Running head: DECREASED RETENTION RATES 1

Factors that Contribute to Decreased Nurse Retention Rates

Blaine Reichart, BSN, RN

University of Saint Mary

DECREASED RETENTION RATES 2

Abstract

The current registered nurse shortage is an international healthcare issue that is related to many

factors including the increase of nurse turnover within organizations. There are serious costs and

consequences related to this shortage. Nurse turnover critically impacts hospital budgets,

threatens quality care, and increases the likelihood of medical error (Duffield et al., 2014). In

order to identify the top reasons nurses are leaving organizations and contributing increased

turnover rates, this study included a review of fifty exit interviews throughout a twelve month

time frame from a community hospital in the Midwest. Age of the employee and reason for

departure was recorded and the data was then analyzed to identify common themes. It was

determined that nurse turnover is heavily influenced by two main factors: bedside nursing was

not what the nurse expected and scheduling paired with compensation did not meet the departing

nurses' expectations. Other less significant themes included lack of leadership support, lack of

breaks, lack of patient time, and too much paperwork associated with nursing tasks. These results

should be seriously considered when implementing policies and programs targeted at decreasing

nurse turnover rates within an organization.

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Factors that Contribute to Decreased Nurse Retention Rates

Duffield, Roche, Homer, Buchan & Dimitrelis (2014) describe turnover as any job move

which could be internal, such as between nursing units within the same hospital or external, or

when staff members leave the organization or profession entirely (p. 2704). Recently, nurse

retention has received more attention by healthcare employers due to the aging population,

escalating nurse retirements, and growing complexity of healthcare demands (OBrien-Pallas,

Murphy, Shamian, Li & Hayes, 2010). Nurse turnover critically impacts hospital budgets and

threatens quality care and increases the likelihood of medical error (Duffield et al., 2014). As

suggested by the literature, frontline staff nurses are predominantly the target for turnover. It is

hypothesized that nurse turnover is directly related to workplace empowerment, incivility, and

burnout. In addition, Lang (2008) cites moral distress and lack of ethics education as a reason for

turnover. Recently, programs such as nurse residencies have been implemented within

organizations in an effort to meet the needs of graduate nurses and increase retention (Gormley,

2010). Strategies to address knowledge gaps that exist between managers and nursing staff have

also been implemented within multiple organizations in order to retain nurses in the workplace.

Problem Significance

In 2011, the reported annual rate of nursing turnover totaled 13.9% in the United States

(Duffield et al., 2014). While this percentage may not seem significant, it should be noted that it

costs between $65,000 and $88,000 to replace one nurse (Wieck, Dols & Landrum, 2010;

Barlow & Zangaro, 2010). It should be noted that the significant expense of turnover is directly

related to the monetary costs associated with hiring temporary staff, recruiting, and orienting

nurses (Tang, 2003). Adding to the challenge is the significant shortage of nurses which the

World Health Organization (2011) estimates at 4.3 million workers worldwide. In the next two
DECREASED RETENTION RATES 4

decades, this number is expected to increase by 20%. These numbers combined have caused

healthcare organizations to refocus their energy and money into an effort to attract and retain

nurses. Although the need for retention has been recognized, nurse managers and administrators

continue to be presented with this ongoing challenge. As turnover rates in organizations

increase, staffing commonly becomes suboptimal and affects quality patient care, increases

service waiting time, and ultimately decreases the amount of services the hospital can offer

(Kleinman, 2004). In addition, turnover can have negative effects on remaining staff by

increasing their workload causing physical exhaustion and burnout. Given the current shortage,

Laschinger, Leiter, Day & Gilin (2009) suggest that every effort must be made to ensure that

nurses are exposed to high quality work environments that engage them with their work (p.

309).

Purpose Statement

The purpose of this project was to determine the top factors that contribute to nursing

staff severing their employment from an organization. Recognizing the factors that most

commonly influence nurse turnover and therefore decrease retention rates is essential for nurse

leaders in order to implement strategies that assist in increased retention of nurses. Research

questions for this study were: What are the top factors that influence nurses to leave

organizations? Is there a common theme for departure?

