Buffington, Annsley RN, BSN, OCN; Zwink, Jennifer RN, MS, OCN; Fink, Regina PhD, RN, AOCN, FAAN; DeVine, Deborah RN, MS, AOCN, CRNI; Sanders, Carolyn PhD, RN, NEA-BC
Creating an organizational culture committed to registered nurse (RN) retention is a strategy to reduce nurse turnover. Turnover has negative organizational consequences in replacement, recruitment, and training costs but more importantly in decreased continuity, quality of care, and productivity. Average nurse turnover rate is estimated at 15% to 36%, with economic costs estimated to be 4 to 5 times higher than reported owing to underreported indirect costs.1 The financial burden to replace RNs who leave ranges from $42,000 to $64,000.2
When nurse turnover is high, secondary turnover becomes a concern. This results from the impact on the work environment due to workforce shortages and loss of experience. Such attrition negatively impacts job satisfaction, organizational commitment, and patient care quality.2 When nurses are empowered to practice in high-quality work environments and are free from supervisor incivility, they are less likely to experience burnout, thereby promoting workplace retention.3 Nurses who are highly involved at the unit level were more committed to their jobs.4 Tourangeau and Cranley5 found 4 key determinants to predict RN retention: job satisfaction, work group cohesion and collaboration, nurse organizational commitment, and personal characteristics. They found that nurse supervisor support is a key component of job satisfaction and has an indirect effect on RN retention.5 Extroverted leader personalities with transformational and transactional leadership styles are the most successful in nurse satisfaction and retention and in engaging the individual nurse in professional development both intellectually and clinically.6
Current evidence-based strategies for nurse retention focus on nurse leader behavior because of the positive correlation with employee satisfaction and retention.1 Three essential nurse retention interventions have been identified: autonomy, recognition, and communication.1 Wieck et al7 studied nurse satisfaction with employment incentives and managerial actions that might decrease nurse turnover and found that nurses know what they want: a cohesive work environment and greater control over their schedules. They also discovered generational differences in stress scores and years nurses intended to stay; younger nurses were most stressed and likely to leave an organization. Schmalenberg and Kramer8 studied clinical work units with the healthiest work environments, finding that nurses working 8- to 12-hour day shifts were more satisfied, reporting better working conditions than did nurses working evening or night shifts. This study further indicated that the least and most experienced nurses reported a healthier, more productive work environment and were more satisfied with their jobs than were nurses with 5 to 15 years of experience.
The nursing profession is not immune to the aging workforce. Attention to generational needs is an important consideration to influence nurse retention. In the next decade, 40% of the RN workforce will be older than 50 years, with many expected to retire.9 A key to retention is creating an environment where all generations of nurses feel welcomed and valued. Personal attention from the manager and input in hospital decisions appeal to 27- to 40-year-olds, whereas decreasing long hours and physical demands are priorities for nurses older than 40 years.10 Nurse leaders are encouraged to develop innovative retention strategies for older nurses.11
Despite the recent economic recession resulting in decreased RN turnover and vacancy rates, national projections continue to indicate a long-lasting, future nursing shortage. The recruitment and retention committee at the University of Colorado Hospital (UCH), a 3-time Magnet®-designated facility, supported this study to obtain RN perceptions about retention and intent to leave with the goal of developing a strategic plan to promote a culture of organizational retention. The UCH received the 2011 University Health System Consortium Quality and Leadership award.
About the Study
This study examined RN perceptions about retention in an acute care, academic Magnet hospital. Specific aims were as follows:
1. Identify RN perceptions of the work environment, support, and encouragement.
2. Determine factors that influence RN job satisfaction.
3. Understand RN perceptions of professional development, mentoring, and recognition.
4. Test an investigator-developed instrument to measure factors that influence nurse retention.
A descriptive survey design gathered data from RNs (N = 1,250) with 1 or more years of experience providing direct patient care and employed in inpatient and ambulatory settings at UCH, an academic Magnet facility in fall 2009. A submission to the Colorado multiple institutional review board determined that this study was not human subjects’ research as defined by policies and regulations. An invitation to voluntarily complete the revised Casey-Fink Registered Nurse Retention Survey© (2009) was disseminated to the targeted RN population via ZoomerangTM methodology; survey completion implied consent. All hospital RNs had access to e-mail. Responses were anonymous and confidential.
