Running

head: NURSE RETENTION

Nurse Retention
Jamie Wertz
Ferris State University

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Abstract

This paper examines the issue of nurse retention in the healthcare industry through
analysis of available research and statistics. Retention, shortage, and turnover are defined
and examined and recommendations for improvement are discussed utilizing supportive
theories. An assessment of the healthcare environments role in nurse retention is
examined through various study statistics, systems framework, policies, assumptions, and
quality and safety issues. The problems surrounding a decline in nurse retention are
outlined through root cause analysis, The American Nurses Association (ANA) Standards
of Practice, and the QSEN Institutes competencies, which provide guidelines to discuss
inferences, implications and consequences of nurse turnover, retention, and shortage.
Implementation of strategies such as offering incentives to reward achievement, selfscheduling, organizational and managerial support, and lowered nurse-to-patient ratios
will help increase job satisfaction as well as generate a healthy, safe, and quality
environment for nurses and patients. However, analysis of research in this paper shows
that the issue of nurse retention can be combated, but not completely resolved.

Keywords: nurse retention, turnover, shortage, incentives, job satisfaction, burnout,

quality, safety, theory

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Nurse Retention

There are many factors that lead to job turnover in nursing. High nursing turnover
rates and shortage lead to a decline in retention. Retaining staff requires careful
consideration and constant evaluation. Effective strategies for retention should provide
flexible solutions to meet individual needs (Currie & Hill, 2012). There is no one reason
or motive behind the intention to quit. Nurse turnover is expensive, troublesome and
threatens the quality of care and patient safety. According to Kovner, Brewer, Fatehi, and
Jun (2014), Total yearly organizational costs for new RN turnover is $1.4 to $2.1
billion (p. 64). Each nurse possesses his or her own reason behind leaving a job at some
point in his or her career. Work environment, workload, style of management, lack of
career development and lack of organizational support are all major contributing factors
of high intent to quit (Currie & Hill, 2012).
Important Definitions
Nursing shortage, turnover, and retention are interrelated concepts; it is almost
impossible to experience one concept without the other. Defining these concepts helps
understand the big picture of retention. Nurse turnover rate indicates an organizations
ability to prevent existing employees from voluntarily leaving (Hayes et al., 2011).
Nursing shortage is a lack of sufficient skilled nursing staff, as well as lack of sufficiently
educated staff that are able to care for patients (Morgan & Lynn, 2009). Nurse retention
is the ability to decrease nurse turnover through the continued employment of staff in an
organization. It is important to understand all three of these concepts in order to best
prepare a framework to secure retention so that nurses needs can be fulfilled, experience

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can guide great nursing practice for patients, and healthy work environments can generate
the best positive outcomes for patients and nurses alike.
Theory
Applying a theoretical framework can help generate a deeper understanding of
nurse retention. Theories help guide research and initiate insight into complex nursing
issues such as nursing turnover and retention. Two theoretical frameworks researched can
help provide additional awareness into why turnover happens frequently and why
retention is an important factor to consider and understand in nursing. Ericksons
modeling and role modeling theory draws concepts from other theories such as Maslows
hierarchy of needs theory, stating that basic needs drive behavior (Nurse Theory, 2013).
Helen Erickson: Modeling and Role Modeling Theory
Modeling and role modeling serve as a foundation for education and career
advancement. The roles of nursing are facilitation, nurturance, and unconditional
acceptance (Nursing Theory, 2013). Erickson's model also says the five goals of
nursing intervention are: to build trust, to promote the patient's positive orientation, to
promote the patient's control, to affirm and promote the patient's strengths, and to set
mutual, health-directed goals (Nursing Theory, 2013). This theory also emphasizes the
fact that when basic needs are unmet, this can lead to increased distress and illness. Lack
of growth-need satisfaction usually provides challenging anxiety and stimulates growth.
Need to know and fear of knowing are associated with meeting safety and security needs
(Nursing Theory, 2013).
Ericksons theory proposes that the mind, body, emotion, and spirit are all entities
that function to meet basic needs. People have an instinctual drive to be accepted and