Current Evidence

The current registered nurse shortage is an international healthcare issue and is related to

many factors including the increase of nurse turnover. Barlow and Zangaro (2010) project that

the United States healthcare system will be short 500,000 registered nurses by 2025. There are

serious costs, both human and financial, related to this shortage. High quality patient care, patient
DECREASED RETENTION RATES 5

safety, employee safety, and employee satisfaction are just a few of the effects that have been

correlated to high turnover and decreased retention rates within an organization. In addition, the

cost endured by an organization with each staff turnover is estimated to be between $65,000 and

$88,000 (Barlow & Zangaro, 2010; Wieck, Dols & Landrum, 2010). Previously published

literature has suggested many factors contribute to decreased retention rates of registered nurses.

Factors previously identified that correlate with high turnover intentions include job satisfaction,

high staff demands, and perceived leadership support. Wallis and Kennedy (2013) state that

leadership that values staff contributions and promotes retention, autonomy and good working

relationships, and a management style that facilitates rather than directs are consistent with high

retention rates (p. 625). To make the challenge of retention even more difficult, a new

generation of nurses is emerging into the workplace with different workplace expectations. The

millennial generation is less career driven and, compared to past generations, have an increased

interest in balancing work and family (Wallis & Kennedy, 2013). Li and Jones (2013) suggest

that healthcare administers identify the reasons for staff turnover in an effort to implement

approaches to better allocate human an monetary resources, increase retention rates, and improve

the quality and safety of care provided to patients.

Theory

The Learned Needs Theory provided a framework for this project. This theory focuses on

the fact that regardless of gender, culture, or age, there are three motivating drivers (achievement,

affiliation, and power) that provide importance to an individual (McClellands Human

Motivation Theory, n.d.). The Learned Needs Theory suggests the lack of these drivers is

correlated with increased nurse turnover rates and decreased retention. As a result, emphasis was
DECREASED RETENTION RATES 6

put on the three motivating drivers (achievement, affiliation, and power) when reviewing exit

interviews.

Outcomes

Outcomes of this project include the clear understanding by nursing staff and

organizational leaders of the top reasons that contribute to nurse turnover and decreased nurse

retention rates. These results will assist in recommendations and future research of implemented

topic specific programs aimed at decreasing nurse turnover.

Project Map

This project is an evidence-synthesis design and will include the phases of preparation,

validation, translation, and evaluation (Bonnel & Smith, 2014). This project took place at

community hospital in the Midwest over a two month time frame. Exit interviews were obtained

at an executive level through the director of professional practice office (See Appendix A). Staff

nurse exit interviews from the past twelve months were reviewed. By narrowing review to the

last twelve months, the most current theme for nurse turnover within the organization were

identified.

Evaluation and Analysis

Credibility, dependability, and confirmability of data obtained were considered. A total of

fifty exit interviews were identified over the last twelve months. These interviews were collected,

reviewed, and analyzed based on common themes that nursing staff stated as reasons they were

departing from the organization. Demographic information provided during the interviews

included age of the departing employee and their length of employment prior to departure. In

addition, a table was created in Microsoft Excel and reasons stated for departure were labeled.
DECREASED RETENTION RATES 7

Based on data obtained, recommendations for further research and the implementation of topic

specific programs were made. No ethical considerations exist at this time.

Results

Using information provided by the exiting employees during the interviews (Appendix

A), it was determined that 64% (32) had been employed at the organization for less than 5 years

while the remaining 36% (18) had been employed for greater than 5 years. It should also be

noted that 36 of the departing employees were from the Millennial generation while the

remaining 14 fell under Generation X (See figure 1).

Figure 1

Age Characteristics of Nurses Who Departed The Organization Over the Past Tweleve Months
8

0
1960 1965 1970 1975 1980 1985 1990 1995 2000

As reasons were repeated during different exit interviews, themes began to emerge. Of

the fifty departing nurses, 32% (16) cited their reason for leaving was because bedside nursing

was not what they expected. Specific reasoning related to this answer included that patient

acuity is high, the work is stressful, and the inpatient setting is not a satisfier for these

nurses. Inconvenient twelve hour work shifts and weekend/holiday requirements were
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answers given by departing nurses that were factored into this theme. The second theme that

emerged was voiced by 24% (12) of nurses who were leaving the organization and was related to

scheduling paired with compensation. According to departing intention statements, many

registered nurses are leaving the direct care roles in the hospital setting and are making the same

amount of money in other nursing roles that are typically Monday through Friday jobs with no

holiday or weekend requirements. Historically, these nursing roles have not paid what nurses

could make in the hospital setting, but exiting nurses are now indicating that these

ambulatory/outpatient areas are paying just as much and in certain cases offering nurses more.

