High nursing turnover costs health systems significant dollars and has a negative effect on the quality of patient care. Leaders can take steps to solve this vexing problem.
“The issue of turnover in healthcare is huge,” said Frederick P. Morgeson, PhD, Eli Broad Professor of Management at Michigan State University in East Lansing, Mich. He reports healthcare turnover is expensive, with direct and indirect costs, including lost productivity and worse patient outcomes.
Christina Dempsey, MSN, MBA, RN, CNO at Press Ganey in Chicago and author of the book “The Antidote to Suffering: How Compassionate Connected Care Can Improve Safety, Quality, and Experience,” estimates the direct cost to replace one nurse, including onboarding, at $45,000. Nationally, she added, healthcare organizations spend $17 billion annually because of nurse turnover.
“Turnover matters to the bottom line, and it matters to patients,” Dempsey said. “We are not only losing nurses to another hospital down the street but also to [nurses who leave the] profession. It’s a critical issue.”
Industry experts suggested several strategies to improve retention and reduce nursing turnover.
1. Hire a good fit to reduce turnover
“Retention begins with the people you bring in,” Morgeson said. “Some people are more prone to staying or leaving.”
Certain people tend to commit to an organization or job, an orientation known as “embeddedness.” During the hiring process, Morgeson advises hiring authorities to assess work history and behavior and personality traits.
“Past behavior is one of the best predictors of future behavior,” Morgeson said.
Morgeson recommends using behavioral assessments and structured interviews in a systematic approach to hiring. Additionally, the assessment and interviews can evaluate whether the candidate’s values match the organization’s values. Turnover in the first six months, he said, is often due to a cultural misfit.
“You want to hire someone who is a good fit for the job and the organization,” Morgeson said. “People are who they are, and some stylistic things and core approaches are baked into who they are. You are unlikely to change that in a big enough way.”
2. Improve the work environment
“It is vitally important for hospitals to focus on the work environment,” said Seun Ross, DNP, CRNP-F, RN, director of nursing practice and work environment at the American Nurses Association in Silver Spring, Md. “The only way to create loyalty and engagement in any nurse is creating an awesome place to work.”
That includes fostering a culture of safety, staffing adequately, offering flexible scheduling, sharing decision-making, minimizing mandatory overtime, supporting safe patient handling and promoting collaboration between colleagues.
Morgeson said he predicted not having enough nurses will not improve soon, with the continuing nursing shortage and increased demand for healthcare. Double shifts, mandatory overtime, six shifts per week are not sustainable.
“It’s a staffing thing, and to the extent you can, try to hire more people,” Morgeson said.
Dempsey added that “staffing is absolutely important,” and it’s positively correlated with perceptions of the care provided, and negatively correlated with poorer outcomes, including pressure ulcers, hospital-acquired infections and injurious falls. But, she added, the work environment is more important than staffing. It is dependent on having a safe place to practice and being able to make a meaningful contribution.
3. Engage your nurses to avoid burnout
“You want to always tip toward engagement rather than burnout,” Dempsey said.
Dempsey reported that 16% of nurses are disengaged, costing employers $22,000 in lost productivity for each disengaged nurse.
She found nurses are most engaged when they have been with an organization for less than six months or more than 10 years.
Dempsey also found that nurses who work as leaders and educators, and spend little or no time providing direct patient care, tend to be more engaged than direct-care nurses.
Providing leadership development opportunities to nurse managers could help. Nurses are often promoted to management positions but may not be given training in coaching others, being a role model, succession planning and creating a supportive environment.
“[Managers] create the culture the nurses will work in,” Dempsey said. “That’s the first step in making nurses want to stay.”
Dempsey is working on research about resilience, the opposite of burnout. That may include opportunities to decompress and have time to rejuvenate.
4. Nurses value meaningful recognition at work
“Anytime [a nurse] feels valued is important to that nurse, it gives that nurse pride,” Ross said. Nurses tend to talk about rewards to friends and that can bring more people to the organization.”
Recognition matters and it needs to be tailored to the employee and what he or she needs in the way of feedback, Morgeson said.
“People do want recognition, but it needs to be genuine and authentic,” Morgeson said. The younger generation may need this even more than older nurses, he added.
5. Create growth opportunities for nursing staff
More nurses go back to school for graduate degrees and then seek work away from the bedside. Hospitals often offer some tuition reimbursement. Ross thought that increasing the amount reimbursed could help keep nurses.
“Longer-term turnover is often due to reasons of development and advancement,” said Morgeson. “People want to grow and develop and leave when that is not happening.”
Compounding this problem, Morgeson said, are nurses who leave for lack of opportunities for growth and advancement who are, typically, an organization’s best employees, the most ambitious. They want to learn and will find an employer who will deliver on that.
“The retention piece is one of the biggest things organizations are struggling with,” Morgeson said. “How do you keep people and how do you keep the best people?”
Freelance writer Debra Anscombe Wood, RN, contributed to the writing and research of this article.