“Retention is now a critical issue...as we risk losing nurses faster than we can train them.” This startling statement was made by Howard Catton, CEO of the International Council of Nurses (ICN), at the ICN International Workforce Forum in March 2019.1 Discussion at the ICN Forum recognized that the nursing shortage spans continents, necessitating an urgent global response. In the US, the nursing shortage continues to worsen, with a 17.2% turnover rate for RNs in 2018, tying with the 2015 rate as the highest in the last decade.2 Increasing RN job satisfaction and improving retention have become high-ranking strategic priorities for healthcare organizations everywhere.
Intent to stay and burnout
Based on survey responses from nearly 250,000 RNs, the 2018 Press Ganey Nursing Special Report identified that nurses planning to leave their jobs soon typically cite dissatisfaction with the work environment as the reason; nurses on units with lower intent to leave more often perceive turnover as a threat to the delivery of quality care.3 Regarding the drivers of intent to stay, the report showed differences between experienced and newly licensed nurses, emphasizing that a one-size-fits-all approach won't work. For experienced nurses, job satisfaction, joy in work, quality of care, and career development opportunities were identified as strong drivers of intent to stay. For new nurses, nurse manager support, joy in work, and praise and recognition were more important factors.
When considering how to address the nursing shortage, it's important to delve into burnout—one of the main contributing factors of nursing turnover.4 Far too common among nurses, burnout is manifested by emotional exhaustion, cynicism, and a sense of inefficacy.5,6 Unresolved professional stress, such as increased workload demands and limited resources, poses a risk of burnout.7,8 However, lower job dissatisfaction and burnout rates are associated with better work environments.5
Healthcare agencies are acknowledging the crucial need for action. To address the staggering reports of burnout among healthcare providers, the Institute for Healthcare Improvement issued a framework for improving joy at work that aligns with the tenets of a positive practice environment.9 Factors that precipitate burnout also impact joy in the workplace.9 Because providing care for others requires a holistic and often deeply personal investment of one's self, organizations have the responsibility to safeguard nurses' well-being to foster joy. As the World Health Organization's Director General Tedros Adhanom Ghebreyesus stated in his address to the ICN 2019 Congress, “Health facilities must not only be places of healing for patients. They must be places that foster well-being for health workers, especially those working in vulnerable and fragile settings.”10
The reality is that when organizations support and engage their nurses, they're more likely to retain the professional staff they need to deliver on the promise of safe, high-quality patient care.11–13 To support nurses to the fullest, many organizations need to drive the cultural change necessary to create a positive practice environment.
Strengthening the practice environment
To achieve an effective culture, elements such as shared governance, transformational leadership, teamwork, safety, role clarification, open communication, person-centeredness, lifelong learning, and stakeholder involvement and participation must be fully embraced.14 The Pathway to Excellence® Program provides a framework for organizations to successfully transform their practice environment, creating and sustaining a culture of excellence.
The first Pathway standard—shared decision-making—ensures that a shared governance structure is in place as the foundation for empowering nurses and giving them a voice to communicate care delivery concerns. When leaders foster shared decision-making within their sphere of influence, clinical nurses feel that their input is valued. Clinical nurses spend the most time with patients and families; therefore, they must drive nursing practice. When nurses perceive that they're being heard and contributing to change, they're more engaged in their role, which translates to higher job satisfaction.
Leaders are also critical to organizational success, as noted by the second Pathway standard—leadership. Accountability, transparency, and advocacy for patients, families, and nursing staff are crucial leadership competencies. The nurse manager has a central role in the creation and maintenance of positive practice environments at the unit level, fostering lifelong learning and professional growth. For the 2017 Nursing Special Report, Press Ganey researchers used RN survey data from a sample of 171,789 nurses to study the influence of nurse managers on practice environments and outcomes. The analyses focused on a scale measuring nurse manager ability, leadership, and support to reflect nurse manager influence on eight work environment mediators associated with nurse manager performance and patient outcomes.15 Nurse manager influence was found to be significantly related to every one of the work environment mediators almost uniformly across seven different unit types. (See Direct effects of nurse managers on the work environment by unit type.)
Including Press Ganey patient experience data, the RN survey responses, and engagement data in cross-domain, mediational analyses, the study further found that nurse managers have a significant impact on the quality of the nurse work environment and the influence of the work environment on outcomes:15
- Nurse managers directly and indirectly influence nurse and patient outcomes.
- The quality of the work environment influences nurse and patient outcomes.
- Nurse manager leadership is associated with multiple work environment mediators across unit types.
- Autonomy and professional development are the work environment mediators that exert the most influence on nurse outcomes.
- Autonomy, appropriate staffing, and teamwork are the work environment mediators that exert the most influence on patient outcomes.
- The primary drivers of outcomes differ across unit type, both in number and rank order.
Christy Dempsey, CNO for Press Ganey Associates, expresses the impact that nurse managers have on creating and sustaining healthy work environments in this way: “Nurse managers are critical to any healthcare organization across the continuum, as our research demonstrates. Nurse managers are the key to any performance improvement or outcomes the organization desires to achieve. They're the role models for direct caregivers relative to the clinical, operational, cultural, and behavioral aspects of care provided every day. Their impact can't be overstated.”16
Sustaining positive practice environments
Creating positive practice environments that promote excellent patient and staff outcomes entails cultural transformation.13 According to the ICN, positive practice environments foster a culture of excellence that safeguards staff members' health, safety, and well-being, translating to high-quality care and improved staff morale, productivity, and efficiency.17 Clinical nurses employed in organizations that are fully vested in sustaining positive practice environments through the six Pathway standards (shared decision-making, leadership, safety, quality, well-being, and professional development) attest to a multitude of benefits.
