Nursing Retention and Turnover Nursing CE Course

scheduling inflexibilities, staffing ratios, and inappropriate shift assignments due to staff shortages. Experienced nurses often report leaving the bedside to pursue employment elsewhere due to the scheduling demands, inflexibility of management with scheduling, lack of professional recognition, and the physical demands of bedside nursing. Burnout is the emotional and physical effects of a stressful work environment, leading to emotional exhaustion, depersonalization, and lack of personal accomplishment. It is estimated that the prevalence of burnout in healthcare professionals ranges from 10-70% in nurses, and burnout significantly contributes to turnover (Ackerson & Stiles, 2018; Clark, 2021; Maslach & Leiter, 2017).

Job satisfaction is "the personal positive perception toward work and work experiences" (Laschinger et al., 2016, p. 659). In contrast, dissatisfaction is associated with turnover, burnout, and patient dissatisfaction. Quality nursing care is central to positive patient outcomes, and the ability to deliver quality care is paramount to nursing satisfaction. Literature shows a correlation between nurses who feel they can provide care the way the patient deserves and higher job satisfaction. Staffing, resources, policies of an organization, or organizational leadership can impact the standard of nursing care. The nurse's perspective on their ability to deliver quality care can lead to a desire to remain or leave not only the place of employment but, at times, the nursing profession altogether (Laschinger et al., 2016).

Interpersonal relationships are shown to be a factor in turnover. Individuals are happiest in an environment where they get along with their coworkers, and nurses and other healthcare workers have a long-standing reputation for conflict. There was once a saying that "nurses eat their young," and incivility among nurses and other healthcare workers is well documented. It is much easier to walk away from a position in an environment with strained or poor interpersonal relationships than one of a cohesive nature. Violence within healthcare settings can also negatively impact job satisfaction. Nurses and other healthcare professionals can often experience emotional, verbal, or physical abuse from coworkers or patients. Nurses working in emergency departments and psychiatric units are at higher risk for violence in the workplace (Haddad & Toney-Butler, 2022; Kaiser, 2016; Smith et al., 2017).

Personal reasons are another cause of turnover and may vary from compassion fatigue (CF) to personal obligations such as being a caregiver for minor children or older parents. Increasing the use of technology and a lack of empowerment are other commonly noted reasons for turnover. Women disproportionately hold the title of nurse, and their additional obligations to childrearing and family care can add stress to an already stressful environment. With staffing and scheduling conflicts, long shifts, and mandatory overtime, nurses may leave the profession to be able to care for their children. CF is the emotional, physical, and spiritual distress resulting from caring for others. The emotional strain from caring for those who experience suffering can culminate in detachment and a loss of empathy (Clark, 2021; Haddad & Toney-Butler, 2022).

In addition to turnover from one workplace to another is the risk of career turnover by nurses. Career turnover refers to a nurse's intention to leave the profession. It is caused by job dissatisfaction that seems unmanageable even with a change in employer or practice area. New graduate nurses seem to be overwhelmingly at risk for job dissatisfaction as they question their current employment and the choice of nursing as a profession. In addition, more nurses are going on to further their education to get out of the clinical setting and away from bedside care; they are training to become nurse educators, nurse leaders, or other advanced practice nursing roles (Laschinger et al., 2016).

Nursing management has been noted as another source impacting turnover rates. The phrase, "people do not leave a position; they leave a manager," also holds true in healthcare. Nurse managers often have little to no formal training, leading to poor management skills and dissatisfaction among those working for them. Other cultural issues for leaving a position may be salary issues, an uncomfortable work environment, communication barriers, insecurity related to nurse-to-patient ratios and responsibilities, lack of opportunity for career advancement, or a lack of recognition and appreciation (Ackerson & Stiles, 2018; Dewanto & Wardhani, 2018).

Implications of Turnover

The cost of turnover is a significant concern as it contributes to the overall cost of healthcare. Studies have shown that new graduate nurses are often unprepared for patient care. Their inexperience can lead to increased patient falls, pressure ulcers, medication errors, or other poor patient outcomes. Teamwork is necessary for effective patient care, and it requires trust and effective communication, which is difficult to achieve with constant turnover. Patients have difficulty trusting visibly unprepared nurses that lack the confidence to manage their care, such as a new graduate nurse or a new hire unfamiliar with the environment and expectations. A high number of inexperienced nurses also creates a higher workload demand and stress for experienced nurses within an organization and can lead to patient dissatisfaction. Patient dissatisfaction leads to lower reimbursement and negative survey scores on the Hospital Assessment of Healthcare Providers and Systems survey (HCAHPS), which can directly affect an organization's income (AACN, 2020a; Driscoll et al., 2018; Weninger Henderson, 2020).

