keepingThe entire staff was surprised to hear that Chris was leaving the unit to take a position across town. This was a real blow to the whole crew. Chris was a fabulous nurse who provided excellent care and always helped others. She worked hard to remain up to date on everything from new policies and procedures to the latest in medication administration and technology. The staff so enjoyed working with her that frequently they would look at the schedule to see if she was working their shift. She had told no one she was leaving, but no one had asked. Now she was gone.

When it comes to recruitment, retention is your best strategy. Quality workplaces attract quality staff and employers and nurses across the nation need to make nurse retention a high priority. For years, employers have invested a majority of their resources in a recruitment revolving door. Large signing bonuses, free trips to Disney World and even pet health insurance have been used to entice nurses.

In reality, no matter what incentives are offered, skilled professionals won’t hang in there unless an employer provides meaningful work and creates an environment that meets professional and personal needs.1 While health care employers must focus on providing quality patient care, a primary goal for achieving that mission is to provide a quality work environment that holds on to its nurses.

At What Price?

The cost of replacing a staff nurse is estimated to run as high as 1.2 to 1.3 times the nurse’s annual salary.2,3 Replacing a nurse with additional training, such as critical care or labor and delivery, may cost even more. High turnover produces staggering replacement costs. And let’s face it — if these costs were lowered, funds could be redirected to improving patient care services and the workplace environment.

Keeping the best nurses helps improve worker morale. Consider the extra workload that unfilled positions put on the nurses who remain. Vacancy rates of 2% to 3% in medium- to large-size staffs are manageable, since a group can collectively work the overtime needed to cover these open positions. But, as vacancy rates increase, nurses may experience loss of empowerment, incivility and burnout.4 Morale starts to plummet, and nurses begin leaving because it seems that everyone else is doing the same.

On the whole, retaining nurses reduces errors and improves continuity of care.5 Knowing the skills, strengths and routines of coworkers allows nurses to focus on evolving patient care demands. As trust in coworkers’ abilities is developed, nurses are more assured that delegated tasks will be completed. But when staff is pulled from another unit or a travel nurse arrives to fill a temporary staffing need, time and energy are redirected away from patient care to orienting all personnel on the unit.

The lesson here is that ultimately, retaining staff improves productivity and quality patient care. Activities such as transporting lab specimens, obtaining supplies and completing mounds of paperwork remove nurses from patient rooms and should be minimized. There’s an old saying: “Take care of the nurses and they will take care of the patients.”

That’s the nurse manager’s job, right? Wrong. While much of the responsibility for nurse retention has been placed on the nurse hierarchy, nurses themselves must take an active role in understanding why colleagues remain and help develop a work environment that promotes retention of nurse colleagues.

Where the Grass Is Greener

What makes a nurse want to look for greener pastures? Nurses can choose from a variety of jobs. Typically, though, multiple job options don’t cause a nurse to quit. Why a nurse leaves can be based on a number of factors, but the most frequent reasons fall into five categories: 6

• Intense workload

• Lack of scheduling flexibility

• Low compensation

• Inadequate access to continuing education

• Minimal opportunity for career growth

Workload is a major issue for nurses. At the very least, nurses want to complete their shift knowing they have provided the care encompassed in their patient-care assignment. Health care differs greatly from other employment settings. As acuity rates rise, lengths of stay are compressed and nurses are assigned larger patient loads. Meeting the goals of quality patient care and even patient safety needs may be overwhelming — perhaps impossible. The perception of unsafe, unbearable or even unfair workloads can put a nurse over the edge.

Scheduling flexibility may take precedence, as well. Job seekers have many career options that offer much more flexibility than that of an RN. Look at information technology jobs that even allow you to set your own work times and schedule. Though health care must be available 24 hours a day, to attract employees, employers need to provide flexibility through four-, eight- and 12-hour shifts, as well as a variety of full-time and part-time options. With the high value placed on family, recreation and time away from work today, health care employers need to provide scheduling options that are both worker and family friendly.

Provide competitive compensation and benefit packages. Employers should pay their staff fairly and review compensation levels at least twice a year to make sure they remain competitive. It all makes good sense. Look around you — employers with high retention rates include flexible benefit programs and consistently provide competitive salaries.

