Nursing turnover rates, as reviewed in 25 articles published between 1990 and 2010, range from 9.49% to 250% [1]. Duffield and others [2] examined the nurse turnover rate and cost in Australia, Canada, New Zealand and the United States. New Zealand had the highest turnover rate (44.3%), followed by the United States (26.8%), Canada (19.9%), and then Australia (15.1%)The turnover costs per nurse were reported as highest in Australia ($48,790), followed by Canada ($26,652), New Zealand ($23,711), and the United States ($20,561). A significant proportion of nursing turnover costs was attributed to hiring temporary replacements for the nurses who left their jobs [2]. According to a report from Nursing Solutions, the average hospital cost for bedside registered nurse turnover was between 4.9 million and 7.6 million dollars per year [3].

Framework

Nurse retention is an important area to examine from a financial standpoint as well as from a nursing quality care view. Some of the reasons identified by nurses for leaving their nursing positions are directly related to patient safety and staffing concerns. Cowden and Cummings [4] proposed a theoretical model of clinical nurses’ intentions to stay. The theoretical model is composed of manager, organizational, work, and nurse characteristics. The interaction among the 4 types of characteristics described by Cowden and Cummings result in a cognitive and affective nurse response that ultimately leads to an intent to stay or leave decision. The model developed by Cowden and Cummings (2012) could be strengthened by including external factors, outside of the organization/work environment, that may impact the nurse intent to stay. Some of the proposed external factors include family and work/life balance issues.

Perhaps the place to begin looking at intent to stay is to first examine factors that lead to turnover intention. Takase [5] conducted a concept analysis of turnover intention. Internal and external antecedents lead to turnover intention, which is a part of the multi-stage process of leaving a nursing position. Some of the antecedents involve characteristics of working conditions such as workload, role stress, work schedule, level of autonomy, and interpersonal relations within organization. Additional antecedents involve organizational characteristics such as profitability, unionization, teaching or magnet status and organizational climate such as ethics, support, equality, justice, and power [5]. It is the perception of the antecedents that leads to a positive or negative psychological experience by the nurse.

According to Takase [5], turnover is a multi-stage process involving the nurse terminating current employment. The nurse employee experiences a negative psychological response resulting in a cognitive and behavioral withdrawal. The nurse withdrawal leads to the development of a cognitive turnover intention, which ends with an actual turnover event. Intervening during the multi-stage termination process might prevent nurse turnovers. This discussion paper will focus on interpersonal leadership strategies, targeting internal and external antecedents of nurse turnover, to improve nurses’ intent to stay at current nursing position.

Method

A literature review was conducted utilizing PubMed, CINAHL Plus, and PsycINFO for search terms “nurse retention”, “intent to stay”, “nurse turnover”, and “nursing leadership”. Abstracts for papers published between 2000 and 2017 were reviewed for relevance. Papers included in the review were examined for factors that contributed to nurse retention, nurse intent to stay or nurse turnover. Based on findings from the literature review, Cowden and Cummings Model of Clinical Nurses’ Intent to Stay, and thirty plus years of personal nursing experience, this discussion paper will propose leadership strategies for promoting nurse retention.

Discussion

Trust

Ever worked for a boss that you could not trust? How did you feel? Miserable? I have had this experience several times. When the words of your boss do not match his or her actions, which do you believe? When the boss communicates different messages based on their audience, what guidance do you follow? When something goes wrong, does the supervisor accept responsibility or always blame the subordinates? Does the leader support his/her people or blame them? How many people have left the workplace because of the leader? It is emotionally draining to work for someone whom you cannot trust. Trust is one of the components necessary for a person to feel safe in high risk and emotionally charged situations. When people do not trust, they begin protecting themselves from potential harm.

Most of the people that I have worked for during my career have demonstrated strong moral ethics. When looking at leadership, integrity is the core component of any leader. A leader with integrity will admit when he or she is wrong about a subject. A leader with integrity will accept responsibility when situations go wrong. A leader with integrity realizes that he or she does not know everything and needs others to help them discern the facts before drawing a conclusion. A person’s personal integrity is demonstrated through character. Integrity is doing the right thing even when no one is looking. Personal integrity is one of the characteristics demonstrated in successful nurse leaders [6-10].

Wieck, Prydun & Walsh [11] surveyed 108 nursing students and 126 hospital managers to rank 56 traits for the most desired and least desired in their leaders. The number one response of both groups was honesty. Honesty is vital to the establishment of a trusting relationship. Atiyeh and AbuAlRub [12] discovered that when the level of trust increased, the level of intent to stay at work for nurses also increased. Perhaps the sense of trust also promoted a sense of loyalty as demonstrated by the intent to stay.

There are two leadership styles that seem to focus on integrity and building trust, Authentic Leadership and Aesthetic Leadership. The attributes associated with authentic leadership include genuineness, trustworthiness, reliability, compassion and believability [13]. The American Association of Critical-Care Nurses [14] listed authentic leadership as the 6th critical element in establishing and sustaining healthy work environments. The authentic leader must have clear values and moral courage in order to maintain authentic leadership [15]. Aesthetic leadership in clinical nursing has been found to have an explicit moral dimension which included embodying principled practice, ethical leadership in ambiguous situations, and providing fair and just solutions. Nurses value clinical leaders who embrace and operate with a strong moral compass [10].

