Recruitment and retention of RNs are the greatest challenge facing healthcare organizations.1 In 2015, the national turnover rate was 17.2%, with the majority of RNs leaving within 1 to 2 years of hospital employment.2,3 Baby boomer retirements and unyielding nurse turnover rates threaten efforts to maintain a stable workforce essential to quality patient care. Further, analysis of shortages in the United States reveals regional variations based on the demographics and population in the area.4
Decades of research have uncovered factors known to influence nursing turnover. Several conceptual models5-8 and other published literature suggest that individual factors, workplace characteristics, transitional support, leadership, and job satisfaction are strongly associated with turnover intentions.7-11 Work-related fatigue and stress, incivility, and burnout are also widely reported variables impacting job satisfaction.5,8,9,11,12 More recently, nurses' racial and ethnic background13,14 and the presence of a multigenerational workforce15,16 have been linked to job satisfaction and turnover. Although the circumstances surrounding nurse turnover and retention are complex, nurse leaders must understand factors affecting turnover rates, including generational and cultural differences and the needs of their unique nursing staff, if they are to succeed in retaining qualified nurses while cultivating a more diverse workforce.
The presence of multiple generations in the workforce and their differing characteristics obscures a clear understanding of retention issues and is further complicated by cultural differences in a diverse workforce. The highest turnover occurs in the 1st 5 years, with 50% of RNs changing employment after 2 years at a hospital.2
Currently, employed US nurses represent the 3 primary generations of Millennial, Generation X (Gen X), and Baby Boomer (Table 1). Hospitals merge all 3 generations in the work setting with new graduates selecting hospitals for 1st-time employment and loyal, long-term employees continuing to work in acute care settings.17 Intergenerational differences related to communication, teamwork, and comfort using health information technology contribute to work-related stress and influence job satisfaction.15,16 Recommendations for improving intergenerational work relationships include enhanced orientation tailored to generational needs,16 leadership training and development,18 sustaining a positive work environment whereby staff respect one another and commit to a common goal,16 implementing support resources for staff,19 and pairing staff from different generations to enhance teamwork and skill development.15
Amid multigenerational influences, cultural issues related to ethnicity are emerging. Persons of Spanish origin or culture have become the largest ethnic minority in the United States.20 In 2015, a majority of the 56 million Hispanics in the United States were of Mexican origin (63.3%) with 34.4% foreign born.21 The top 5 states in Hispanic residents/total residents are California (38.8%), Texas (38.8%), Florida (24.5%), New York (18.8%), and Illinois (16.9%).21 Hispanic nurses represented 6% of the US nursing workforce in 2014 and are estimated to increase to 8% of the workforce in 2030.22 In contrast, the Texas workforce of licensed Hispanic nurses dropped from 9.1% in 2006 to 7.3% in 2016.23,24 A significant diversity gap between the Hispanic patient population and the nursing workforce will occur if recruitment and retention of Hispanic RNs are not addressed.
Hispanic nurses encounter disparities in the work environment. While benefits include bilingual and bicultural knowledge and skills, these nurses often face bias and discrimination from patients and staff.25,26 Hispanic nurses report feeling overlooked and undervalued while at the same time working to demonstrate competency in the nursing role.26 Unwritten expectations to provide translation services contribute to increased workload and feelings of stress and isolation among Hispanic nurses.27 Exacerbating these challenges are feelings of inadequate mentorship support, uncertainty related to mentoring relationships, and reliance on informal (friends or family) mentors.27,28 Regardless of the added responsibilities, Hispanic RNs earn less than white nurses despite unexplained differences in workforce characteristics.29
Efforts to understand the link between race and ethnicity on variables associated with turnover, such as job satisfaction and intent to quit, were undertaken by both Doede13 and Xue.14 A secondary analysis of the 2008 National Sample Survey of Registered Nurses data found that nurses who intended to quit employment within 3 years had the greatest odds of job dissatisfaction; with Hispanic nurses 35% more likely to report an intent to quit than white nurses.13 Analysis of the same data by Xue14 revealed that 78.9% of Hispanic nurses reported being satisfied in their job and only slightly more satisfied than black (76%) or multiracial nurses (75.7%).
Personal Investment Theory (PIT) was used to guide this study.30 PIT asserts that meanings assigned to a person and situation drive personal investment (motivation) and behaviors. Personal factors include cultural background and age, whereas structural factors represent influences beyond the person. Within the context of nurse retention and turnover, such situational factors include the work environment and manager leadership style. Understanding nurses' personal investment (intent to leave) to an organization may help reduce negatively motivated behaviors such as turnover.
The purpose of this study was to describe nurses' work satisfaction level, intent to stay at their current hospital, and the factors perceived to influence their intent to stay. The annual turnover of RNs at a southern US hospital was 22%, with nurses hired in the last 6 years having the most turnover.
