Running head: LITERATURE REVIEW OF RETENTION AND TURNOVER 1

Literature Review of Retention and Turnover

LaTraesha Davis

Siena Heights University

LITERATURE REVIEW OF RETENTION AND TURNOVER 2

A Literature Review of Retention and Turnover

Retention and turnover has been a constant issue in the healthcare field. Many health care

facilities have encountered various nurses and certified nursing assistants not only working short

amount of times but, resigning both with and without notice. In return, the facility is forced to

recruit, train, and orientate new employees on a constant basis. When hiring new employees, the

facility is using valuable time and money that can be used in another area of the organization to

help patients receive the most adequate and efficient amount of care. There are many things

within an organization that requires financial assistance. However, ensuring that an organization

is efficiently staffed is among the most important. Staffing and turnover sometimes takes the

attention from other imperative things in a healthcare organization. It is imperative to both the

patients that are being cared for as well as the leaders of the facility to hire valuable hard

working employees who want stability in the position and dedicated to working for their

organization. Employee turnover not only affects the leaders and the entire organization, it also

affects the patients and continuity of care. It is imperative that patients are familiar and

comfortable with who is caring for them daily. It is also important to family members to be

familiar with the individuals that are caring for their loved ones. Knowing who is taking care of

their mom, dad or grandparents can give the patients family member a sense of peace and relief

knowing that the patient will be cared for to their standards. If a facility is constantly changing

staff, the family member may not want their loved one to remain at the facility due to instability.

A leader must ensure that they are attempting to do everything possible to retain his or her

employees for the organization to continue to run up to standards. In many situations, the leader

is not retaining their employees. Thus, the leader is continuously focused on hiring individuals

instead of other operations of the organization. Employees are constantly receiving positions in
LITERATURE REVIEW OF RETENTION AND TURNOVER 3

these organizations, but they are not holding positions for a reasonable amount of time.

Continuous hiring with multiple individuals coming in the organizations and resigning from

positions lead to a high turnover rate and a decrease in the number of employees being retained.

Outline

This literature review is to review the correlation between nurses and certified nursing

assistants and their unwillingness to commit to one facility and position. The research will help

look at scenarios, definitions, and situations in which high turnover and retention has occurred. It

will also evaluate turnover, retention, impact on patients and organizations, and methods to

efficiently reduce turnover and increase retention in healthcare organizations. Then, this

Literature Review will contain information based upon retention and turnover. It will evaluate

qualitative data derived from scholarly articles and journals. This information will be collected

from multiple sources ranging over the years. It will include reasons that turnover and retention

occurs, the effects turnover has on patients and facilities, and the financial strain that has been

placed on organizations in attempting to ensure that their organization constantly employs

individuals for his or her facility and organization. Lastly, this literature review will answer

questions derived from this topic to significantly understand and possibly help the issue of

retention and turnover within the healthcare field.

This literature review will focus on the following questions

What programs or incentives can help to retain employees of healthcare

organizations?

Why are so many nursing staff resigning from their positions?

How can turnover be reduced while increasing retention in the Health Care Field?

Literature Review
LITERATURE REVIEW OF RETENTION AND TURNOVER 4

Turnover

Turnover is when individuals are hired to replace those who have resigned or have

been terminated in an organization. It measures the ratio of individuals that are no

longer employed with the company to number that are currently with the company as a

total. Son (2015) states that in an environment in which people are in constant need of care,

workers are constantly leaving their positions. However, the patients are doubling and do not

have the adequate staff to ensure they are being cared for efficiently. This affects the other

employees as well as the patients and the patient care that needs to be performed. In nursing

facilities, it is imperative to keep in mind that the patients are priority. If there are no employees

in the organization to care for these patients, the purpose of the organization is not being filled. It

is the responsibility of the leader to ensure that he or she undergo the proper systems as it relates

to hiring and terminations. It is important to hire the correct individual for the position. One can

decide if they are choosing the right candidate for the position simply by asking the correct

questions. Son (2015) states the turnover rate for healthcare is 16.5% annually. The large

percentage of turnover costs healthcare facilities about $732,000 a year. $ 732,000 is a very

large sum of money to lose in only one calendar year. If the leaders of organizations took the

time and effort into finding the correct individuals for the job, organization will in turn save

money on constant new hires and orientation.