Instrument and Data Analysis
In 2008, a panel of nurse administrators and clinicians reviewed an investigator-developed instrument for content validity. The instrument was pilot tested with oncology/bone marrow transplant nurses (n = 60), further establishing content validity. The instrument was revised by the researchers based on pilot testing results and an evidence-based literature review.1,12,13 Original instrument items found to be redundant on factor analysis were deleted. Questions related to shift work, scheduling, the economy, nurse retention, and manager support were added.
The Revised Casey-Fink Nurse Retention Survey (2009) consists of 6 sections. First, nurses were presented with 33 items related to work environment, support, and encouragement using a Likert scale (1, strongly disagree, to 4, strongly agree). This work environment/support/encouragement section was used for factor analysis. An exploratory factor analysis (EFA) was conducted on 33 items using the totally completed surveys (n = 614, 91%) of 677 nurses. The initial solution (EFA) using the Kaiser criterion14 suggested up to 9 factors; the most interpretable solution was a 4-factor set of correlated subscales: recognition/rewards, professional nursing role, mentorship, and scheduling flexibility (Table 1). These subscale names, identified by team consensus, made conceptual sense based on the various survey item factor loadings. The final 4-factor solution accounted for 49.4% of the variance across survey items. Each subscale contained from 2 to 13 items, which were assigned to subscales based on factor loadings and theoretical considerations regarding which items tapped similar constructs. Two items, “I would encourage other nurses to work here” and “There are positive role models for me to observe on my unit,” were placed on different subscales per final reliability testing. Although scheduling flexibility included only 2 items, they loaded together on a single factor and seemed to provide valid data. One item, “I believe nurses should be rewarded based on seniority rather than clinical performance,” was eliminated from the 33-item scale because it did not load onto any of the subscales (constructs) well (factor loadings were <0.10). The overall scale’s Cronbach α was .922. Cronbach α values for the subscales (Table 1) ranged from .767 (for the 8-item mentoring subscale) to .939 (for the 13-item recognition/rewards scale).
The 2nd section has 2 items related to stressors experienced by nurses. The 3rd section lists 13 items about job satisfaction (eg, salary, benefits, schedule, orientation, and career advancement) using a Likert scale (1, very dissatisfied, to 5, very satisfied). The 4th section consists of 3 questions focused on professional development, goal setting, and mentoring. The 5th identifies demographic data (age, gender, number of years as RN, specialty, time employed at the hospital, educational degree, unit, and scheduled work pattern). Respondents were asked to choose 1 item from a preconstructed list the top reason why they continue working in their current job. The survey’s final section consists of 4 open-ended questions related to praise, recognition, and retention. The instrument takes 15 minutes to complete.
Quantitative data were entered into SPSS 19.15 Survey items and demographics were summarized using descriptive statistics, tests of difference, and association. Items comprising each subscale were summed and analyzed by demographic factors. To compare data by employment setting (inpatient/ambulatory), t tests were used. Missing data were omitted from each calculation if there were any missing data on a subscale. The value for α was set at .05.
Qualitative question responses were analyzed by research team members, who collaborated face-to-face for the final analysis. Key words from respondent narratives were independently identified by 2 investigators (A.B. and J.Z.) and 3 research assistants. The investigators applied a general inductive approach to identify themes embedded in the responses, reconciling rival explanations until consensus was achieved.16
Of the potential 1,250 inpatient and ambulatory nurses, 699 responded, of whom 677 (56%) met inclusion criteria. The average respondent was female (n = 657, 91%) and 40 years old (SD, 11.21 years) with a BSN degree (n = 507, 76%). Inpatient RNs (n = 477, 72%; mean [SD], 36.97 [10.27] years) were younger than ambulatory RNs (n = 185, 28%; mean [SD], 46.71 [10.57] years; P = .000). Mean (SD) years as a nurse was 13 (10.67) (n = 636, 94%), with approximately 7.5 (7.26) years (n = 628, 93%) employed in the hospital. Seventy-nine percent (n = 535) were full-time and 61% (n = 400) worked straight days. Respondents indicated their nursing credential level in the hospital’s professional practice framework based on Benner’s novice to expert model17; 79% (n = 505) of respondents were level 2, 19% (n = 125) were level 3, and 2% (n = 15) were level 4 nurses.