This descriptive, single-center study was designed to identify factors influencing nurse retention or turnover from the view of 3 different generations and Hispanic/non-Hispanic nurses. Criteria for inclusion were RNs in clinical nursing roles hired at the study hospital in the last 6 years. Excluded were nurses in leadership roles starting at the nurse manager and higher. The study was approved by the hospital institutional review board.
A 250+ licensed bed tertiary care hospital located in south Texas was the selected setting. The setting is representative of the generational and ethnic changes of the southwest United States with a near-absent population of diploma-educated nurses and traditionalist generation RNs, a decline in Boomer generation nurses, a rising population of Gen X and Millennial nurses, and a large population of Hispanic nurses.
An online survey, composed of 3 instruments, was selected to collect data. The 1st instrument, the Career Survey for Nurses, included demographic questions, job satisfaction measures, intent to stay with current employer, and 1 qualitative question asking what the hospital could do to keep the nurse working at the hospital another 5 years.18 The demographic questions included age, sex, ethnicity, support status, years actively worked as an RN, years actively worked at this hospital, highest nursing education, employment setting, employment status, and the average number of hours worked per day and per week. Job satisfaction measures included the percentage of time the nurse was unable to meet patient needs and the nurse's overall satisfaction.
The 2nd instrument, the Nursing Leadership Preferences Survey, provided 56 leadership traits categorized as attitudes, intrinsic qualities, and personal and acquired skills. Nurse respondents ranked their perception of the 3 most and 1 least important nursing director traits.18 This survey developed by Wieck18 measures the traits nurses identify as most desirable and least desirable in their nurse leader. The nurse leader for this study is considered the nursing director of the unit.
The 3rd instrument was the Nursing Work Index–Revised (NWI-R) developed by Aiken,31 which has a Cronbach's α of .96 and aggregated subscales of .84 to .91. The scales measure organizational traits and differentiate the presence of a professional practice environment.
A letter of invitation and the survey were distributed by hospital email to every RN hired by the hospital in the last 6 years as the majority of RN turnover occurs in the 1st 3 to 5 years. The survey was built in a computerized software survey tool enabling follow-up reminders without respondent identification to ensure anonymity of responses. Survey data were analyzed using Excel and IBM SPSS (Armonk, New York).
A total of 309 RNs met the inclusion criteria, of which 95 (30.7%) completed the survey, exceeding the number of responses required for a 95% confidence level. Among eligible nurses, the respondents were primarily female (84.2%), white (64.3%), non-Hispanic (60%), and younger (39.8 years) than the national average age (48.8 years) for nurses32 (Table 2). The 3 generations (Boomers, Gen X, and Millennials) were each represented in the sample, and respondents included nurses from each inpatient care area. The nurses were more likely to be the sole support for themselves and their family (55.8%), especially Gen X and Millennial Hispanics (64.8%). Most of the respondents had a BSN (50.5%). Nurses, at this hospital, with an associate degree nursing/associate of arts (ADN/AA) degree declined from the Gen X to the Millennial Generation reflecting the movement to hire BSN-prepared nurses; however, most Hispanic nurse respondents had an ADN/AA (68.4%). While the average time respondents had been employed as an RN was 7.2 (SD, 8.97) years; 1.7 (SD, 1.44) years was the average length of time worked at this hospital (Table 3).
The majority of nurses (73.7%) were generally satisfied with their current position followed by nurses being highly satisfied (16.8%), generally dissatisfied (6.3%), and highly dissatisfied (6.3%). There was no significant difference among nurses' satisfaction by generation, ethnicity, unit, sex, length of time employed at the hospital, or by highest level of education. There was, however, a significant difference in nurses' satisfaction based on the percentage of time they felt they were able to meet their patients' needs (F 3,91 = 4.145, P < .01). Nurses who perceived that they were unable to meet patient needs more than 10% of the time were more dissatisfied. Boomers felt they were unable to meet their patients' needs an average of 16.34% (SD, 25.99%) of the time; Gen X, 19.93% (SD, 24.81%) of the time; and Millennials, 21.10% (SD, 23.98%) of the time.
Nurses estimated the number of years they planned to stay with their current employer. Boomers averaged 8.25 (SD, 5.10) years; Gen X, 5.83 (SD, 5.26) years; and Millennials, 3.03 (SD, 2.72) years. When asked to describe what the hospital needed to do to retain them for the next 5 years, respondents, regardless of generation, focused on pay, staffing, and nursing leadership support. Respondents perceived a disparity in pay between nurses working in similar positions in the geographic area coupled with a lack of compensation for loyalty to the hospital and pursuit of more education. The RN respondents cautioned that a more concerted effort to hire nurses who fit the mission and values of the hospital is needed to better align with established staffing ratios. The nurses advocated for hiring more nursing assistants, at a better wage, to improve patient outcomes. Finally, support from nursing leadership through presence, communication, and transparency was the most requested effort needed to retain the nurses.