Impact of Employee Turnover

Employee turnover can lead to organizations experiencing unfortunate situations leading

to demise of the organization as an entity. Continuous employee turnover can lead to a decrease in

the quality of patient care. Turnover can result in the loss of patients in the organization by patients

leaving due to insufficient care or patients not coming in due to the reputation of the facility. If
LITERATURE REVIEW OF RETENTION AND TURNOVER 5

there is continuous turnover, the facility can experience financial strain by an increase contingent

staff costs. If there is a lack of regular staff, the organization will be more likely to spend more

money staffing contingent staff to care for the patients. Turnover can cause more medical staff

turnover by not having enough staff and the current staff experiencing stress and burn out. When

nursing individuals are stresses and burned out, they begin to make more accidents. Accidents in

the nursing field can be identified as medication errors, confusion between patients, and errors in

doctors errors. Lastly, the impact of employee turnover can be affected by absenteeism rates. If

individuals are constantly working without the proper number of staff, they will become

unmotivated to work leading to more absenteeism and attendance issues (Hunt, 2009, p. 2).

Retention

In the healthcare field, nurses play a vital role in the financial aspect of many healthcare

organizations. However, organizations are experiencing more challenges in their ability retain

nursing staff (Hunt, 2009, p. 9). It is imperative for leaders to understand the financial struggles

that may occur if their employees are not retained. Izzo and Withers (2017) state Over the past

year that shortage of staff has received increased attention. Leaders have been more aware of

their lack of staff and how they can ensure they retain employees to efficiently care for their

patients. This increased attention could come from complaints from patients, complaints from

staff members, and going through basic reports. This attention could also come from staffing

issues and budgeting. Cooley (2016) states Before a leader can create effective retention

techniques, they must first understand and attempt to fix any unresolved issues that are occurring

within the organization. Leaders can attempt to fixed unresolved issues by implementing

monthly meetings between the staff addressing their issues. Issues can also be addressed by

ensuring that Human Resources is performing exit interviews with individuals that have resigned
LITERATURE REVIEW OF RETENTION AND TURNOVER 6

from their positions. Then, the leader must come up with ways to fix the problems that the staff

addressed by evaluating each issue and coming up with resolutions, new policies and procedures.

Once the issues within the organization are addressed and reasonably fixed, the leader should

then attempt to build a solid foundation among their employees and an environment in which the

employees want to be a part of for a stable amount of time. There are several strategies and

techniques that leaders can use to help retain both their current employees and their future

employees. However, the most important strategy is to listen. If leaders do not listen to the needs

of their employees or the important things that are happening in their organization, they will

continuously lose valuable employees.

Why are Nursing staff resigning From Positions?

Feeling overworked; not being able to manage workload

Lack of role clarity and low sense of control over job performance

Not feeling respected and valued for contributions and capabilities

Poor communication with management around critical issues affecting work

Not receiving recognition or rewards for accomplishments

Lack of career opportunities and support for career development

Lack of trust and effective collaboration with coworkers

Work schedule does not match job needs or expectations

Work is too physically demanding (Hunt, 2009, p. 5)

Many individuals love their position within their organization. However,

employees that are driven and educated often strive for higher positions in their company. If

there is no room for advancement in their current organization, employees will most likely resign

and find a new position that will benefit them in the future.
LITERATURE REVIEW OF RETENTION AND TURNOVER 7

Unappreciated

When employees feel that they are unappreciated by their leader, they become

unmotivated. When individuals are unmotivated, they tend to begin to perform below standards

and receive disciplines until they are terminated or decided to work for another organization in

which they feel will appreciate the work that they perform.

Understaffed

When staffing issues are a constant issue, it can cause stress on a nursing professional

(Johnson 2013). Leaders must understand the affect that not having enough staff has on the

nurses that want to retain their position with the organization. It is hard on a persons body and

mind when they are being given more work than they can handle. When floor staff is

continuously subjected to working short, they tend to begin to consider working at other

organizations and resigning from their position. In turn, the building loses more staff and patient

care declines.

Approximately 30% of employees stated that they were very likely to look for work outside

of their organization in 2010. Experts expected job satisfaction rates would be even lower this

year due to company layoffs and pay cuts that several employees faced during the period of

recession. However, job satisfaction is still dropping at a steady rate. Of the individuals

surveyed, 28% indicated they were less satisfied with their jobs given the economic climate in

2010. This was a relative increase of 6% from the individuals that were studied in the year 2009

(Hobbs, 2010).