The following testimonials from nurses in Pathway-designated organizations highlight the impact of positive practice environments on work experiences and job satisfaction:∗
- “Pathway to Excellence affected my professional practice by giving me a voice to positively influence change within my department ... And through Pathway, we removed barriers and now function as one team.”—Barbara “Cindy” Thomasson, BSN, RN, Baptist Health Richmond (Ky.)
- “Our Pathway journey...made us realize the importance of involving ourselves in the hospital's decision-making processes. A high level of camaraderie was apparent as we all worked toward achieving the goal.”—Katrina R. Valbuena, BSN, RN, St. Luke's Medical Center-Global City, Philippines
- “After the journey to Pathway, communication with our nursing leaders improved, and I began to participate in nurses' selection interviews, among other activities. I realize that ABC is the best place to work.”—Carolina Monjaras Guerra, RN, ABC Medical Center, Mexico
- “Working in a Pathway organization makes me feel secure because I know it's a safe environment and national nursing standards are in place to support me and my patients. Nurses are appreciated. They have input and feel empowered in decision-making.”—Mary Roxanne A. Azucena, BSN, RN, St. Luke's Medical Center-Global City, Philippines
- “[Centro Medico ABC] is an institution that takes care of my safety and well-being. Pathway allows me to be a leader and promote ideas of improvement on my unit that are reflected in my patients' well-being.”—Tania V. Chavarria Cuandon, RN, ABC Medical Center, Mexico
- “The Pathway to Excellence journey is an experience I'll never forget. The journey has given me several opportunities to grow personally and professionally.”—Sarah Sienes, MN, RN-BC, Sentara Nursing Center, Virginia Beach, Va.
Sustaining a positive practice environment has led to significant improvements for organizations, patients, and nurses alike, which these clinical nurses attributed to the Pathway framework. Pathway to Excellence case studies provide further examples of improvements related to nurse retention and satisfaction.18 St. Luke's Medical Center-Global City, Philippines, cited consistent high performance for 2016, 2017, and 2018 on the RN satisfaction measures of professional development opportunities, autonomy, staffing and resource adequacy, nursing foundations for quality of care, nurse-to-nurse interaction, and nursing administration. Sentara Nursing Center in Virginia Beach, Va., reported the following turnover and vacancy improvements in just over a year: RN turnover fell from 27.7% to 19.6%, RN vacancy dropped from 14.7% to 7.8%, LPN turnover dropped from 19.7% to 15.3%, certified nursing assistant (CNA) turnover fell from 44.6% to 33.8%, and CNA vacancy dropped from 21.5% to 17.7%.
To address the nursing shortage, improving RN job satisfaction and retention have become high priorities. Organizations that integrate the tenets of a positive practice environment—aligned with the six Pathway standards—into their strategic goals can foster joy and well-being, mitigate burnout, and positively impact nursing satisfaction and retention.
1. International Council of Nurses. ICN International Workforce Forum calls for urgent action from governments to address global nursing shortage. 2019. www.icn.ch/news/icn-international-workforce-forum-calls-urgent-action-governments-address-global-nursing
3. Press Ganey. 2018 Nursing Special Report. Optimizing the nursing workforce: key drivers of intent to stay for newly licensed and experienced nurses. www.pressganey.com/resources/white-papers/2018-nursing-special-report
4. Leiter MP, Maslach C. Nurse turnover: the mediating role of burnout. J Nurs Manag
5. McHugh MD, Kutney-Lee A, Cimiotti JP, Sloane DM, Aiken LH. Nurses' widespread job dissatisfaction, burnout, and frustration with health benefits signal problems for patient care. Health Aff (Millwood)
6. Maslach C. Job burnout: new directions in research and intervention. Curr Dir Psychol Sci
7. Maslach C, Jackson SE. The measurement of experienced burnout. J Occup Behav
8. Jourdain G, Chênevert D. Job demands—resources, burnout and intention to leave the nursing profession: a questionnaire survey. Int J Nurs Stud
9. Perlo J, Balik B, Swensen S, Kabcenell A, Landsman J, Feeley D. IHI framework for improving joy in work. Institute for Healthcare Improvement. 2017. www.ihi.org/resources/Pages/IHIWhitePapers/Framework-Improving-Joy-in-Work.aspx
10. World Health Organization. Speech by Dr. Tedros Adhanom Ghebreyesus to International Council of Nurses 2019 Congress, Singapore, June 30, 2019. www.who.int/dg/speeches/detail/international-council-of-nurses-2019-congress
11. Jarrín OF, Kang Y, Aiken LH. Pathway to better patient care and nurse workforce outcomes in home care. Nurs Outlook
12. Pauley T, Fox C. Using a positive practice environment framework to support recruitment. Nurs Times
13. Tillott S, Walsh K, Moxham L. Encouraging engagement at work to improve retention. Nurs Manag (Harrow)
14. Manley K. ‘The way things are done around here’: developing a culture of effectiveness: a pre-requisite to individual and team effectiveness in critical care. Aust Crit Care
15. Press Ganey. 2017 Nursing Special Report. The influence of nurse manager leadership on patient and nurse outcomes and the mediating effects of the nurse work environment. www.pressganey.com/resources/white-papers/2017-nursing-special-report
16. Personal communication with Christy Dempsey, CNO, Press Ganey Associates, July 22, 2019.
17. International Council of Nurses, International Centre for Human Resources in Nursing. Positive practice environments fact sheet. 2007. www.wpro.who.int/topics/nursing/ichrn_fact_sheet.pdf
18. American Nurses Credentialing Center. Pathway to Excellence: testimonials and case studies. www.nursingworld.org/organizational-programs/pathway/overview/testimonials-and-case-studies