The constant advances in medical science and treatment can make keeping up to date a Herculean task. But doing so is the cornerstone of improving patient care and outcomes. Nurses know that staying abreast of new skills, procedures and medications is vital to their practice. Yet in many settings, as budgets are tightened, continuing education is often put on the chopping block. Providing continuing education in a variety of user-friendly formats is a key to retaining nurses.

Last but not least, there’s career growth. To retain nurses, employers need to provide opportunities for nurses to explore their potential. For many years, excellent bedside nurses who looked for ways to boost their earning power or develop additional expertise were limited to manager or educator positions. Many, however, found that their passion was to remain at the bedside. Clinical care models that recognize expanded levels of patient care expertise would recognize and reward professional growth in direct patient care. Here’s another area in which employers need to develop strategies that encourage nurses to develop personal and professional growth and expertise.

Nurses can use a variety of strategies to directly influence the workplace even though their employer may determine workload, schedules, compensation, continuing education and career growth. Looking closely at each of these areas can help build a workplace environment that retains nurses as well as other health care personnel. And while nurse managers are being asked to improve their retention skills, creating such a workplace environment is everyone’s responsibility.

Hold on to What You’ve Got

We nurses are great at providing care to patients, but how good are we at taking care of our own nurse colleagues? The bottom line is we all need to accept responsibility for creating a positive workplace environment. Let’s acknowledge positive work behaviors and suggest ways to improve behavior that detracts from a personally and professionally fulfilling workplace.

We need to turn some things around. Let’s think outside the box: Instead of giving a going-away party for colleagues who are leaving, why not throw a “welcome to the unit” party for those who’ve decided to join you? Consider giving staff nurses an opportunity to interview job candidates to get their take on how well that person might fit into the unit work culture. Once they arrive, welcome them with open arms. Be flexible with start dates and pair new employees with seasoned nurse preceptors who have similar interests. If you’re bringing in new graduates, connect them with one of your excellent nurse colleagues who’s been out of school for two or three years. He or she will remember what it felt like to be a novice. Tell them where the hidden supplies are located, and describe the different nurse preferences on the unit. Help them learn to blend into and shape workplace culture.

Approach colleagues already in your workplace in a professional manner to discuss how behaviors affect the work environment. If a colleague consistently arrives late or tasks are not completed, talk with him or her about the impact that has on you. You might even openly discuss some of these issues in staff meetings and determine as a group what is acceptable and what is not. Certainly, discuss workload situations when you feel it influences patient or nurse safety.

Communicate openly and honestly with your nurse manager. There’s a difference between complaining and communicating pertinent issues. Approach your manager with a “What can we do about this?” attitude versus a “What are you going to do about this?” attitude. As actions are taken to address particular issues, clearly communicate these improvements to your colleagues and staff.

Suggest developing a retention committee on your unit. Talk about how to create a quality workplace. The committee may wish to survey staff or hold focus groups to determine priority retention issues. Members might collect information from other employers about how they distribute nurse workloads. The committee might compare and contrast scheduling models in other health care settings and develop a unique model to meet staff needs. It could develop a process for gathering nurse input by piloting the model before implementation. Self-scheduling may even be a part of the model.

The retention committee would be an excellent way to develop clinical advancement programs for your unit. Tracks for management and education can be implemented for those nurses interested in these areas. You’ll certainly need to get buy-in from administration, but you should also help administrators understand the need for direct care nurses to improve salaries, grow professionally, and continue to provide direct patient care. Clinical advancement programs that provide higher salaries for expert levels of clinical expertise are an integral part of a professional work environment.

Help administration develop compensation methods that reward productivity. Request that the human resources department provides a written annual update on individual compensation packages. Many nurses are unaware of how much their employers contribute to fringe benefits.

Nursing staff can discuss new competencies and skills required on your unit. Inform staff development personnel of the evolving clinical challenges nurses face as acuity levels rise. Also, include suggestions on education topics that improve the workplace, such as communication, teamwork and quality improvement. And encourage programs that improve both work life and home life, such as stress reduction and financial management. Maintain a personal continuing education file and look at a variety of options from which to obtain offerings, such as professional journals and online courses.