The group previously known as the Institute of Medicine (IOM, 2000), now the National Academy of Medicine, published their report, To Err is Human. This report highlighted the problems with patient safety and reported that tens of thousands of patients die each year due to issues with healthcare delivery. Numerous historical examples demonstrate the impact of nurse staffing levels on patient outcomes. In 2004, the Centers for Disease Control and Prevention (CDC) identified profound implications for infectious diseases related to nursing staffing patterns and nurse turnover, including a methicillin-resistant Staphylococcus aureus (MRSA) outbreak in a neonatal intensive care unit due to understaffing, Enterobacter cloacae outbreaks related to understaffing, central venous catheter-associated sepsis due to understaffing, and nosocomial infections related to a high nurse-to-patient ratio in a pediatric unit. In 2012, Cimiotti and colleagues found an association between high nurse-to-patient ratios and increased surgical site infections and catheter-associated urinary tract infections. In 2014, Aiken and colleagues found that an increased nurse workload by one patient increased the likelihood of patient mortality within 30 days of admission by 7%. More recently, the impact of the Covid-19 pandemic has highlighted the importance of adequate staffing levels for safe patient care. In 2022, Falk and colleagues conducted a cross-sectional study to evaluate missed nursing care during the pandemic in the critical care setting. Higher nurse-to-patient ratios were associated with missed nursing care, usually related to basic care elements (Aiken et al., 2014; AACN, 2020a; Falk et al., 2022).

Turnover is not limited to acute care settings but is also a problem within long-term care facilities. Turnover may indicate greater systemic issues stemming from management or corporate concerns within healthcare organizations and not only nursing implications. Direct causality between high turnover and patient outcomes is difficult to establish; however, a review of California long-term care facilities found that a 10% increase in nursing turnover equated with a 19% increase in deficiency citations (i.e., violations) on their annual surveys. The impact of the Covid-19 pandemic on long-term care nurse staffing was significant. In addition to caring for vulnerable older adults, nurses working in long-term care experienced burnout due to staffing shortages, increased workloads, and the emotional burden of caring for residents experiencing isolation and high mortality rates (Antwi & Bowblis, 2018; White et al., 2021).

Hospital managers describe turnover as disrupting hospital service delivery. Consequences range from workload increases on the nurses left behind to patient complaints about nursing services delivered. Nurse turnover increases the cost of recruitment and training. New nurses require time for adaptation to the work environment and orientation, a learning period that may be associated with decreased quality and quantity in the delivery of services during this time. Experienced nurses and providers may perceive new nurses as lacking critical thinking skills and may be less trusting in their care abilities. Patients and families may perceive a lack of trust when a recently hired nurse is unfamiliar with their environment or skills (Dewanto & Wardhani, 2018).

 

Retaining Nurses

In 2007, the Institute for Healthcare Improvement (IHI) presented the Triple Aim framework to optimize healthcare system performance. The three dimensions of the Triple Aim include: improving the patient care experience, improving the health of populations, and reducing the per capita cost of health care. Healthcare organizations and national leaders have recently highlighted that the healthcare professional's (HCP's) work environment is critical to achieving the Triple Aim. Therefore, many organizations have advocated expanding the Triple Aim to include a fourth dimension of attaining joy in work. The evolution of the Quadruple Aim addresses the importance of a healthy work-life for HCPs as a foundation for achieving the Triple Aim. Addressing burnout and promoting joy in the workplace can improve patient outcomes and safety (Feeley, 2017; Fitzpatrick et al., 2019).

A study on healthy work environments and nurse retention noted that up to 63% of nurses were very satisfied with their choice of nursing as a career, but less than 29% were satisfied with their current workplace. The nurses surveyed mentioned leaving their current job for other positions in nursing, returning to school, or retiring. Those desiring to leave their positions further noted they might reconsider leaving if conditions in their current workplace were to improve. The areas identified as needing improvement were staffing, leadership, and respect from the administration. The same study noted that healthcare environments lacked joy for employees (Kennedy, 2019).

The IHI released a white paper that focused on restoring joy in the healthcare workplace to improve both the morale of employees and patient outcomes by changing the culture. The focus of this white paper was to present joy in the workplace and make a positive focus rather than negative connotations of discussing incivility, burnout, and CF. Of particular interest was the notion of changing the dialogue in the workplace to one of "What can we do today?" and "What do we need today?" This dialogue focuses on the workforce as a team and suggests that working together is possible. Reshaping the workplace culture to focus on positivity and helping nurses look at their work from a perspective of joy is a start to changing the overall clinical environment. Nurses spend a significant part of their life at work, and this suggestion of joy as becoming the standard can impact the profession of nursing overall (Perlo et al., 2017).