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dependent on support systems throughout life, which also maintain a sense of

independence and freedom (Nursing Theory, 2013). Organizations can minimize
turnover by supporting their staff. Research shows that nurses choose to work for
organizations based on factors that cater to their specific needs and desires. Work
schedules, opportunities for growth within the organization, and commuting distance are
some primary factors that influence nurses decisions on where to work (Hunt, 2009).
Abraham Maslow: Hierarchy of Needs Theory
Maslows Hierarchy of Needs Theory states, when a need is met, it no longer
exists, and growth can occur. When needs are left unmet, a situation may be perceived as
a threat, leading to distress and illness (Nursing Theory, 2013). Maslow theorized
human needs through a pyramid concept. He described that humans seek to fulfill unmet
needs at the very basic level first before they can meet their needs at the top of the human
needs pyramid. Individuals have basic, or physiological, needs such as air, water, and
food before safety and security, love and belonging, self-esteem and self-actualization
can be realized in their life.
Nurses perceive their work environments differently. All work environments can
provide physiological needs, but not all can provide safety and security. If safety and
security are not met, then individuals cannot grow and experience love and belonging,
self-esteem and self-actualization in that working environment. This is when turnover
rates increase. This is also where Maslows theory can be utilized in order to better
recognize the needs nurses have in order to understand how to meet those needs. In doing
this, the individual can grow and prosper within the organization instead of leaving
because he or she feels valued, appreciated, and recognized. The strongest predictor of

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nurse job dissatisfaction and intent to leave is that of stress in the practice environment
(Paris & Terhaar, 2010).
Health Care Environment Assessment
Nurse retention is not an easy matter to resolve. Healthcare organizations need to
constantly be assessing the work environments of their nursing staff and the
consequences the environments have on turnover and retention rates. Retention is a
complex issue that cannot be taken carelessly. Evidence-based research can provide
insight into ways organizations can provide proper assessment, planning, communication,
implementation, and evaluation of what it takes to truly retain nursing staff. A systems
framework involving policies, assumptions, impacts of shortage in the workplace, and
quality and safety issues needs to be addressed to generate a background toward the cause
of the nurse retention problem in society today.
Team Nursing was a concept put into practice in the 1950s. It replaced the
concept of the functional model adapted during World War II, which was an initial
response to the need for less skilled staff to work along side the Registered Nurse so the
nurse could focus on more complex needs of the patient and less skilled staff could tend
to more routine tasks (Fairbrother, Jones & Rivas, 2010). The Team Nursing approachs
main objective was to integrate nurses with diverse qualities in skills, education, and
professional registration to work collaboratively and share the same responsibilities
(Fairbrother et al., 2010). This framework of shared leadership and team nursing proved
to increase job satisfaction and retention.
Research conducted just last year states that the national nursing turnover rate for
hospitals is 16.5%, up from 14.7% in 2012 (NSI Nursing Solutions, 2014). Likewise, the

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national turnover rate for bedside nursing also increased to 14.2% from 13.1% in 2012
(NSI Nursing Solutions, 2014). Medical-surgical nursing generated the highest turnover
rates in 2014. NSI Nursing Solutions (2014) reports that the turnover rate for medicalsurgical nurses is 24%. Further explanation through research is needed in order to
understand the effects of turnover and nursing shortage on healthcare organizations,
employees and patient satisfaction, and quality and safety.
Systems Framework
Organization policies. According to national research, The average cost of
turnover for a bedside RN ranges from $44,380 to $63,400 resulting in the average
hospital losing $4.21M - $6.02M (NSI Nursing Solutions, 2014). Research has proven
that poor job satisfaction increases turnover rates and decreases retention. According to
the NSI Nursing Solutions report (2014), An overwhelming majority (89.1%) of
organizations view retention as a key strategic imperative, it is not evident in
operational practice/planning and less than half (43.5%) have a formal retention strategy
(p.1).
Assumptions. Nurse retention may not come across as an important factor to
many in todays society because there is always discussion through various media outlets
about nursing shortage in healthcare environments. In order to understand this
assumption, nursing shortage must be further evaluated.
Nursing shortage. Turnover rates tend to be higher when unhappy nurses are
presented with more appealing job offers, as well as during the early years of a nurses
career (Kovner et al., 2014). Nursing shortage occurs when there is a greater demand
from the public than there is supply of nurses to assist in care. This could lead to