Nurse-physician communication and work relationships are reported as a retention issue in a number of agencies. Many facilities have developed and implemented nurse-physician policies that outline unacceptable behavior, a process for reporting that behavior, and recourse for correcting it. Not only will you want to promote a culture of trust and respect with physicians, but you’ll also want to value each employee’s unique contribution in nurse-to-nurse and nurse-to-nurse assistant communication. Any communication or behavior that demeans another should not be tolerated in workplace interactions.

Encourage employers to develop nurse council governance structures that promote nurse autonomy and allow nurses to provide input into workplace decisions.7 Council members usually consist of nurses elected to represent various units and/or committees in an agency.

Differences Definitely Make a Difference

Be aware of colleagues’ and your own behaviors that exclude others because they’re “different.” Understand that difference can be a great thing. Health care requires diverse ideas to care for our patients and provide a quality work environment.

Nurses need to embrace diversity in the workplace. While we want to encourage colleagues to conform to mutually agreed-upon work and performance standards, we also should recognize individual preferences and differences. We need to be open-minded and willing to learn from others. And not just the skills and competencies of nursing care — we need to learn and appreciate the individual perspectives that each person brings to the job. We need to be open to exploring and understanding how colleagues perceive health care and the world differently.

When diversity is discussed, the immediate thought or focus is usually ethnic background — African American, Asian, Caucasian, Latino, Native American, and so on. There’s no reason to categorize individuals, because we’re all different. Diversity is broad and includes many differences in our nursing workforce, including age, disability, ethnic or national origin, gender, race, religion, sexual orientation and a number of other attributes. There’s diversity in marital status, values and beliefs. There’s even geographical diversity — east coast and west coast, northern and southern, and rural and urban. Then, there’s short and tall, skinny and — well, you get the picture. We’re all different.

And what difference do differences make? They can help patients quickly identify with particular caregivers. Diverse skill sets and expertise allow teams of nurses to provide care for a wider variety of patient needs. Think about how overwhelming it would be if the skills of only one nurse were available to care for the patient needs of an entire unit. Differences shape the work culture of a unit. And how a nurse reacts to colleagues’ differences can either encourage or discourage them from remaining on your unit.

Employ inclusive rather than exclusive practices with your colleagues. Exclusive practices include stereotyping, making assumptions about colleagues’ preferences, or deciding it’s their responsibility to blend into your workplace. Look for opportunities to include colleagues and make them feel an integral part of the work culture. As nurses are introduced to your unit, invite them to go on break. Offer to make yourself available if they have questions and touch base often to see how they’re doing.

Use the Platinum Rule instead of the Golden Rule. Treat others the way they prefer to be treated rather than treating others the way you would like to be treated. We can use similar assessment techniques that we use with our patients — ask. Watch for nonverbal cues. When you observe that something is not quite right with a colleague, ask if something you did offended the person and how you might respond more appropriately in future interactions. Don’t be quick to criticize and react. Seek to understand others’ points of view.

Agree to disagree. Recognize and value individual nurse contributions, but you don’t always have to agree with colleagues’ ideas and opinions.7 However, you can be respectful in how you disagree. And if it’s an issue you feel passionate about, choose carefully when, where and how you express your beliefs. You might decide that a political rally would be appropriate, whereas a staff meeting might not be the place or the time to express your sentiments.

Groups Requiring Special Retention Attention

While retention efforts are important for all nurses, there are a couple of groups for which you’ll want to develop specific strategies. One is new graduates and the other is mature or experienced nurses. Retention strategies must be individualized to meet specific needs of individuals and groups.

Much has been written on the challenges new nurse grads face as they move into the workplace. New graduates require transitional support through orientations, internships, residencies, preceptors, mentors, and close assessment and monitoring as they move from academia and acquire “real world” work experience. Some employers feel they’re providing adequate orientation periods of three months. However, evidence is revealing that new graduates begin to integrate evidence-based practice in the six- to 12-month period, and that can be the most difficult role adjustment time period. Therefore, they are most likely to become disillusioned with nursing and leave six to 12 months after starting their first job.8 Employers must work closely with new graduates throughout the first year and provide transitional support well into the second year.