In addition to creating a positive working culture that values all employees within the organization, new nurses need support as they transition from the academic setting to their initial clinical roles. Much literature has been written on this transition period and the value of implementing structured programs to facilitate a successful transition to clinical practice. Hospitals recognize the value of a nurse residency program and the support offered for new nurses in these programs. With critical aspects similar to a new physician residency program, a nurse residency program supports new nurses entering practice through didactic and hands-on educational support, mentors, preceptors, and other structured roles to offer psychosocial and transitional support to the nurse graduate. This transitional period can be very stressful for new nurse graduates with the disparities between the professionalism and ideal work environment taught in most nursing schools compared to the reality of clinical practice. This reality can lead to early job dissatisfaction, and a strong mentor can help bridge this gap. Nurse mentors can also be helpful as the experienced nurse transitions from one area of practice to another to offer resources during the transitional period. Mentorship, coaching, or other support roles help to enculturate nurses entering new areas of practice and have been identified as valuable tools for retention (Horner, 2017).

Nurse residencies are strong indicators of successful role transition for the new graduate nurse across the literature. Graduates of nursing schools enter the workforce with anticipation of a supportive and caring environment and a somewhat altruistic view of patient care and, instead, may find discord and dissatisfaction. There is a distinct incongruence between real-world practice and the preconceived notions formulated during school in the ideal educational environment. Within the literature base, this transition is referred to as "culture or reality shock" or role transition at best. Since the transition time is crucial for long-term role satisfaction, success, and safety of patient care, the value of nurse residency programs is evident (Price & Reichert, 2017). Eckerson (2018) conducted a literature review to determine how nurse residency programs impact retention. Using nurse residency programs improved job satisfaction and retention at the one-year mark. Similarly, Ackerson and Stiles conducted a literature review to explore the value of nurse residency programs in acute care settings. The researchers found that nurse residency programs improved retention at the 1-year mark; however, retention was not sustained at the 2-year mark. Therefore, hospital administration should focus on improving the retention of nurse residents after the 1-year mark (Ackerson & Stiles, 2018).

Mentoring is a long-term and mutually beneficial relationship where the experienced professional supports, teaches, mentors, and encourages the less experienced individual to foster professional and personal growth as they adapt to their new role. A mentor should be confident, have effective communication, good listening, maturity, and a nurturing nature. They should not be judgmental or impatient. Early mentoring focuses on clinical competence and basic nursing skills that may be adapted in a particular facility versus how they were taught in school. Over time, the mentor may focus on developing advanced nursing skills and higher levels of problem-solving, clinical judgment, and even emotional intelligence. New nurses who have been part of a mentoring program report increased satisfaction, competence, and confidence with their new roles; enhanced communication and leadership skills; and the development of close interpersonal relationships with other nurses on the unit and their mentor, all leading to improved retention. Hospitals with mentoring programs and nurse residencies report improved retention, with turnover rates dropping to less than 10%. The annual cost of a mentoring program can be $50,000 to $100,000, much less than the cost of nurse turnover (Horner, 2017).

Coaching is a more time-limited and structured relationship between a skilled facilitator and an individual or group of learners. For instance, a coach may work with a particular hospital unit to improve morale or teach leadership behaviors. Goals are agreed upon before the coaching, and the coach promotes the development of the desired skills to reach those goals. Knowledge, skills, and attitudes are focused on developing new behaviors to enhance the learner's performance and role effectiveness. Coaching can have higher up-front costs than other types of mentoring that may be primarily volunteer. However, the tradeoff is a higher impact on job satisfaction and organizational or cultural improvements. Studies have demonstrated improved relationships, higher intention to remain in a position, and increased job satisfaction by nurses where coaching has been initiated (Horner, 2017).

Role adjustment is not limited to the new graduate nurse entering practice but can also impact newly hired advanced practice RNs (APRNs). Mentors can be a vital source of support and aid in adjustment to the role of a healthcare provider. A study of 37 new APRNs reported that positive relationships with their mentors contributed to high job satisfaction and decreased stress. The researchers noted that the new APRNs held recognition, potential advancement, and career growth as key intrinsic factors driving job satisfaction and retention. Mentors were reported to validate those intrinsic factors and aid in the retention of new APRNs (Horner, 2017).