Work Environment/Support/Encouragement Subscales
There were no statistically significant relationships between nurse respondents’ perceptions of work environment/support/encouragement and age, years of experience, and length of service. However, there were significant differences between inpatient and ambulatory nurse subscale responses (Table 2).
Recognition/Rewards (13 Items)
Overall, respondents felt that they were respected members of the healthcare team (n = 672, 99.3%; mean [SD], 3.08 [0.64]) and believed that their talents were appreciated (n = 676, 99.9%; mean [SD], 2.91 [0.70]) but did not agree as strongly that their contributions were acknowledged (n = 668, 98.7%; mean [SD], 2.63 [0.70]). Most felt supported by their charge nurse (n = 672, 99.3%; mean [SD], 3.20 [0.74]) and believed that their charge nurse was approachable (n = 665, 98.2%; mean [SD], 3.26 [0.68]) but were less agreeable that their charge nurse (n = 672, 99.3%; mean [SD], 2.96 [0.74]) or nurse manager (n = 671, 99.1%; mean [SD], 2.82 [0.85]) provided encouragement/feedback about their work.
Inpatient nurses were generally more favorable regarding recognition/rewards than were ambulatory nurses (Table 2). Inpatient nurses felt more supported than ambulatory nurses by their unit team (n = 475, 71.9%; mean [SD], 3.26 [0.64]; and n = 185, 28.1%; mean [SD], 3.12 [0.75], respectively; P = .015); would encourage other nurses to work at the institution (n = 470, 72.2%; mean [SD], 3.26 [0.64]; and n = 181, 27.8%; mean [SD], 3.14 [0.71], respectively; P = .036); and believed that their managers were more approachable (n = 480, 72.5%; mean [SD], 3.14 [0.81]; and n = 182, 27.5%; mean [SD], 2.92 [0.90], respectively; P = .003), followed through with their concerns (n = 478, 72.6%; mean [SD], 2.93 [0.84]; and n = 180, 27.4%; mean [SD], 2.69 [0.86], respectively; P = .002), and helped them to develop confidence in their practice (n = 477, 72.9%; mean [SD], 2.74 [0.78]; and n = 177, 27.1%; mean [SD], 2.56 [0.86], respectively; P = .018).
Professional Nursing Role (9 Items)
Most respondents believed that they made a difference with patient care (n = 672, 99.3%; mean [SD], 3.37 [0.58]), were satisfied with their chosen nursing specialty (n = 668, 98.7%; mean [SD], 3.29 [0.68]), felt that job expectations were realistic (n = 670, 99%; mean [SD], 2.87 [0.65]), and would like to be working at the institution in 5 years (n = 674, 99.6%; mean [SD], 2.88 [0.71]). Less often, respondents felt overwhelmed by workload (n = 673, 99.4%; mean [SD], 2.74 [0.75]), had been in their position as long as they wanted to be (n = 668, 98.7%; mean [SD], 2.69 [0.78]), and would think about finding another job (n = 672, 99.3%; mean [SD], 2.89 [0.83]).
More ambulatory than inpatient nurses believed that they were supported by physicians (n = 186, 28.1%; mean [SD], 3.04 [0.68]; and n = 477, 71.9%; mean [SD], 2.92 [0.57], respectively; P = .016) and felt comfortable communicating with patients/families (n = 187, 28.1%; mean [SD], 3.64 [0.53]; and n = 479, 71.9%; mean [SD], 3.52 [0.52], respectively; P = .009).