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dangerous outcomes in patient care if nurses are rushed through skills or medication
administration, stressed and have negative attitudes because of short-staffed shifts. The
continuous need for more nurses will soon impact retention if the shortage is not
addressed. The increased demand for nurses has been fueled by a growing elderly
population with a longer life expectancy, advances in medicine that require well educated
nurses, increased numbers of patients requiring care for chronic conditions, and
hospitalized patients with higher acuity levels (Egenes, 2012, p. 21).
Quality and safety issues. Many factors such as nursing fatigue, shortage, job
dissatisfaction, and burnout can have serious ramifications when it comes to quality and
safety in patient care.
Root Cause Analysis
The problem. There is lack of consistency in the definition of turnover
(Kovner et al., 2014). Fully comprehending the issue of turnover is a difficult and
complex issue.
Causes of the problem. There are many personal and organizational factors that
influence a reduction in retention rates.
Intention to quit. Job dissatisfaction and intent to leave a job can be predicted by
the amount of stress in the nurses practice environment. Patient acuity, work schedules,
poor physician-nurse interactions, new technology, staff shortages, unpredictable
workload or workflow, and the perception that care provided is unsafe are all foundations
of stress in the health care environments (Paris & Terhaar, 2010).
Employer influences. Although healthcare organizations are well aware of the
implications turnover and shortage has on cost and reputation, there is little being done

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today to contest this problem. One group that could have a positive influence in this
regard is nurse managers. Nurse managers must actively listen to nurses who express job
stress or are unhappy with their job (Wieck, Dols & Northam, 2009, p. 10). Nurse
managers are the leaders and influencers staff look to when issues arise. There is a
current need for organizations to implement policies and strategies to stabilize the
demand for nurses, improve working conditions such as improving staffing-to-patient
ratios, and raise wages and benefits (Wieck et al., 2009).
Personal decisions. Research has offered much insight into why nurses choose to
leave their jobs. Some reasons are voluntary, involuntary, or a combination of both. Job
satisfaction is a good indicator of whether or not a nurse will leave his or her job. The
main personal factors that drive turnover are job dissatisfaction, salaries, lack of time
with patients, lack of shared governance, lack of autonomy, lack of value or worth, lack
of respect from employers or managers, and poor communication (Perrine, 2009).
Inferences and Implications
Consequences of Nurse Turnover
The consequences nurse turnover can have on an organization can be very costly
and have negative implications. According to Hayes et al. (2012), turnover has proven
more costly to an organization because temporarily replacing nurses using overtime pay
or outside agency staff, as well as the cost of recruiting is expensive to do. In other
words, is much more inexpensive to retain nursing staff than it is to replace them.
Nursing shortage in the workplace generates negative attitudes. Nurses feel that
opportunities to engage in humanized care work comforting, educating, making a
difference and advocating are being systematically removed from their jobs as their