In the healthcare field, there are many career opportunities and many different organizations

that will hire individuals. With there being so many opportunities, healthcare staff is more likely

to look for employment in other areas when they have reason. Leaders of organizations must
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ensure that they are giving their employees the opportunity to advance in the company, showing

that they appreciate their employees, and that they are trying their hardest to ensure that they are

retaining their employees by implementing multiple techniques to help increase retention.

Effective Techniques and Strategies

In every organization, retaining good worker is critical to the United States Healthcare

Industry. If employers ensure that they treat their employees as valued contributors to the

health care environment, they will be more likely to stay in their position within the company.

These employees will tend to feel appreciated by their organization and feel more connected as

an employee. (Gering and Connor 2002) Valued contributors are individuals that contribute their

input and suggestions to their leaders to help the organizations overall operations. It is important

to listen to the employees of an organization because they are working in the areas that the

leaders constantly speak about; the employees sometimes know what it best for the organization.

If employees were given the opportunity, they could possibly help the organization grow with

their thoughts and ideas about certain things.

In September 2000, the HCA and CEO of the Company Mid America implemented a

retention plan that resulting in the decrease of the companys turnover rate from 30 percent to

19.2 percent. This HCA and CEO implemented several strategies one by one to ensure that each

strategy was efficient. They were both very dedicated to the company and the employees that

were a part of the company. After implementing these strategies, the companys retention and

turnover was reduced at a very large rate. The CEO and leader of Mid America implemented a

plan to ensure that he or she retained their employees at a much higher rate than previously. The

leader of that company ensured that he or she came up with a strategic plan to keep their

employees with the company. There are several strategies that can be implemented in a work
LITERATURE REVIEW OF RETENTION AND TURNOVER 9

environment. These strategies are known to be effective and has helped many leaders decrease

the high turnover rates in their healthcare organization. (Gering and Connor, 2002)

Strategies That Can Help Increase Employee Retention

Tuition Reimbursement

Sign- on bonuses

Referral Bonus

Monthly staffing meetings to address concerns

Staff appreciation

Opportunities to Grow within the company

Tuition Reimbursement

Tuition reimbursement is a program that employers use to help pay for their employees

education. In many instances, the employee is instructed to pay for their tuition and in turn the

organization will reimburse them for their payment up to a certain amount each year. By

assisting their employees retrieve a degree, their employees will be able to receive higher paying

positions within the company. The employees will feel as if their employer believes in them

enough to help further their education.

Landes (2012) states When an employer agrees to pay for its employees education, it is

making an investment for those employees. The degree should help the employee perform

better in some capacity. There is a risk that the employee may leave the company after their

degree is complete. For example, an employee may receive tuition assistance from their

employer and choose to look for other employment after obtaining their degree. However, if the

organization is one that promotes within, it will help the employee have the requirements for a
LITERATURE REVIEW OF RETENTION AND TURNOVER 10

better position but still an employee. These employees will be more marketable and able to

obtain a better position in the company without going to an outside source.

Another way to retain employees is to implement tuition reimbursement to employees

after they have signed an agreement stating that they will stay employed with the company for a

certain amount of years if their education is paid for by the company. In signing this agreement,

the employee knows that they will receive an education, and the employer knows that they have

a definite employee for the designated amount of years. This signed agreement will help the

employer retain that employee and ensure that they are not losing more money by ensuring that

the employee has received a free education, then later decided to go on to another organization.

Sign-on Bonuses

A sign on bonus is a designated promised to the employee upon hire. Sign- on bonuses

are usually dispersed over a certain amount of time. The sole purpose of a sign-on bonus is to

entice applicants to accept a job offer from the organization. Sign- on bonuses are implemented

to make organizations look more enticing to potential applicants instead of other organizations

(Heathfield, 2016). If an employee is promised a sign-on bonus, they must agree to the terms and

conditions given to them upon employment. Usually, employees are required to stay with the

company for at least one full year receiving their sign-on bonus within the first six months of

employment. If the employee does not stay with the company for the designated amount of time,

they will be responsible for paying the full amount back to the company. In many situations,

some individuals may only stay at the company for the required amount of time, then decide to

find other employment. However, sign on bonuses still ensure that the company has retained that

employee for a longer amount of time than they could have. This also gives Human Resources a

timeline to potentially begin looking for other applicants for the position.
LITERATURE REVIEW OF RETENTION AND TURNOVER 11

Referral Bonus

A referral bonus is an incentive that organizations put in place to bring more prospective

employees to their organization. Bika (2017) states referred candidates have to work for the

company for more than a couple of months before referrers get their full reward.