Mentorship (8 Items)
Inpatient nurses had a higher mentorship subscale score than ambulatory nurses did (Table 2). More inpatient nurse respondents than ambulatory nurses believed that their work was challenging (n = 481, 72%; mean [SD], 3.31 [0.57]; and n = 187, 28%; mean [SD], 3.21 [0.64], respectively; P = .042), have other nurses available to assist during new situations/procedures (n = 480, 72.1%; mean [SD], 3.24 [0.59]; and n = 186, 27.9%; mean [SD], 3.10 [0.69], respectively; P = .008), have a positive role model to observe on their unit (n = 476, 72%; mean [SD], 3.32 [0.57]; and n = 185, 28%; mean [SD], 3.07 [0.75], respectively; P = .000), enjoyed socializing with team members outside working hours (n = 478, 72.1%; mean [SD], 3.06 [0.71]; and n = 185, 27.9%; mean [SD], 2.83 [0.78], respectively; P = .001), and have a mentor available (n = 475, 72.6%; mean [SD], 2.82 [0.74]; and n = 179, 27.4%; mean [SD], 2.58 [0.83], respectively; P = .001).
Inpatient nurses, compared with ambulatory nurses, believed that their nurse educator was approachable (n = 472, 74.2%; mean [SD], 3.14 [0.81]; and n = 164, 25.8%; mean [SD], 2.78 [0.91], respectively; P = .000), believed that their preceptor provided them with a sound foundation (n = 463, 73.4%; mean [SD], 3.17 [0.62]; and n = 168, 26.6%; mean [SD], 2.93 [0.73], respectively; P = .000), and agreed that their educator provided encouragement/feedback (n = 476, 74.3%; mean [SD], 2.71 [0.84]; and n = 165, 25.7%; mean [SD], 2.42 [0.88], respectively; P = .000).
Schedule Flexibility (2 Items)
More ambulatory than inpatient nurse respondents would like the option of working shorter shifts (n = 180, 27.4%; mean [SD], 2.78 [0.74]; and n = 477, 72.6%; mean [SD], 2.54 [0.89], respectively; P = .001) and would consider staying employed if given the option of shorter shifts (n = 179, 27.5; mean [SD], 2.51 [0.79]; and n = 473, 72.5%; mean [SD], 2.37 [0.81], respectively; P = .036). Registered nurse age was weakly correlated with the option of working short shifts (r = 0.158, P = .000).
When asked about personal life stressors, more than 50% (n = 339) of the respondents said that they experienced stress, with the greatest reasons being financial (n = 181, 53%), personal relationships (n = 109, 32%), child care (n = 72, 21%), and student loans (n = 56, 16%). Age was not a factor in the experience of stress.
All respondents were queried about job satisfaction. There were no statistical differences in job satisfaction by RN age, years of experience, and years worked. There were differences between inpatient and ambulatory nurses (Figure 1) related to several items.
All respondents were somewhat satisfied with salary, benefits, and the amount of manager encouragement/feedback. Inpatient nurses were less satisfied than ambulatory nurses with schedule issues: number of weekends off, opportunity to work straight days, and rotating shifts. Ambulatory nurses were not as satisfied with orientation adequacy and career advancement opportunities. Schedule flexibility was more satisfactory for inpatient versus ambulatory nurses.
When asked “What are your professional goals for the next 1 and 5 years?” 1-year goals included developing competence in the current role/position, involvement in unit process improvement projects and committees, obtaining specialty certification, attending conferences, and credentialing within the hospital professional practice model. Five-year goals were similar, but differences included pursuing a master’s degree or higher, publishing, transferring to a new position within the hospital, and retirement.
When asked if mentoring assistance was available to achieve these goals, 39% (n = 227) responded in the affirmative. More inpatient nurses than ambulatory nurses (n = 176, 77.9%) believed that they had a mentor available (R = 5.44, P = .020).
Nurses were queried about participation in activities during the past year that enhanced their professional development. Results included membership within a professional nursing organization, subscribing to a nursing journal, and unit/hospital committee involvement.
Praise and Recognition
Nurses were asked, “Describe ways in which you have received praise or recognition for a job well done” and “How would you like to receive recognition for a job well done?” Respondents referenced ways they receive recognition related to unit-based programs but also mentioned value in consistent verbal praise from the manager and the educator, a personal thank you from patients/families, and unit recognition. Suggestions to improve praise and recognition included receiving sincere verbal “thank you’s,” management showing interest in employees, wanting personal time with the manager and other hospital leaders, and receiving immediate praise and recognition versus just during yearly evaluation.