Preferred Traits in Nursing Leaders
Overall, the 3 generations want directors who have an attitude that is supportive, approachable, and respectful of their subordinates. The generations also admire and respect directors who have acquired professionalism skills and advocate for the nurses; however, whereas Gen X and Boomers want a leader with good reasoning skills, the Millennials want a leader with clinical competence. In the areas of personal qualities, the 3 generations want, as a director, a team player receptive to people and ideas. Millennials and Boomers prefer directors who are empowering, whereas Gen X nurses would like mentors. There are distinct differences in the intrinsic qualities of directors desired by Millennials. The youngest nurses respect leaders who are dependable, dedicated, motivated, understanding, and nonjudgmental. Gen X and Boomers emphasize intrinsic qualities of trustworthiness and integrity in leaders. The 3 generations agree that the least important director skills, personal traits, intrinsic qualities, and attitudes are those of a leader who is a risk taker, possessing high energy, demonstrating creativity, and being inspirational.
While the leader skills, traits, qualities, and attitudes admired and respected across the generations are similar, there are distinct differences seen between the Hispanic and non-Hispanic nurses in the Gen X and Millennial generations. Most notable differences are in the areas of director attitude and intrinsic qualities (Table 4). Hispanic nurses ranked a hard work ethic and honesty as important attitude/value, an attribute not ranked as important by non-Hispanic nurses. Millennial Hispanic nurses identified the importance of a leader who is calm and cooperative, whereas Gen X Hispanic nurses consider fairness important, an attribute not ranked as important by non-Hispanic nurses. Motivation, dedication, and being strong willed are ranked higher in importance for Millennial Hispanic nurses as compared with Gen X Hispanic nurses. High ranking in importance for non-Hispanic nurses are integrity for Gen X nurses and dependability for both Gen X and Millennial non-Hispanic nurses.
Nursing Practice Environment
Variation on the NWI-R Scales measuring the nursing practice environment was present when comparing the Millennial and Gen X Hispanic and non-Hispanic nurses (Table 5). Millennial Hispanics were more positive about each aspect of the nursing practice environment as compared with the Millennial non-Hispanic nurses. This difference was not present in Gen X Hispanics whose perceptions of the practice environment were substantially less positive than the Millennial Hispanics. At the same time, the Gen X non-Hispanic nurses were substantially more positive than the Millennial non-Hispanics.
There are several limitations that influence the generalizability of the findings. The results are drawn from a sample of RNs employed at a single Texas hospital. Responses on the survey reflect perceptions of nurses at a single point in time. The sample represents only 31% of the eligible nurses, which leaves many viewpoints unknown. Further, of the 95 nurse respondents, 40% were Hispanic (n = 38), a percentage that may be unique.
Discussion and Recommendations
This study focused on emerging changes in the nursing workforce, namely, increases in Hispanic nurses and decreases in Boomer and traditionalist RNs. Unlike other studies, most of the sample represented the Gen X population followed closely by Millennials and included 46.5% and 41.5% Hispanic nurses, respectively, in these groups.16,19 Overall respondents reported feeling satisfied in their current work role, regardless of age, sex, unit, or length of employment. The combined percentage of nurses who scored highly satisfied/generally satisfied exceeded 90%, which is better than previously reported scores.18 The inability to meet patient needs correlated with a significant difference in nurse satisfaction. The wide variation in the estimated percentage of time the nurses felt unable to meet patient needs reflects substantial differences in individual perceptions. While generational and cultural differences have an impact on the nurses' perceptions, individual differences continue to determine responses.
Respondents identified primarily as the sole support for themselves and their family (55.8%), especially Gen X and Millennial Hispanics (64.8%), an occurrence that is not uncommon for Hispanic nurses.28 Support status is important as it denotes a person's responsibility to keep a job to support themselves and their family. When individuals have assistance, financial security may enable a decision to leave their current employer. The lack of assistance may increase the hours worked leading to fatigue, inability to meet patient needs, and an increase in the intent to leave followed by dissatisfaction when they are unable to risk a change of employers. Attention to nurses continually pursuing additional hours may assist leaders to identify individuals whose dissatisfaction may be increasing.
Desired leadership traits varied by generation and ethnicity. This study found that Millennial Hispanics do not desire leaders who are mentors, whereas Gen X Hispanics would like mentors. Interestingly, the results both support and refute experiences and perceptions of mentors reported by Egues.27 For Hispanic nurses, mentoring from leaders fosters personal and professional growth translating to retention in the workforce and a shared understanding of experiences.27
All RNs surveyed valued the leadership traits of approachability and support while adding the trait of supportive of subordinates. This finding was seen in literature reinforcing approachability and support as capable of influencing turnover and job satisfaction.33 Leader support was the most requested action to retain nurses at the surveyed hospital for another 5 years.
