professional practice (p. 7). Understaffing is a barrier that keeps nurses from meeting their responsibilities. Today’s healthcare environment is demanding with limited resources. Dealing with ethical issues can be frustrating and can drive nurses away from an organization if nurses feel inadequately prepared to address the issues.
Nurses should have an influence on health policies that affect them greatly. As more nurses get involved in the political process and the legalities of the profession, real change will take place. Nurses need to be aware of policy agendas and ways to get involved. Nurse comprise the majority of the healthcare profession and could have a strong political force. Issues like nurse to patient ratios, nurse retention, medical errors, nurse workload, etc. can be improved, but nurses need to become key participants in health policy. Nurses need to be a part of the decision making that affects the nursing profession.
Having been in nursing for a while, I do think that effective leadership is one of the key components in nurse retention in any healthcare setting. Leadership can make or break, not only an individual nurse, but an entire unit. According to Yoder-Wise (2015), “A leader is an individual who works with others to develop a clear vision of the preferred future and to make that vision happen” (p. 35). All nurses must exhibit leadership regardless of their title and role. Yoder-Wise (2015), goes on to say that “Nurse satisfaction within the workplace is an important construct in nursing administration and healthcare administration. Turnover is extremely costly to any work organization in terms of money, expertise and knowledge, as well as care quality” (p. 37). The need for high-quality patient care is evident. Providing high-quality care and reducing healthcare costs can be, at best, challenging for any organization. Many times, a nurse leader is caught between administration visions and mission’s verses what the staff nurses need to provide a good work environment. Sometimes the two worlds collide, and the nurse leader is caught somewhere in the middle. Nurse leaders are responsible for a wide range of functions that include system performance, achievement of health reform objectives, time care delivery, system integrity and efficiency (Daly, Jackson, Manix, Davidson, & Hutchinson, 2014). Advanced leadership training programs utilized by organizations help to produce leaders that possess the ability to drive and implement the vision of delivering safety in healthcare and to promote an efficient and healthy work environment (Daly, Jackson, Manix, Davidson, & Hutchinson, 2014). Leaders need the ability to influence peers to act and enable clinical performance, provide support and motivation, enact organizational strategic direction, challenge processes, and address ethical issues (Daly, Jackson, Manix, Davidson, & Hutchinson, 2014). Leaders are not necessarily born, but emerge and continually evolve by a range of experiences and interactions with a variety of people (Scully, 2015).
As crucial as effective leadership is to nurse retention, the work environment is just as important. Long shifts, high stress, and ineffective leaders seem to be synonymous with the nursing profession. This increases the burnout rate and directly affects the nurse retention problem. Patient experience scores can even be affected when an organization has adequate staffing. According to Gooch (2015), “Even hospitals with high nurse staffing scores fall below the overall mean of patient experience scores when nursing work environments are poor” (para. 3). A Press Ganey report in 2015 examined the impact that the work environment has on the safety, quality, and patient experience of care and resulted in four key findings:
Ø The work environment of nurses can have a greater impact than nurse staffing on many safety, quality, experience, and value measures.
Ø Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores across all patient experience domains respond favorably to better nursing work environments, regardless of staffing composite scores.
Ø Performance on Value-Based Purchasing (VBP) patient experience scores increase with improving work environments.
Ø Higher quality nurse work environments enhance patient and nurse perceptions of care quality (The influence of nurse work environment on patient, payment, and nurse outcomes in acute care settings, 2015).
Recommendations on improving the work environment includes shared governance by improving RN autonomy, enhanced interprofessional relationships and communication, consistent and adequate staffing and skill mix, a highly educated workforce, and appropriate and consistent leadership support (The influence of nurse work environment on patient, payment, and nurse outcomes in acute care settings, 2015).
Nurse retention is a problem and will continue to be in the future. Decreasing the turnover rate will be challenging for leadership. The problem of the nursing shortage will continue to be a factor in the foreseeable future in this country. With the aging of nurses, the increased demand for nurses, and increased burnout the nurse retention problem will increase. Factors that contribute to the nurse retention problems that leadership face can be due to burnout, poor leadership qualities, increased demand, lack of job satisfaction, lack of peer support, etc. When organizations start to face nurse retention issues, patient safety and patient satisfaction can be affected. Retention issues can have a huge economic impact on any organization and more money will have to be spent on new hire training, recruiting, and marketing. Effective leadership can and does have a huge impact on the retention of nurses. Nurse leadership needs to support a good work environment, improve job satisfaction, foster safe nurse-patient ratios, encourage competitive salaries, and intolerance of physicians that may be disrespectful. When leaders help to provide a culture in which nurses feel valued, respected, and appreciated, the turnover rate can be greatly reduced. This is a win for the nurse, the organization, the leaders, and the patients and community. With an aging population, the demands on nurses will continue to increase. Leadership that continually works on reorganizing nurse workloads and having adequate resources will impact a nurse’s decision to stay or to leave the organization. Promoting a healthy work environment encompasses a sense of safety, empowerment, and satiety that benefits the entire organization and promotes nurse retention.