Some other reasons given for departure included lack of leadership support (22%), lack of breaks

(13%), and lack of time with patients (11%) (See figure 2).

Figure 2

Top Reasons Nurses Are Leaving The Organization

Schedul e Pa i red Wi th
Compens ation ; 23.53%

La ck Of
Beds i de Nurs i ng Is Not Leaders hi p/Support ;
What They Expect ; 21.57%
31.37%

La ck Of Breaks ; 12.75%
Lack Of Patient Ti me;
10.78%

Discussion
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The top two factors that contribute to nursing staff severing their employment from an

organization were recognized to be that bedside nursing was not what they expected and

scheduling paired with compensation. Recognizing that these are the top factors that influence

nurse turnover and therefore decrease retention rates is essential for leaders in order to

implement strategies that assist in increased retention of nurses. These themes were supported by

current evidence that suggested increased patient demands, heavy workloads, and high stress

levels were all reasons for an increased nurse turnover rate (Dawson, Stasa, Homer, et al., 2014).

Current evidence also suggested that the perception of lack of leadership from

management was a major factor that contributed to nurse turnover although this study failed to

prove that. Lack of leadership was given as a reason for departure in 22% of exit interviews.

Shared governance is a strong staple and vision of the organization studied, which may have

contributed to a lower number of nurses leaving for lack of leadership. It should be noted that

the majority of exit interviews were provided by employees of the millennial generation.

Evidence suggests that this group is less career driven and more focused on balancing their

work/family life (Wallis & Kennedy, 2013). The second most identified theme for leaving the

organization was identified as scheduling paired with compensation. This theme may be

emerging from the millennial generation whose priorities are different of past generations.

Strengths and Limitations

Strengths of this study include the standardized approach of obtaining exit interviews in

order to collect data and the low cost of the study. Many healthcare organizations encourage

departing employees to participate in exit interviews. As a result, this study can be replicated in

different organizations and areas over time to determine specific areas of improvement

organizational leaders should focus on in an effort to increase nurse retention. In addition, the
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cost of the study is minimal due to the fact that acquiring exit interviews is all that is needed to

analysis themes. A limitation of the study that has been identified is that this study only took

place in one organization instead of multiple facilities. While the results can be generalized, there

is no way of positively knowing, without a further population study that includes multiple

organizations, whether these results can be applied to all healthcare facilities.

Recommendations and Conclusion

Manion (2004) suggests that the way to create a culture of retention is, in fact, to create

a culture of engagement and contribution (p. 30). It is recommended that nurse leaders use these

results as a baseline in assessing their own staff to identify needs of improvement before actual

turnover occurs. Mentoring and preceptoring programs are valuable in meeting the challenges of

retention (Mbemba et al., 2013). These proposed programs would offer support and mentoring to

the new employee throughout the first three years instead of the typical one year. Trybou (2013)

cite social exchange and nurse support as influences to nurse retention. Although further research

is needed pertaining these programs, it is hypothesized that by continuing support throughout the

novice nurse stage retention rates of nurses with less than 5 years of employee will increase.

Implementing an assessment for all nursing staff that would assist in identifying strengths and

weaknesses in an effort to improve and energize peak work performance. It is recommended that

these programs are implemented during a trial period and then results measured following the

phase. Metrics to consider in the assessment of program success include nurse retention rates at 6

months, 1 year, 2 years, and 3 years, transfers to different departments during the first three

years, overpay time, and nurse satisfaction scores. It may also be helpful for nurse leaders to

identify and track which schools new graduates are coming from that are stronger nurses

clinically and professionally. This information can be used for focused recruitment efforts.
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Continuous efforts should be made by leaders to identify and improve perceived weaknesses in

order to run an efficient and effective healthcare organization whose nursing staff provides

patients with the highest quality care.