Nursing empowerment has been identified as a significant source of nurse retention, and the lack of empowerment is a key indicator of turnover. Professional practice behaviors go above and beyond nursing tasks and skills. They include the development of therapeutic relationships with patients, evidence-based practice, exercising clinical judgment, and collaborating with the healthcare team. Nurses have the knowledge, skills, and attitudes to handle and adapt to complex and unpredictable situations, yet must have the autonomy to practice at their highest scope of practice. Without sufficient support from administrators, the nurse may not feel empowered to extend themselves to meet the full potential of professional practice. Nurses want autonomy to deliver quality patient care. As previously noted, research indicates that a nurse's perception of patient safety and quality of care delivered through their institution is directly linked to their turnover intentions. Not surprisingly, nurses' perception of the quality of care is directly correlated to objective hospital quality indicators, including patient satisfaction, failure to rescue, and infection or mortality rates (Laschinger et al., 2016).

Ongoing training and opportunities for attending educational summits or conferences are also essential aspects of nurse satisfaction. These opportunities expand a nurse's knowledge of current evidence, allow networking with peers, and encourage professional development. In a study of 185 nurses that included students, early-career nurses, and mid-to-late career nurses, professional development was identified as an expectation and an expressed need across the lifespan of a nurse's career. Students require sufficient training to deliver safe and effective care. Further, the graduate nurse must have adequate training for role transition and skill mastery. Mid-to-late career nurses (over 50) understand the need for lifelong learning, maintaining competency within their nursing role, and understanding the latest evidence-based guidelines to ensure they deliver optimal care; these nurses cited professional development opportunities as essential for job retention. Despite this, only 12% of late-career nurses surveyed reported that their institution supported or provided educational opportunities. The researchers noted that nurses across various career stages felt that ongoing education was critical to a healthy work environment. They further indicated that healthy work environments directly weighed on their job satisfaction and the desire to remain in the nursing profession (Price & Reichert, 2017).

Provision 5 of the ANA Code of Ethics (2015) discusses the nurse's responsibility to maintain competence through professional development. The ANA states that this continued competence and professional growth affect the quality of patient care as well as the nurse's "self-respect, self-esteem, and meaningfulness of work" (ANA, 2015, p. 22). The IOM published The Future of Nursing in 2011, which confirmed the importance of lifelong learning in nurses and tied the retention and recruitment of nurses to educational and professional development opportunities from their employers to hone skills and master competencies, which also improves patient care and outcomes (IOM, 2011).

Magnet status has been associated with nurse satisfaction and retention for some time, and it is well known that hospitals with the Magnet designation attract and retain nurses. Magnet facilities hold high standards of care and promote professional practice through control over the practice environment, clinical autonomy, and healthy nurse/physician relationships. Other values held by Magnet facilities are adequate staffing, decisional involvement, leadership, and nursing as the foundation of care. Lower burnout, greater job satisfaction, and a strong desire to remain in the nursing profession are identified in Magnet facilities (Laschinger et al., 2016). The ANA (n.d.-a) notes the following about Magnet status: "to nurses, Magnet Recognition means education and development through every career stage, which leads to greater autonomy at the bedside. To patients, it means the very best care, delivered by nurses who are supported to be the very best that they can be (para. 2)."

A focus on manager training and leadership succession can be vital to retention. A strong leader will be an advocate for those they lead. This includes ensuring adequate staffing and resources, recognition of employee performance, and empowering nurses. Professional recognition can consist of financial awards such as bonuses or raises for performance, clinical excellence appreciation programs, and retention awards for years of service; these recognitions act as incentives to remain at an organization. Employee retreats, continuing education support, higher education opportunities, and clinical ladder programs can be positive aspects of an organization that entices the employees to remain in place (Ackerson & Stiles, 2018).

Nurses over 45 years old are entering and remaining in practice due to financial constraints. However, the role of a clinical nurse can be challenging for the most physically fit individual. Evidence has been introduced that many older nurses would remain in the clinical setting much longer if they could have adaptations to current scheduling, including shorter work days, patient loads that are less physically demanding, increased pay based on their experience, and more support from management. While this may not eradicate the current shortage, retaining experienced nurses can improve the overall patient outcomes and the morale of individual units where each person is valued (Ackerson & Stiles, 2018).