One quantitative question (“What keeps you working in your current job?”) and 2 qualitative questions (“What might cause you to leave?” and “What do you think can be done to improve RN retention?”) were asked about retention. In response to the quantitative question, most nurses continue to stay because of the nurses they work with and the patients they care for (Table 3).
Themes for stated reasons to leave included management, workload/staffing, salary/benefits, scheduling/shift hours, and retirement/family. Regarding management, nurses reported feeling a lack of support and appreciation/recognition. Some comments referred to lack of manager, charge nurse, or director integrity and follow-through. Most comments about workload and staffing expressed dissatisfaction with staffing, nurse-patient ratios, burnout, and stress. Regarding salary and benefits, nurses stated a desire for improved pay and financial opportunities. The greatest dissatisfaction for scheduling/shift hours was lack of self-scheduling, flexibility, and predictability.
Of the 677 nurses surveyed, the majority (n = 463) provided multiple suggestions related to RN retention. Themes for improving nurse retention included benefits/salary, shifts/staffing/scheduling, management/leadership, and appreciation/recognition (Figure 2). Most nurses stated a need for improved manager support, respectability, relationships, a desire for improved shared leadership, and listening to ideas/concerns. Thoughts related to appreciation and recognition centered on acknowledgment of contributions and accomplishments. Most stated that improved pay/benefits and receiving a raise for obtaining specialty certification would enhance retention. Comments about staffing and scheduling included improved nurse-patient ratios, shorter shifts, and eliminating shift rotation.
Nurses reported factors influencing retention commensurate with recent literature such as work environment, rewards/recognition, mentorship, scheduling, and management. Developing an environment where retention is a priority is paramount for today’s nursing leaders. Although our turnover rate is low at 3%, these study data indicate an opportunity to enhance our culture of retention. Although findings indicate overall satisfaction with receiving respect for their team contributions, RNs perceive lack of support, mentorship, and appreciation from the unit manager and educator, although both were viewed as approachable. Ambulatory nurses were less satisfied with nurse educator support and mentorship than inpatient nurses were. Lack of direct feedback and encouragement from unit leadership and organizational leaders was identified as dissatisfiers, which might impact nursing turnover.
The differences noted between ambulatory and inpatient nurses could be explained by organizational structure differences, where inpatient units have 1 educator per floor/service, whereas ambulatory clinics have 1 educator for multiple clinics/services. Because of our findings, a second nurse educator was hired specifically for the ambulatory setting.
Our results related to retention influenced the creation of unit-specific committees to focus on creative ways to recognize staff and promote a culture of appreciation. Nurse Week celebrations include recognition for work toward the hospital’s critical success standards, specialty nursing certification, clinical advancement, and exceptional patient care. In addition, an employee of the month is recognized at staff meetings. On a more global level, staff throughout the hospital can nominate nurses for Magnet Nurse of the Year awards. These nurses are recognized at the Nurse Week celebration and receive a fleece vest identifying this designation. The hospital chief executive officer also celebrates exceptional achievements of nurses through the President’s award program, where individuals are recognized at an annual dinner.
The disparity between ambulatory and inpatient nurses relative to the mentorship subscale may reflect the ambulatory work environment in this organization. Many clinics employ fewer than 5 nurses, leading to the perception of limited peer-to-peer assistance, role models, and mentors. Inpatient units typically have a larger cadre of nurses, where these resources may be more apparent. Since 2002, only inpatient units have recruited graduate nurses (GNs) into our nationally accredited GN residency program; UCH ambulatory clinics do not. The GN residency program curriculum focuses on mentorship, professional development, and advancement throughout the 2-year program, which may account for higher inpatient RN satisfaction with mentorship and career advancement opportunities. In addition, our GN residency program has seen an overall 5-year RN retention rate of 93%, with more than 48% UCH inpatient RNs having graduated from this program.