The referral bonus is usually only obtainable for staff that is paid hourly. Referral bonuses are

usually put in place when the applicant flow for the open positions is very low. It helps the

Hiring Manager seek potential employees using the referral of a current employee. To help

increase retention, employer sets certain standards to successfully implement a referral bonus.

According to a 2014 World at Work survey, approximately 71 percent of companies have paid

their employee referral bonus in full after a complete employment period between 45 days and

six months for both the current employee and the referred employee (Bika, 2017)

Standards and Regulations to Implement Referral Bonus

1. Employees referral must receive a position with the company and stay employed

for at least 6 months.

2. Employee must remain employed at the organization to receive the referral bonus

money.

3. Half of the funds will be dispersed after 90 days of the referrals employment with

the company. The remaining funds will be dispersed after 6 months of

employment.

4. The employees referral must not be a family member.

Implementation of the referral bonus helps the employer retain both their current

employee and their employees referral for a certain amount of time. If the regulations that are

agreed upon have not been followed, the employee can possibly owe back all the money that
LITERATURE REVIEW OF RETENTION AND TURNOVER 12

they were given by the organization. When sign-on bonuses are implemented, they are given to

make the company more marketable, and retain employees for a certain amount of time.

Monthly Staffing Meetings to Address Concerns

In the healthcare field, communication is noted to be one of the most important aspects of

patient care and employee retention. In some instances, communication can be misunderstood,

confused, or not relaying in a proper manner resulting in multiple issues for both patients and

employees in an organization (Floyd, 2016). Communication between employees and employers

is vital in retaining employees. Implementing monthly staff meetings to listen to the comments

and concerns of other employees shows that the organization sincerely cares about their

employees thoughts, feelings and concerns as it regards to their employment with the company.

Employees want to feel like they are important. In monthly staff meetings, the leaders of the

organization listen, respond and ensure that they implement policies and procedures to help their

employees overall success in the organization. Staff meetings can help employees effectively

communicate, ensure that they are understanding certain policies, and help them understand

appropriate work systems.

Staff Appreciation

In being a leader, one must retain their employees by showing them that they are

appreciated. Employees that feel appreciated are more likely to stay in a position with their

company. They are more likely to understand different processes in their organization by

listening to what their leader must say. Appreciated employees are more likely to listen,

motivate, and retain their positions in their health care organization and place of employment.

More than 80 percent of employees say theyre motivated to work harder when their boss

shows appreciation for their work. The 80 percent of employees were compared to less than 40
LITERATURE REVIEW OF RETENTION AND TURNOVER 13

percent, who are inspired to work harder when their boss is demanding or because they fear

losing their job. (Brooks, 2014)

This statement means that over half of the individuals in the working environment agreed

that they are more motivated when their boss shows how much they appreciated them for being a

part of the organization. Under half of individuals have expressed that they are motivated due to

fear. In an organization, the leader should want his or her employees to be proud to be a part of

their organization. The leader should also ensure that his or her employees are in an organization

where the employees are comfortable in their position due to a motivation leader and not a

dominating leader. Fear can lead to turnover. If an employee is always afraid to be terminated or

afraid that they will be disciplined, they will begin to look for an organization that does not

implement scare tactics on their employees. It is important that an individual can come in and

perform their job duties without constant fear of their leader.

Whether an individual is leading an organization or is an employee of the organization,

he or she wants to feel as if they are appreciated in their position. If an organization never

acknowledges their employees for working effectively or even putting their best foot

forward, employees will be less likely to remain an employee with that company.

Examples of Staff Appreciation

Employee of The Month/ Employee of The Year

CENA/ Nurses week Celebrations

Pizza Parties

Gift Cards/ Thank you cards for great work

Verbal appreciation

Thank you notes

LITERATURE REVIEW OF RETENTION AND TURNOVER 14

Thank you notes sent to the staff shows that they are appreciated in their current position.