 

Value of Retention

When workplace issues are addressed and resolved, positive outcomes for nurses and patients result. Many states have recognized the value of retention and have tried to actively slow down turnover through legislation controlling nurse-to-patient staffing ratios. The California Nurses Association proposed and advocated for ratios based on the nurse's experience, and eventually, the California Ratio Law was passed. Under Title 22 of the California Code of Regulations, Section 70217, general acute care facilities must adhere to staffing ratios, which may vary based on the unit type. In addition, nurse administrators (e.g., supervisors, managers) and other licensed nurses shall be included in the calculation of the licensed nurse-to-patient ratio only when those licensed nurses are engaged in providing direct patient care. When nurse administrators or other licensed nurses are engaged in activities other than direct patient care, those nurses shall not be included in the ratio. See Table 1 for the ratios required by the state of California (Smith, 2007).

 

Table 1

California Law Staffing Ratio Requirements

Hospital Unit	Nurse: Patient Ratios
Intensive Care: Critical care/ICU Neonatal ICU (NICU) Continuing care	1:2 or fewer 1:2 1:4
Mother/Baby: Labor and delivery Antepartum Postpartum Couplet care Well-baby nursery	1:2 (active labor) 1:4 (non-active labor) 1:6 (mothers) 1:4 (couplets) 1:8
Emergency (ER) Trauma Critical care Visits	1:1 1:2 1:4 + triage nurse
Hospital Services Medical/surgical Operating room Pediatrics Post-anesthesia Psychiatry Specialty (e.g., Oncology) Step-down Telemetry	1:5 1:1 1:4 1:2 1:6 1:4 or fewer 1:3 1:4

(Smith, 2007)

In addition to passing this law, several studies have focused on its success or lack thereof. While there has been no definitive evidence that mandatory staffing ratios are associated with less turnover, many studies have reported improved patient outcomes. In a 2015 systematic review and meta-analysis, the following conclusions were drawn:

• Higher RN staffing was associated with a lower hospital-related mortality rate. With each additional RN full-time equivalent per day, there was a 9% decrease in the mortality rate in the ICU, a 16% decrease in the mortality rate in the surgical unit setting, and a 6% decrease in the mortality rate in the medical unit setting.
• Higher RN staffing was associated with decreased healthcare-associated pneumonia, failure to rescue, and healthcare-associated bloodstream infections (Clendon & Gibbons, 2015).

Retention holds value at many levels, including improving the shortage of nurses across our country. Additionally, the retention of nurses within an organization allows nurses to become more comfortable with their work environment and facilitates an expert caregiver (Laschinger et al., 2016). Patricia Benner's theory of clinical competence stages identifies the importance of experts caring for our patient population. In her classic work, From Novice to Expert, Dr. Benner noted the need for professional growth at the different stages of a nurse's career. She further identified that nurses move through levels of competence driven by experiences within the clinical setting, and the movement from novice to expert is a process that takes an extensive amount of time. Retention of nurses can foster the development of these expert skills as the nurse is allowed to flourish and grow in their depth of knowledge and hone their nursing skills (Benner, 1982).

Several hospital systems increased their wages in 2019, intending to decrease costs. Since hospitals employ nearly six million people across the US, higher wages could seem incongruent with saving money, yet executives within some of the largest healthcare organizations in the country, including but not limited to Cleveland Clinic, Advocate Aurora Health, and Atrium Health, advocated to increase wages to encourage retention. While their balance sheet in the short term may not have shown cost-saving benefits, administration and other levels of leadership believe an increase in wages can improve efficiency and care quality for the patients, thus increasing their overall economic health in the long term. The rising wages for permanent nursing positions limit temporary agency hires that can cost a premium to the organization through retention. Despite the potential upside, smaller hospitals may have more difficulty increasing wages. However, with a broad look at long-term outcomes, the sacrifice to the budget must be considered for the positive collateral implications (Kacik, 2019; Weninger Henderson, 2020).

Healthy Nurse, Healthy Nation

Nurses give everything they have physically, mentally, and socially for their profession. It is no wonder burnout and a desire to leave the profession can occur. The ANA recognizes the need for nurses to care for themselves while caring for others. In 2017, the ANA launched the Healthy Nurse, Healthy Nation (HNHN) Grand Challenge. This initiative was designed to transform the health of the nation's 4 million RNs, allowing them to "live life to the fullest" just as they seek for their patients. Poor health outcomes for nurses are often due to long work hours, stress, and exposure to workplace hazards. Further, nurses who practice positive health habits can significantly influence their patients as role models, educators, and advocates (ANA, 2020).

The HNHN initiative begins with an online survey identifying the nurse's health, safety, or wellness risk. The question categories in this online survey include demographics, occupational health habits, employee and personal wellness, individual safety, and overall health. This survey takes about 15 minutes, and the user is guaranteed confidentiality. Both nursing students and nurses are encouraged to take the survey and join the path to living healthier. After all, we cannot care for others if our cup is empty (ANA, 2020).

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