The NWI-R scores showed little variation between the 3 generations indicating that multiple influences on staff, including organizational structure and characteristics, may overshadow generational and cultural differences and may hide the voices of the subgroups. A search of the literature was unable to identify prior studies investigating factors influencing turnover for Hispanic/non-Hispanic nurses. Additional research is needed to attain a greater understanding of the factors impacting nurse satisfaction across generations and ethnicities.
Using a tertiary care hospital with a rising turnover rate and a high Hispanic RN population as an exemplar, this study demonstrated that generational and cultural differences may impact RNs' job satisfaction and intent to stay. For nursing leaders, successfully managing this diverse workforce is a key factor in retaining qualified nurses to meet current and future demands.
Nurse leaders must assess and determine areas within their organization that are impacting job satisfaction and intent to leave. Further, leaders should commit to the reassessment of staff satisfaction beyond mandatory annual staff engagement surveys. This study identifies ethnic variation not seen in prior studies reflecting the impact of emerging changes in the workforce that may influence retention.
3. Kovner CT, Brewer CS, Fatehi F, Jun J. What does nurse turnover rate mean and what is the rate? Policy Polit Nur Pract
4. Auerbach DI, Buerhaus PI, Staiger DO. How fast will the registered nurse workforce grow through 2030? Projections in nine regions of the country. Nurs Outlook
5. Pineau Stam LM, Spence Laschinger HK, Regan S, Wong CA. The influence of personal and workplace resources on new graduate nurses' job satisfaction. J Nurs Manag
6. Brewer CS, Kovner CT, Greene W, Tukov-Shuser M, Djukic M. Predictors of actual turnover in a national sample of newly licensed registered nurses employed in hospitals. J Adv Nur
7. Laschinger HK. Job and career satisfaction and turnover intentions of newly graduated nurses. J Nurs Manag
8. Liu Y, Wu LM, Chou PL, Chen MH, Yang LC, Hsu HT. The influence of work-related fatigue, work conditions, and personal characteristics on intent to leave among new nurses. J Nurs Scholarsh
9. Spence Laschinger HK, Wong CA, Grau AL. The influence of authentic leadership on newly graduated nurses' experiences of workplace bullying, burnout and retention outcomes: a cross-sectional study. Int J Nurs Stud
10. Laschinger HK, Borgogni L, Consiglio C, Read E. The effects of authentic leadership, six areas of worklife, and occupational coping self-efficacy on new graduate nurses' burnout and mental health: a cross-sectional study. Int J Nurs Stud
11. Wu TY, Fox DP, Stokes C, Adam C. Work-related stress and intention to quit in newly graduated nurses. Nurs Educ Today
12. Hickson J. New nurses' perceptions of hostility and job satisfaction. J Nurs Adm
13. Doede M. Race as a predictor of job satisfaction and turnover in US nurses. J Nurs Adm
14. Xue Y. Racial and ethnic minority nurses' job satisfaction in the U.S. Int J Nurs Stud
15. Bell JA. Five generations in the nursing workforce: implications for nursing professional development. J Nurs Staff Dev
16. Keepnews DM, Brewer CS, Kovner CT, Shin JH. Generational differences among newly licensed registered nurses. Nurs Outlook
17. Auerbach DI, Buerhaus PI, Staiger DO. Registered nurses are delaying retirement, a shift that has contributed to recent growth in the nurse workforce. Health Aff
18. Wieck KL, Dols JD, Landrum P. Retention priorities for the intergenerational nurse workforce. Nurs Forum
19. Wieck KL, Dols J, Northam S. What nurses want: the Nurse Incentives Project. Nurs Econ
25. Villarruel AM. A framework for Latino nursing leadership. Nurs Sci Q
26. Moceri JT. Hispanic nurses' experiences of bias in the workplace. J Transcult Nurs
27. Egues AL. Experiences of mentoring influences on the personal and professional growth of Hispanic registered nurses. 2013;11(4):173–180.
28. Cuellar NG, Cheshire M. Leadership challenges in building a Hispanic nursing workforce. Nurs Leadersh
29. Moore J, Continelli T. Racial/ethnic pay disparities among registered nurses (RNs) in U.S. hospitals: an econometric regression decomposition. Health Serv Res
30. Maehr M, Braskamp L. The Motivation Factor: A Theory of Personal Investment
. Lexington, MA: Lexington Books; 1986.
31. Aiken LH, Patrician PA. Measuring organizational traits of hospitals: the Revised Nursing Work Index. Nurs Res
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33. Kovner CT, Djukic M, Fatehi FK, et al. Estimating and preventing hospital internal turnover of newly licensed nurses: a panel survey. Int J Nurs Stud