References
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Barlow, K. M., & Zangaro, G. A. (2010). Meta-analysis of the reliability and validity of the

Anticipated Turnover Scale across studies of registered nurses in the United States.

Journal Of Nursing Management, 18(7), 862873. https://doi.org/10.1111/j.1365-

2834.2010.01171.x

Bonnel, W., & Smith, K. V. (2014). Proposal writing for nursing capstones and clinical

projects. New York: Springer Publishing.

Duffield, C. M., Roche, M. A., Homer, C., Buchan, J., & Dimitrelis, S. (2014a). A comparative

review of nurse turnover rates and costs across countries. Journal Of Advanced Nursing,

70(12), 27032712. https://doi.org/10.1111/jan.12483

Dawson, A. J., Stasa, H., Roche, M. A., Homer, C. E., & Duffield, C. (2014). Nursing churn and

turnover in Australian hospitals: nurses perceptions and suggestions for supportive

strategies. BMC Nursing, 13(1), 11. doi:10.1186/1472-6955-13-11

Gormley, D. K. (2011b). Are we on the same page? Staff nurse and manager perceptions of work

environment, quality of care and anticipated nurse turnover. Journal Of Nursing

Management, 19(1), 3340. https://doi.org/10.1111/j.1365-2834.2010.01163.x

Kleinman, C. S. (2004). Leadership: a key strategy in staff nurse retention. Journal Of

Continuing Education In Nursing, 35(3), 128132. Retrieved from

https://stmary.idm.oclc.org/login?url=http://search.ebscohost.com/login.aspx?

direct=true&db=cmedm&AN=15195785&site=ehost-live

Lang, K. R. (2008). The professional ills of moral distress and nurse retention: is ethics education

an antidote? The American Journal Of Bioethics: AJOB, 8(4), 19.

https://doi.org/10.1080/15265160802147181
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Li, Y., & Jones, C. B. (2013). A literature review of nursing turnover costs. Journal Of Nursing

Management, 21(3), 405418. https://doi.org/10.1111/j.1365-2834.2012.01411.x

McClelland's Human Motivation Theory: Discovering What Drives Your Team. (n.d.). Retrieved

from https://www.mindtools.com/pages/article/human-motivation-theory.htm

OBrien-Pallas, L., Murphy, G. T., Shamian, J., Li, X., & Hayes, L. J. (2010b). Impact and

determinants of nurse turnover: a pan-Canadian study. Journal Of Nursing Management,

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Spence Laschinger, H. K., Leiter, M., Day, A., & Gilin, D. (2009). Workplace empowerment,

incivility, and burnout: impact on staff nurse recruitment and retention outcomes. Journal

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Tang, J. H.-C. (2003a). Evidence-based protocol. Nurse retention. Journal Of Gerontological

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Wallis, A., & Kennedy, K. I. (2013). Leadership training to improve nurse retention. Journal Of

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6198.2009.00159.x
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Appendix A

EXIT INTERVIEW FORM

EXIT INTERVIEW FORM

Employee Name ________________ Employee DOB______________

Job Title _______________ Employee ID _______________

Termination Date
Employee Name ________________ _______________
Employee DOB______________

Job Title _______________ Employee ID _______________

Reason for Termination
Termination Date _______________
Involuntary Voluntary
Layoff Reason for Termination
Personal Reasons
Position Eliminated
Involuntary Took Another Position
Voluntary
Attendance
Layoff Retirement
Personal Reasons
Reorganization
Position Eliminated Relocating
Took Another Position
Violation of Company Policy
Attendance Returning to School
Retirement
Other:
Reorganization Other: Relocating
Violation of Company Policy Returning to School
Other: Other:

Questionnaire
Questionnaire
What is your primary reason for leaving? If multiple, please specify.
What is your primary reason for leaving? If multiple, please specify.
Would
Would you youreturning
consider consider returning to this
to work for work for this company
company in the future?
in the future?

What did What

you find
didmost satisfying
you find about yourabout
most satisfying job? your job?

What did What

you find
didmost frustrating
you find about yourabout
most frustrating job? your job?