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work shifts to accommodate the shortage (Morgan & Lynn, 2009, p. 408). Consistent
turnover does not generate good patient outcomes. When turnover is high, the shortage of
nurses does not allow for the best patient-center care. When nurses feel rushed, they often
focus more on the tasks at hand and not the quality of care they are providing. When the
nurse-to-patient ratio is low, nurses simply do not have the time to focus on education,
serve as true advocates, or make differences in the lives of those they serve. Nursing is all
about comforting, educating, advocating and providing the best quality and safe care for
patients. When patients do not feel like a priority because staffing is low in relation to
high turnover, negative outcomes and attitudes transpire. Strategies to minimize turnover
will help to decrease negative attitudes and increase quality and safety in patient-centered
care.
Recommendations
Several factors that lead to turnover in the nursing profession can be addressed
and acted upon in order to increase retention. An ideal work environment for nurses
encompasses an organizational culture that embraces teamwork, promotes shared
governance, minimizes stressors, fosters group cohesion and autonomy, strives for a
manageable workload, and encourages supervisor support (Cohen et al., 2009, p. 314).
Increase Job Satisfaction
Increasing job satisfaction among nurses should be a priority for all health care
organizations. Paris and Terhaar (2010) state, Good communication, control over
practice, decision making at the bedside, teamwork and nurse empowerment are aspects
of the practice environment that increase satisfaction and decrease nurse turnover (p. 1).
Resolving the nursing shortage in healthcare environments can help increase job

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satisfaction. Nurses want to feel they are valued and trusted within their organization.
Research shows organizations that give nurses autonomy in their practice have better
retention rates. Cohen, Stuenkel & Nguyen (2009) state, The level of control and
autonomy that RNs can exert over their practice greatly affects their level of job
satisfaction (p. 313). Nurses want to feel supported and trusted by their organization,
management, and peers. Autonomy and support help generate positive working
environments, which then make nurses more willing to go above and beyond in their care
because their job satisfaction needs are met.
Support Staff
Healthcare organizations need to be engaged in constant change within their
environments. Environments for nurses are constantly changing as the medical field is
constantly evolving through evidence-based practice. Other factors such as increased
technology usage, continuing fluctuations of staff, management and leadership, increased
expectancies of additional tasks to be performed, as well as increased expectations of
nurses to pick up hours when shortages occur can lead to burnout.
Research indicates that organizations need to encourage nurses to leave their
responsibilities to take breaks during their shifts and some are reluctant to do so. In a
research study written by Lisa Groff Paris and Mary Terhaar (2010), the authors state,
Without a break, concentration and performance are impaired (p. 7). Nurses who take
time to remove themselves from stressful situations and heavy workloads are better able
to combat burnout and negative results in patient care. Being able to take a few minutes
for them to reevaluate and better prioritize time helps improve positive attitudes and
patient outcomes. Teamwork plays a vital role in nurses being able to take a few minutes

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to remove themselves from stressful situations. Nurses can hold each others phones, help
out on the floor with incomplete tasks, and can offer encouragement to peers in need.
Teamwork helps generate positive environments that give nurses the support they need to
get through tough situations. Organizations should also pay attention to desires nurses
request in order to stay, and use those desires as strategic incentives nurses to increase
retention rates.
It will also be important to encourage organizations to implement a retention
strategy for when turnover rates begin to increase, or when turnover is being predicted.
Having a plan in place will enable organizations to be more aware of their staffing needs
and prevent shortage from occurring. Listening to nursing staff and taking their concerns
and needs into consideration will enable nurses to feel valued and want to stay knowing
their voices are indeed heard.
Strategic Incentives
Nurses know what they want, and they arent willing to work in unsafe
environments that decrease quality of patient care. One incentive offered to all nurses is
not going to have a positive impact on retention because individuals are unique and rate
benefits or incentives differently. There is a generational consideration in todays
workforce that consists of Veterans (1922-1945), Baby Boomers (1946-1964),
Generation X (1965-1980), and Millenials (1981-2000), and each generation appreciates
incentives offered differently (Wieck et al., 2009). Understanding what incentives are
important within each generational group will be imperative to nurse retention and will
also show organizational support.