Mature nurses 50 years and older are the fastest growing segment of the nurse workforce and they can make up anywhere from one-fourth to one-half of your nursing staff. You’ll want to pay close attention to this group, as they are probably already considering retirement and it’s a great opportunity to develop strategies that might encourage them to continue in the workforce. Some hospitals are developing “Rehire Retirees” programs, but why would you ever want to let your highly valued employees leave? One of the best strategies for retaining valued nurses considering retirement is to ask, “What can we do to keep you?”

Consider work environment improvement strategies such as including larger text and fonts and improved lighting on your units. Implement lift technologies and use supply, specimen, and patient delivery services. Maximize schedule flexibility and scheduling options by incorporating compressed work schedules, flexible start and stop times and job sharing alternatives. Consider three-month and six-month contracts for your mature nurses who want to travel or your “snowbirds” who migrate from colder to warmer climates in the winter. Make sure you offer phased retirement options, since only about one-half of mature nurses plan to work full time up to their final day of retirement. That means the other half will be looking for phased retirement options such as working 30 hours a week and filling in 10 hours from retirement pay, working six months and taking off six months on retirement pay, drawing retirement pay and supplementing with contract work, or maybe working one day a week for insurance benefits. If you don’t offer options, these nurses may look somewhere else. Also, offer benefits that address specific needs of mature nurses such as health insurance and retirement contribution or catch-up programs.

Both new graduates and mature nurses require special retention attention. While both groups sit at opposite ends of the workforce continuum, specific strategies can be developed and implemented to address the individual needs of each and assure a capable and competent nurse workforce.

Know Your Colleagues

Talk occasionally with nurse colleagues to find out how they’re feeling about their work and their workplace environment. Ask how your unit can make their work more meaningful. Ask how you can help improve your workplace. Ask about areas that would make work more enjoyable for them. Be on the lookout for signs of employee discontent, such as argumentative behavior, episodes of absenteeism and distancing themselves from fellow employees. Intervene immediately by talking with your colleague to determine what needs to be done to rectify the situation. Keep the lines of communication open.

When you arrive at work each day, remember that each employee plays an integral part in making the workplace exciting and rewarding. Administrators, managers, educators and individual nurses play an important role in retaining our colleagues. Nurse retention is everyone’s business.

Dennis Sherrod, RN, EdD, is the Forsyth Medical Center endowed chair of recruitment and retention at Winston-Salem State University, Winston-Salem, N.C. The author has declared no real or perceived conflict of interest that relates to this educational activity.

References

1. Tourangeau AE, Cummings G, Cranley LA, Ferron EM, Harvey S. Determinants of hospital nurse retention to remain employed: broadening our understanding. J Adv Nurs. 2010;66(1):22-32.

2. Jones CB. The costs of nurse turnover: part 1: an economic perspective. J Nurs Adm. 2004;34(12):562-570.

3. Jones CB. The costs of nurse turnover, part 2: application of the nursing turnover cost calculation methodology. J Nurs Adm. 2005:35(1):41-49.

4. Spence Laschinger HK, Leiter M, Day A, Gilin D. Workplace empowerment, incivility, and burnout: impact on staff nurse recruitment and retention outcomes. J Nurs Manag. 2009;17(3):302-311.

5. Committee on the Work Environment for Nurses and Patient Safety, Board on Health Care Services, Institute of Medicine. Keeping Patients Safe: Transforming the Work Environment of Nurses. Washington, DC: The National Academies Press; 2004.

6. Cohen S, Sherrod D, Beckley NJ. The Essential Guide to Recruitment and Retention: Skills for Therapy Managers. Marblehead, MA: Opus Communications; 2007.

7. Wieck K, Dols J, Landrum, P. Retention priorities for the intergenerational nurse workforce. Nursing Forum. 2010;45(1):7-17.

8. Ferguson LM, Day RA. Challenges for new nurses in evidence-based practice. J Nurs Manag. 2007;15: