Nursing retention and turnover impacts health care on many facets; pressures are increasing to provide quality care in a cost-effective manner to a satisfied patient with an engaged staff as defined by the Quadruple Aim (Bowles, Batcheller, Adams, Zimmerman, & Pappas, 2019). Turnover is costly both financially and emotionally. The monetary costs associated with staff turnover are related to recruiting and orienting nurses (Kovner, Brewer, Fatchi, & Jun, 2014; NSI Nursing Solutions, 2019). Turnover also affects staff's satisfaction and disturbs productivity of nursing, frequently causing the hospital to turn patients away due to inadequate staffing numbers, which decreases revenues (Vardamann, Rogers, & Marler, 2018). Insufficient staffing leaves nurses feeling disenfranchised, increases stress, and impacts job satisfaction, causing many nurses to leave the profession as they cannot care appropriately for their patients (Aiken et al., 2017; Spence Laschinger & Fida, 2015). Buerhaus (2017) has predicted the profession will experience a shortage of nurses in the next 10 years. The supply of nurses over the next decade is uncertain due to changes in age of nursing population, economy, interest in nursing, and availability of nursing faculty (American Association of Colleges of Nursing, 2019).
Because of the shrinking pool of available nurses, it is especially important to retain staff nurses within the organization/unit (Hollis, 2019). Retention is a process that should be started before a staff nurse is hired and needs to be ongoing (Ziebert et al., 2016). Nurse managers are critical to promoting job satisfaction and diminishing turnover of nurses working in their area. Although some factors that contribute to turnover are not in the control of managers, there are many actions that can be taken by them (Boamah, Read, & Spence Laschinger, 2017; Brunges & Foley-Brinza, 2014; Haid et al., 1993). Therefore, the purpose of this evidence-based practice guideline is to provide strategies for first line nurse managers in various health care settings to use in enhancing job satisfaction and decreasing turnover of staff nurses. The goal of this guideline is to present strategies that will retain experienced nurses beyond compensation issues.
Factors Influencing Job Satisfaction
Studies have found that turnover has resulted in many nurses leaving the profession, making it costly for health care agencies. Among the factors studied, job satisfaction has been widely recognized as a critical factor affecting retention and turnover (Bolima, 2015; Cotton & Tuttle, 1986; Dilig-Ruiz et al., 2018; Ellenbecker, Porell, Samia, Byleckie, & Milburn, 2008; Gillet et al., 2018; Gregory, Way, Lefort, Barrett, & Parfrey, 2007; Halter et al., 2017; Hom & Griffeth, 1995; Irvine & Evans, 1995; Kovner et al., 2016; Letvak & Buck, 2008; Leveck & Jones, 1996; Li et al., 2018; Lucas, Atwood, & Hagaman, 1993; Mueller & Price, 1990; Nei, Snyder, & Litwiller, 2015; Portoghese, Galletta, Battistelli, & Leiter, 2015; Price, 2001; Price & Mueller, 1981; Saber, 2014; Sourdif, 2004; Tang, 2005, 2008; Tourangeau & Cranley, 2006; Yang & Kim, 2016). Job satisfaction is a complex phenomenon. Although many factors have been associated with job satisfaction, no one single factor can stand alone as the major explanatory variable (Blegen, 1993; Hinshaw & Atwood, 1983). The following factors, which are grouped into four categories, are directly related to nurses' job satisfaction in multiple settings:
- Work environment: includes factors such as job stress or burnout, autonomy, group cohesions or peer support, recognition or feedback, routinization of work, and pay.
- Nurses' characteristics or mobility factors: include race/ethnicity, age, marital status, dispositional affectivity, nurse experience or tenure, educational level, amount of time worked, shift type/length, clinical service and type of unit, availability of alternative jobs in the community, and organizational commitment or loyalty.
- Organization characteristics: factors such as distributive justice or fairness, promotion or advancement opportunity, professionalization, or career commitment, and value congruence.
- Nurse manager characteristics: include communication with supervisors and management/leadership support, and management/leadership style.
The first step toward improving nurse retention is to take an initial measurement of retention and turnover. Essential areas for assessment of nurse retention and turnover include: (a) nurse demographic information; (b) turnover rate; (c) job satisfaction; and (d) intent to stay.
Demographic information provides a quick reference for nurse managers to understand their staff nurses. Demographic data (e.g., age, education, marital status, number of children, clinical experience, employment status, stress levels) may be obtained through survey, interview, or review of nurses' personnel records or human resource electronic database.
There are several possible ways for managers to determine the level of job satisfaction of their staff nurses. For example, personal interviews, group meetings, or questionnaires can be used. In addition, there are numerous existing tools available for measuring job satisfaction (Bolima, 2015; Cicolini, Comparcini, & Simonetti, 2014; Dilig-Ruiz et al., 2018; Li et al., 2018; Saber, 2014). Among them, the Price Job Satisfaction Scale (Table A, available in the online version of this article) is one of the most common tools used to measure staff nurses' attitudes toward their job (Chu, 2001; Price, 2001; Tang, 2005, 2008).
Price Job Satisfaction Scale
Purpose: To assess the overall satisfaction of staff nurses with their current job.
Instructions: For each nurse receiving the Nurse Retention guideline, please have s/he complete the Price Job Satisfaction Scale. This scale should be completed at baseline (before the nurse retention guideline is initiated) and on a regular basis, such as every 6 months.
Scoring: Each item is scored from 1 to 5, with “strongly disagree” scored as 1 and “strongly agree” as 5. Scores are summed and divided by the number of items to attain a mean. A higher score indicates higher level of satisfaction.
Directions: Please circle the number that best reflects your response to the following statements about your overall satisfaction with your current job.
Intent to Stay
It is important to detect staff nurses' perceptions of likelihood of staying in their current job. McCain's Intent to Stay Scale (Table B, available in the online version of this article) is one way of understanding staff nurses' perceptions (Al-Hamdan, Nussera, & Masa'deh, 2016; McCloskey, 1990; Tang, 2005, 2008).
McCain's Intent to Stay Scale (A 5-Item Subscale from McCain's Behavioral Commitment Scale)
Purpose: To assess the staff nurse's perception of the likelihood to stay in her or his current job.
Instructions: For each nurse receiving the nurse retention guideline, please have the nurse complete the McCain's Intent to Stay Scale. This scale should be completed at baseline (before guideline is initiated) and on a 6-month basis.
Scoring: Each item is scored from 1 “strongly disagree” to 5 “strongly agree”. Scores are summed and divided by the number of items to attain a mean. A higher score indicated higher intent to stay.
Directions: Please circle the number that best reflects your response to each statement.
Description of the Practice
After assessing the level of job satisfaction and analyzing the turnover data, the next step is to implement appropriate interventions. Despite a large body of research on the phenomena of retention and turnover, empirically supported interventions in this area are limited (Hom & Griffeth, 1995; Kang, Kim, & Yun, 2017; Tullar et al., 2016; Wilson, 2006). Exhaustive literature reviews have shown that nurse retention and turnover are caused by many interacting factors. These complex relationships have resulted in no best or quickest way to fix turnover problems. Recommendations for interventions to address nurse retention and turnover are based mostly on correlational descriptive studies, expert opinions, and informal observations. Although the supportive evidence is not conclusive, the wealth of information and suggestions found in the literature can be useful. Interventions are focused on three areas: (a) autonomy; (b) recognition; and (c) communication. Reasons for focusing on these areas are two-fold. First, these factors are identified as having significance in influencing job satisfaction. Second, these interventions are more controllable and within the purview of first line nurse managers because they are not financial approaches.
Enhance Nurses' Autonomy
Autonomy is a job characteristic that encourages and promotes staff nurses' sense of control over their job, including the ability to make decisions about daily nursing practices or increases in vertical movement, or the ability of employees to perform their job independently by creating clinical guidelines to enhance decision making (Barto, 2019; Palmer, 2014). Nurses value autonomy as an important job satisfier (Laschinger & Finegan, 2005; McCloskey, 1990; Nei et al., 2015). Nurses favor working in a participative environment as opposed to one that is autocratic (Lucas, 1991; Volk & Lucas, 1991). Participative management/transformational leadership is characterized by a caring, supporting, and encouraging environment with opportunities for staff participation and involvement in decision making related to professional practice. Nurse managers should value their staff and have effective communication skills to promote shared control and participation in decision making of their staff nurses. However, it is important for nurse managers to understand and consider individual differences among their staff members. The following are strategies to enhance nurses' autonomy.
Allow Staff Nurses to Have More Control Over Their Work. Nurses should have more control and make their own decisions related to nursing practice and managing caseload (Aiken & Cheung, 2008; Al-Hamdan, Smadi, Ahmad, Bawadi, & Mitchell, 2019; American Organization of Nurse Executives [AONE], 2000; Breau & Reheaume, 2014; Choi, Goh, Adam, & Tan, 2016; Collins et al., 2000; Déry, Clarke, D'Amour, & Blais, 2018; Dilig-Ruiz et al., 2018; González-Gancedo, Fernádez-Martinez, & Rodríguez-Borrego, 2019; Han, Trinkoff, & Gurses, 2015; Kovner et al., 2016; Kretzschmer et al., 2017; Li et al., 2018; Moneke & Umeh, 2014; Morsaini, Bagnasco, & Sasso, 2017; Nei et al., 2015). For example, nurse mangers can encourage staff nurses to have input regarding nurse–patient ratio via mechanisms, such as admissions processes, staffing-level decisions, decisions to open or close units or beds in the health care setting, and determination of unit size. In addition, nurse mangers can involve staff nurses in decisions related to pulling staff nurses or rotation of nurses to different units or have staff nurses decide on substitution among staff nurses and between nurses and auxiliary personnel (Li et al., 2018; Munnangi, Dupiton, Boutin, & Angus, 2018).
In addition, nurse mangers can delegate responsibility to staff nurses for unit schedules. This delegation of responsibility will result in more flexible scheduling and control over working shifts (American Nurses' Association, 1983; AONE, 2000; Brunges & Foley-Brinza, 2014; González-Gancedo et al., 2019; Hinshaw, Smeltzer, & Atwood, 1987; Vermeir, Downs, et al., 2018; Wilson, Squires, Widger, Cranley, & Tourangeau, 2008). Furthermore, nurse mangers can support staff nurses in balancing family and work lives, such as allowing time to take a class or meet family needs, by permitting flexible scheduling (AONE, 2000; Dawson, Stasa, Roche, Homer, & Duffield, 2014; Dilig-Ruiz et al., 2018). In addition, it is important that nurse managers provide staff nurses with some control over how their work time is spent. For example, build time into their schedule to complete paper work/computer charting or attend patient care conference or council meetings (Noblet et al., 2017).
Increase Involvement of Staff Nurses in Decision Making That Affects Nursing Practice. One example is to develop task forces or committees to facilitate staff nurses' participation, such as quality improvement committees, research utilization committees, nurse retention and recruitment committees, or financial planning committees (Goode et al., 2005; Hinshaw et al., 1987; Lageson, 2004). Another example is to use and value staff nurses' input and expertise (e.g., ask staff to interview and provide input on hiring a new staff nurse or nursing aide, consult staff nurses about patient care issues, have nurses lead patient care conferences) (AONE, 2000; Breau & Reheaume, 2014; Déry et al., 2017; Hinshaw et al., 1987; Lucas, 1991). A further example is to create a supporting environment allowing staff nurses the opportunity, freedom, and guidance necessary to participate in unit activities. This can be done by giving staff nurses full accountability to plan for nurses' activity during the week or give staff nurses paid time off to conduct a research utilization project (Cummings et al., 2008; Force, 2005). A final example is to encourage staff nurses to make decisions about nursing practices, such as formulating procedures and policies and implementing changes in the unit. If staff nurses perceive their voices are valued, they will become more involved (Boamah et al., 2017; Breau & Reheaume, 2014; Choi et al., 2016).
Promote Shared Governance. Promoting shared governance as it contributes to nurses' autonomy leads to nurses' job satisfaction (AONE, 2000; Brunges & Foley-Brinza, 2014; Force, 2005; Hess, 2004; Jones, Stasiowski, Simons, Boyd, & Lucas, 1993; Kovner et al., 2016; Moneke & Umeh, 2014). Shared governance provides an environment and structure that enhances professional nursing practice and empowers nurses to make decisions in practice. Promotion of shared governance can be done through several mechanisms.
First, provide means for nurses to express points of view and preferences. This can be done by conducting surveys, using group meetings, or having one-on-one interviews with staff members (AONE, 2000; Khowaja, Merchant, & Hirani, 2005). Second, delegate authority to unit councils, such as education, quality improvement, and practice councils, for important unit activities. For example, the issues of patient care standards, nurses' activity during the week, management procedures, protocol development, and implementing and monitoring quality improvement activities can be decided by staff nurses who participate in the unit councils (Hess, 2004; Specht, 1996; Wilson et al., 2008). Third, show a supportive attitude over shared governance to facilitate the implementation of the model. For instance, recognize and praise nurses' achievement on a group decision (Specht, 1996). Fourth, schedule meeting times wisely so they will not interfere too much with nurses' time for patient care activities (AONE, 2000). Ask staff nurses' input for agendas, circulate the agenda and/or send out information prior to the meeting, and ask for responses. Finally, evaluate staff nurses' perception of shared governance on a regular basis (Specht, 1996).
Demonstrate Recognition and Respect to Nurses
Recognition is defined as “head nurse behaviors that acknowledge, with a show of appreciation, staff nurse performance and achievement” (Blegen et al., 1992, p. 58). Staff nurses want their achievements to be recognized. Consistent recognition of efforts by management and feeling valued and appreciated by management will support the effort of nurse retention (Abou Hashish, 2017; AONE, 2000; Blegen et al., 1992; Goode & Blegen, 1993; Kovner et al., 2016; Morsiani et al., 2017; Munnangi et al., 2018; Perlo et al., 2017; Sveinsdóttir, Ragnarsdóttir, & Blöndal, 2015). Recognition can be formal, such as written acknowledgement, or informal, such as conversation during day-to-day activities. The following strategies may be used.
Provide Verbal Acknowledgement and Feedback to Staff Nurses. Nurse managers should take time to visit patient care areas and socialize with staff members with expressions of appreciation, such as “Thank you for working extra hours,” “You are a very valuable member of our team,” or “I'm proud of the work you did” (AONE, 2000; Blegen et al., 1992; Force, 2005; Goode & Blegen, 1993; Wagner, 2006). Managers can give private verbal feedback for staff nurses' achievements, such as obtaining a Bachelor's degree, receiving nursing certification in their specialty, winning an award, publishing an article, or finishing a specialty course (Blegen et al., 1992; Goode & Blegen, 1993). Immediate and private oral feedback can be provided for staff nurses' outstanding job performance, such as handling a critical patient care situation well or solving a conflict between other staff members (Blegen et al., 1992; Goode & Blegen, 1993).
Provide Written Acknowledgement and Feedback to Staff Nurses. Handwrite thank-you notes to staff nurses for appreciation of their hard work or any outstanding performance, for example, taking an extra shift for a coworker or participating in committee meetings (AONE, 2000; Aronson, 2005; Blegen et al., 1992; Force, 2005; Goode & Blegen, 1993; Wagner, 2006). Send a copy of any letters regarding the outstanding performance of the staff nurse to the nurse executive and place a copy in the staff nurse's personnel file (Blegen et al., 1992; Goode & Blegen, 1993). Provide a copy of patient or family complimentary evaluations to staff nurses and nurse executives (Blegen et al., 1992; Goode & Blegen, 1993). Write a card to staff nurses in remembrance of their special days, such as Nurse's Week, birthdays, anniversaries, graduation, or other events. All of these strategies provide great recognition for staff nurses.
Acknowledge the Performance and Achievements of Staff Nurses Publicly. One example is to create a form that allows patients/families, managers, and staff nurses to nominate a nurse for outstanding job performance (AONE, 2000; Brunges & Foley-Brinza, 2014; Haid et al., 1993). In addition, congratulate the outstanding performance and achievements of staff nurses in front of their peers or others (Blegen et al., 1992; Goode & Blegen, 1993). Finally, post complimentary patient evaluations for individual staff nurses on the bulletin board or in the agency newsletter (Blegen, 1993; Blegen et al., 1992).
Provide Opportunity for Staff Nurses' Professional Growth, Development, and Participation. Encourage staff nurse participation in leadership roles, such as in shared governance or to serve as resource nurses for unit peers (Brunges & Foley-Brinza, 2014; Force, 2005). Another strategy is to provide support and assistance toward professional and career goals of staff nurses. For example, help staff develop specialty expertise, such as pain management, or help them find a school or college to pursue a higher nursing degree (Al-Hamdan et al., 2019; Blegen et al., 1992; Goode & Blegen, 1993; Hinshaw et al., 1987; Nowrouzi et al., 2016; Wilson, 2005). Finally, encourage collaborative relationships especially with physicians. The use of interdisciplinary tools for rounding will increase RN/physician communication and collaboration. Creating RN/physician committees increases the opportunity for building collegial relationships. Well-designed training programs help each discipline understand the needs of the other (Adams & Feudale, 2018; Kovner et al., 2016; Ma, Shang, & Bott, 2015; Moneke & Umeh, 2014; Nantsupawat et al., 2017; Nei et al., 2015; Saber, 2014; Van Osch, Scarborough, Crowe, Wolff, & Riemer-Kirkham, 2017).
Provide Awards to Acknowledge Staff Nurses. Nurse mangers can provide release time for staff nurses to shadow managers or other mentors to experience administrator roles and functions or to work on projects for the unit (AONE, 2000; Blegen et al., 1992; Goode & Blegen, 1993). Another way to show appreciation is by celebrating the long years of service of nurses or any achievements, such as holding a potluck lunch or reception at a unit (Blegen et al., 1992). Design a fun day (e.g., once per month) as staff nurse appreciation day. Lastly, managers can provide a reasonable reward, such as lunch or movie passes, and in some cases, a small cash bonus (Brunges & Foley Brinza, 2014; Hashish, 2017; Li et al., 2018).
Improve Communication With Staff Nurses
Staff nurses who have adequate information about the job and know what is expected of them on the job are more satisfied. Goals should be communicated throughout the organization. Consistent and attentive listening, sharing of information, and follow up from managers will support communication and lead to better nurse retention (Gibson & Petrosko, 2014; Van Osch et al., 2017). There are many ways to support communication.
Start by showing support to staff nurses by encouraging them to express their views and listening to them carefully (AbuAlRub, 2004; AONE, 2000; Farley, 1989; Li et al., 2018; Vermeir, Downs, et al., 2018). Ask staff if they have sufficient accessibility to obtain information and resources necessary to do their job (Boamah et al., 2018; de Almeida, Orgambídez-Ramos, & Batista, 2017; Li et al., 2018; Van Osch et al., 2017; Vermeir, Blot, et al., 2018). Be honest, efficient, and accurate in sharing information and opinions to gain trust and credibility from staff nurses (AONE, 2000; Gibson & Petrosko, 2014; Özer, Santas, Santas, & Sahin, 2017; Van Osch et al., 2017; Vermeir, Blot, et al., 2018). In addition, be visible and available for staff nurses to ask questions and receive support, such as having an open door policy or walking rounds once per shift, day, or week (AONE, 2000; Gregory et al., 2007; Price, Paynter, Hall, & Reichert, 2018; Van Osch et al., 2017). Be willing to ask nurses for input such as, “What do you think is the best way to celebrate Nurses Week?” or “What is your opinion about self-scheduling in our unit?” (AONE, 2000; Brunges & Foley-Brinza, 2014; Li et al., 2018; Perlo et al., 2017; Pincus, 1986).
Use mechanisms such as one-on-one meetings, staff meetings, unit huddles, discussion sessions, focus groups, surveys, suggestion boxes, bulletin boards, and newsletters to enhance communication and feedback (AONE, 2000; Khowaja et al., 2005; Lassiter, 1989; Pincus, 1986; Van Osch et al., 2017). Assess managers' communication on a systematic and regular basis from their staff nurses as a way of improving managers' communication (Boamah et al., 2018; Farley, 1989). It is imperative to recognize and resolve conflict in a supportive manner and proactively (Al-Hamdan et al., 2015; Havens, Gittell, & Vasey, 2018; Kang et al., 2017). Lastly, use communication methods that are familiar to each generation: Baby Boomers prefer personal communication via telephone, Generation X prefer e-mail, and Millennials prefer text (Stutzer, 2019). Managers should ask employees about their preference of messaging (Price et al., 2018).