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Multiple factors throughout various research studies have identified incentives

nurses desire in order to increase retention rates and job satisfaction, which ultimately
increases patient safety and quality of care. These incentives include better benefits
packages and resources, mentorship programs, cohesive work environments with
respectful relationships among interdisciplinary teams, having nurse managers who listen
and support, less workload, vacation days and autonomy (Wieck et al., 2009). When it
comes down to what nurses want, they all seem to agree they desire a respectful working
environment that encourages respect and autonomy in a positive environment that
promotes the best safe and quality nursing care.
Other recommendations
Health care organizations can provide nursing staff with other strategies to better
working environments and improve job satisfaction. Some of these strategies could
include allowing nurses to be involved in interviewing new candidates for the unit,
posting positive comment cards around the unit that call attention to great work the team
members have done, awarding one nurse per month as employee of the month to
generate awareness for being a great team player and patient advocate, and also offering
incentives such as better parking spaces, money to buy a new uniform quarterly, or gift
cards to award those who stay year after year. These are all recommendations that can
enhance the working environment as they give nurses motive to work harder so they can
get their names recognized publicly or stay longer because they want to have more
compensation for their hard work.
Nursing Standards and Competencies
American Nurses Association (ANA)

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Standard 10: Quality of Practice. The registered nurse implements activities to

enhance quality of nursing practice and implements processes to remove or weaken
barriers within the organizations systems (ANA, 2010). An improvement in nurse
retention directly affects quality improvement and outcomes because high turnover rates
can have a negative effect on quality nursing practice.
Standard 11: Communication. The registered nurse uses various forms of
communication to continuously improve conflict (ANA, 2010). Nurse retention is
improved with job satisfaction. Strong communication skills and a positive, supportive
work environment promote workplace satisfaction.
Standard 12: Leadership. The registered nurse mentors colleagues for the
advancement of nursing practice, the profession, and quality health care (ANA, 2010,
p.55). Commitment to continuous, lifelong learning enables nurses to mentor peers and
generate trust that allows advancement in autonomy and competence.
Quality and Safety Education for Nurses (QSEN) Competencies
Teamwork & Collaboration. The QSEN definition of teamwork and collaboration
relates to interdisciplinary collaboration and shared decision making among a healthcare
team (Hunt, 2012, p. 2). Teamwork that emphasizes collective decision-making and
respect is important when factoring nurse retention goals and quality patient-centered
care.
Safety. QSENs safety competency focuses on preventing harm to patients (Hunt,
2012). Nurses who are positive role models and practice safe, quality care toward each
patient set safety standards that other nurses gravitate toward. Positive leaders in nursing
generate positive, inviting atmospheres that enable open communication and security

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among other nurses. Risk of harm to patients is minimized when security in a job is
achieved because security promotes retention. Nurses who do not feel secure and safe in
their job environment will most likely leave. When staffing is short, patient safety and
satisfaction is probable to be compromised, which decreases employee satisfaction.
Quality Improvement. The QSEN competency of quality improvement relates to
data collection, evaluation, and improvement of patient outcomes (Hunt, 2012, p. 2).
Consistently implement best practice in nursing turnover and nursing shortage prevention
in order to increase staff retention will generate positive outcomes in quality and safety of
patient care and job satisfaction.
Conclusion
Understanding nurse retention is an ongoing process. A variety of factors must be
considered in order to combat the issue, even though lifetime retention will never be
achieved among all nurses. Some nurses begin and end in the same position if they are
fortunate enough to find their first job to be their dream job. Nurses leave their current
jobs to further careers, change careers, relocate, enroll in furthering education, or because
they are dissatisfied, burnt out, or retiring.
Organizations and management who invest in their staff retain their staff longer
than those who do not. Clearly defining nursing roles and expectations enable nurses to
be autonomous and held accountable by their employer. Job turnover is an inevitable
factor of employment at some time in nurses careers and can never be fully resolved.
Successful strategies such as offering incentives, recognition of great work, career
development and advancement can help increase retention. A contented nursing work

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environment will help improve the quality of patient care, which is the most important
aspect of nursing.

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