It is not surprising to see statistically significant differences in ambulatory and inpatient nurses relative to job satisfaction. Ambulatory nurses are more satisfied with having weekends off, working straight Monday through Friday versus rotating shifts, although inpatient nurses are more satisfied with scheduling flexibility, as supported in the literature.9 Data from this study indicate that the mean of age of ambulatory nurses is 10 years more than that of inpatient nurses and that ambulatory nurses prefer and are seeking shorter shifts. These data are commensurate with the literature10; evaluation of shift length and work hours must be considered, especially in the ambulatory environment. This hospital uses self-scheduling models on several inpatient units, thereby giving nurses more influence over schedules. Early reports indicate improved RN satisfaction with the scheduling process, but further analysis is needed before hospital-wide implementation. Because of the limited number of nurses in the ambulatory clinics, they may have less influence. These findings support previous research relative to unit level involvement.4,7
Our recruitment and retention committee at UCH has supported the implementation of shorter shifts on inpatient units during peak patient census, including busy admission and discharge times. Each unit has identified unique staffing needs relative to workload, with many implementing shorter shifts (4-8 hours) to assist with patient throughput. During shorter shifts, RNs assist with admissions, discharges, and other tasks versus taking a patient assignment. We have discovered this role to be budget neutral, which is important within a productivity-based budgeting system. Specific metrics are being established to measure this program’s success. In addition to unit-based shorter shifts, the hospital instituted a house-wide “capacity nurse” who floats to various units where workload needs are greatest. Furthermore, strategies to increase satisfaction and retention have been implemented because of National Database of Nursing Quality Indicators (NDNQI) RN survey findings. For 2 consecutive years, our data indicated RN dissatisfaction with lunch breaks. Nurses reported not being able to take a lunch break at all and/or not having a lunch break free of patient care responsibility. Several units have implemented buddy systems to ensure adequate and stress-free lunch breaks. Each nurse chooses another nursing partner to cover patient care while a lunch break is taken. Although met with initial resistance, many units have seen great success. Data from the NDNQI survey indicate that nurses reporting meal breaks “free of patient care” increased from 26% in 2009 to 58% in 2010 and 61% in 2011. These improvements in nursing satisfaction with lunch breaks show promise toward a house-wide change in practice.
Van Oyen Force6 described nurse supervisory support as a key component of job satisfaction with an indirect effect on RN retention. Because our study indicated that 39% of nurses would potentially leave their jobs because of management, steps have been taken to provide support for nurse managers. This includes the identification of organizational barriers to effective management, the examination of optimal full-time equivalent span of control, and a nurse manager orientation and development program. In addition, nurse manager focus groups have occurred to further understand their needs. Strategies to support and develop frontline nurse managers are being developed based on feedback from these focus groups. Mentoring opportunities, leadership development programs geared toward nurse managers, and more focus on work-life balance will be emphasized. It is believed that these strategies will assist frontline nurse managers to become transformational leaders and reinforce a retention culture.
The economic recession may have influenced RN perceptions of workplace satisfaction. This study was conducted in a convenience sample of RNs at one academic Magnet-designated facility; thus, generalizability may be limited. In addition, the organizational structure in the ambulatory setting differed from that in the inpatient setting. Ambulatory clinic managers, often nonnurses, may have influenced ambulatory staff perceptions about manager approachability, mentor availability, and managers instilling confidence in practice, especially relative to clinical situations. Because the instrument used in this study had been revised, reliability and validity had not been established before use in this sample. Further research using this instrument is recommended.
A broader view of nurse retention would enhance the validity and strength of the data by using this survey at other hospitals. After data analysis, scheduling initiatives were instituted so inpatient nurses could work shorter shifts during peak activity. There exists an opportunity to institute similar staffing patterns in ambulatory areas. Future research should examine staff nurse satisfaction with shorter shifts.
Nurse retention is a key issue facing healthcare organizations. Knowledge about specific factors that contribute to turnover is paramount to create and sustain a retention culture. Results from this study can provide evidence to support improved strategies that foster retention and satisfaction of experienced nurses.
Thanks to Kathy Casey, MSN, RN, who assisted in survey development and revision; research/student assistants Lori Harvey, RN, MS, CJ Cullinan, RN, MS, and Stephanie Craddick, RN, MS, who assisted with data management; the RN Recruitment and Retention Committee; and Kelley Williamson, who assisted with survey launch.
© 2012 Lippincott Williams & Wilkins, Inc.