They are not required to be long and drawn out, but precise and straight to the point. Thank

you notes describe the what good deed was observed, the positive impact it had on the

operation, and why it was appreciated by the leader and organization (George, 2011).

Verbal Appreciation

Verbal encouragement and appreciation can help rid of organizations of absenteeism and

tardiness. It can help encourage employees to increase their work performance, more engaged in

their daily duties, and increase the employees production. Lastly, verbal appreciation can help

leaders decrease turnover in organizations (Weigel, 2011)

Opportunities to Grow Within a Company

If an individual is employed in a company that promotes internal growth, they are more

likely to be retained in that company especially when the company is willing to help their

employees. Although the organization may be losing the individual from their current position,

they are still retaining their employee. Promotions within the company also show that the

organization values and believes in their employee enough to help them have a better career,

opportunity and possibly higher income.

Businesses with high employee retention rates help employees visualize upward

movement. They invest in training and mentoring programs that enables workers to show their

skills and they enable employees to recognize hard work will pay off by promoting whenever

possible from within the organization (Griffith, 2016).

LITERATURE REVIEW OF RETENTION AND TURNOVER 15

To effectively keep employees interested in their organization and avoid them looking in

to other companies, the leader must show employees that they are valued and they would like to

offer higher positions in which their employees have the minimum requirements.

Opposing Argument

Many argue that increasing retention is not an important subject as it relates to employees

and organization that they work for (Picoult, 2017). Just because an employee is retained does

not guarantee the employee is happy in their position. The opposition believes that instead of

basing focus on whether the employee stays at the organization, the focus should be to ensure

that the employee is engaged, satisfied and motivated. It is vital in any organization to ensure

that the employees remain full of happiness while they are in their positions. It is also important

to focus on employees being constantly motivated to do well in their current position (Picoult,

2017). However, ensuring that employees are happy and motivated in their organization leads

right back to the employees staying in their positions for long periods of time. If leaders ensure

that their employees are happy in their position, the employees will not have a reason to resign or

look for other places of employment. Employee happiness is very important. However, in a large

organization or in any organization, it is impossible to make everyone happy. Also, it is

imperative that both leaders and employees understand that they are in the organization to ensure

that the patients are well taken care of. The patients happiness is the most important. To ensure

that the patients are cared for efficiently, leaders must focus on increasing retention and

decreasing turnover.

Conclusion

Implementing a highly effective strategic plan to increase employee retention is

imperative in the Healthcare field. Leaders must understand that to ensure patients are receiving
LITERATURE REVIEW OF RETENTION AND TURNOVER 16

exceptional care during this difficult time in their lives, they must have individuals in the

organization to care for them in the manner that they deserve. Patient to caregiver ratio is the

determinant in how high the quality of care will be. If individuals are remaining retained and

stable in their nursing care positions, the patients are more likely to experience high levels of

quality care. In the Healthcare field, turnover and retention not only affects the patients. It also

affects the organization financially. Nursing turnover and the shortage of healthcare professionals

in organizations represent one of the top financial crises that healthcare organizations face in the

United States (Hunt, 2009, p. 9). Effective strategies and techniques must be first thought upon.

Next, these strategies to decrease turnover must be presented to other leaders to ensure that they

are reasonable and can be accommodated financially by the organization. After financial

planning, the organization must ensure that the team members are aware of the new strategies

that will be put in place. Next, the leaders must implement each strategy, technique and policy.

Lastly, the leaders must observe the effectiveness of the implementations and change as needed.

An organization that is aware of how to retain their employees in successful organizations.

Although, there are some situations in which leaders will be unable to make their employees

completely happy, there are many things that leaders can do to ensure that their employees are

happy and retained for as long as possible. Retention and turnover has been a continuous issue

within the healthcare field for several years. In implementing the strategies and techniques listed

within this research paper, this will not ensure that turnover and retention does not happen again

in life. However, these methods will assist in decreasing turnover and increasing retention at a

moderate rate. In the end, ensuring that patients are being cared for effectively is the most

important aspect of healthcare. Patients are in these organizations to receive the care and help

that they are unable to receive at their home or from their loved ones. To ensure that each patient
LITERATURE REVIEW OF RETENTION AND TURNOVER 17

is receiving efficient care, leaders must ensure that they are taking the proper efforts to retain

each employee that is employed in their organization.

LITERATURE REVIEW OF RETENTION AND TURNOVER 18

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