Authentic and aesthetic leadership styles do not build character, but they provide a framework for the leader with integrity to demonstrate the character necessary to establish a trusting relationship. The trusting relationship between the leader and nurse can create an environment where work issues, such as scheduling, patient case load, and overtime requirements, can be honestly discussed and collaborative solutions developed.

Loyalty

The truly great leaders that I have had the privilege to work with realize that it is the leadership position that holds the authority and not the person. In other words, a true leader realizes that “it is not about me”, it is about accomplishing the mission, goals, and responsibility of the position in which I have been appointed with integrity. These leaders are focused on others and inspire others to trust them. Leaders who are others’ focused promote strong sense of loyalty in subordinates. Sometimes this loyalty may continue even after the subordinate no longer works for the leader or at the organization. If called upon, the subordinate may respond not because they “have to” but because they “want to” help. Loyalty can be a strong motivator for action.

Rodwell, Williams, and Gulyas [16] found that loyalty had a direct, specific, and tight relationship to the nurses’ intent to stay or leave. Loyalty is defined as a strong feeling of support or allegiance [17]. Loyalty, as demonstrated through an affective commitment to the supervisor, was found to be most strongly related to job satisfaction and nurse well-being [18]. Positive affective responses can influence a nurse’s intent to stay based on Cowden and Cummings Model [4] or a nurse’s turnover process [5].

Employee loyalty is earned through consistent behaviors and demonstrated loyalty from the leader to the nurse. Staff nurses often work long hours and sacrifice time with their families to ensure the care of their patients. It is important that their supervisors recognize the nurse sacrifice and provide opportunities for the nurse’s growth and development. The first step in creating loyalty is to create a culture of respect. Role model respectful behaviors. Listen to concerns, issues, and especially success stories. Establish respectful behaviors as a priority and promote zero tolerance of disrespectful behaviors to help build a unit culture of respect.

Ensure that you assess for any sign of emotional or physical withdrawal. Withdrawal can indicate a negative psychological or cognitive experience by the nurse. Correcting misperceptions, restoring communication, and empathizing with hurt feelings can go a long way in building team cohesion. Take care of your personnel and they will take care of the mission. When the hard times come, support your staff to work through the conflicts in a respectful manner. This support will help nurses become more confident in your leadership, which in turn helps build trust and loyalty.

Safety/Security

Safety is identified as the second level, just above the physiological needs, in Maslow’s hierarch of needs model [19]. The physiological needs are the basic requirements for human survival, such as food, water, clothing and shelter. In theory, once the physiological needs are gratified, then the safety takes precedence and dominates behavior (Maslow [19]). Arruda [20] proposed that Maslow’s hierarch can be applied to nurse retention. Some areas of safety identified within nursing care nurse-to-patient ratios, exposures to hazardous agents and infections, and workplace abuse/ violence.

It is scary to work undermanned in an acute care setting, taking care of severely ill patients. In the unit culture, sometimes those who complain about understaffing are considered whiners. As a new nurse, I did not want to be considered a “whiner”. During my early years of nursing practice, I often worked short-staffed. I remember after certain shifts feeling literally ill and thinking there is no way that I can continue to work here. The emotional labor of working with the fear that “something bad is going to happen” just drained all of my energy. It was not the feeling busy or working hard that produced the uncomfortable feeling, but the concern for patient safety.

Nurses want to provide safe care. Nurse retention has been positively correlated with a safety climate [21,22]. Nurse collaboration has been positively associated with quality of patient care and nurse intention to stay [23]. But, adequate nurse staffing levels is an ongoing issue within the profession that can negatively impact the quality of care that is provided within the nursing work environment.

Nantsupawat and others [24] conducted a survey in a stratified random sample of 1412 registered nurse who provided direct patient care in Thailand. The reported average number of patients per nurse ratio was 11, with a range of 6 to 15 patients per nurse. The investigators discovered that for each additional patient added to the nurse case load, the reported needle stick and sharps injuries increased by 4%. Workload was one of the antecedents identified by Takase [5] that led to nurse turnover. Furthermore, insufficient resources and inability to ensure quality patient care were important factors in nurse managers’ intention to leave their job [25].

On the other hand, when there is lower nurse to patient ratio, the outcomes have been positive. When hospitals followed the California-mandated nurse to patient ratios, facilities in three states reported a decrease in nurse dissatisfaction, less nurse burnout, and better quality of patient care [26]. Creating staffing models that adhere to recommended nurse to patient ratios may be one way to create a better patient safety climate. Dykstra and Bridges [27] created an intensity index scorecard as a method for nurse workload-leveling. Utilizing the tool provided a quantifiable way for nurse managers to make patient assignments, make staffing decisions, and rotate admissions.

Nurses also want to work in a safe work environment that is free from abuse and violence [20]. There is a growing body of knowledge in the nursing literature on incivility, sometimes identified as nurse mobbing. Incivility is a low intensity deviant behavior that is characterized by ambiguous intent [28]. Cowden and Cummings [4] identified abuse as one of the factors in their model that is associated with nurse intent to leave their employment. Wellbourne and Sariol [28] proposed that because incivility is subtle in comparison to other deviant workplace behavior, it may often go unaddressed with the potential to spiral into increasingly deviant behaviors. Incivility in nursing occurs mainly through nurse to nurse horizontal behaviors [29]. A potential source to the nurse incivility might be related to nurses being considered an oppressed group. Historically, nursing has been viewed as being oppressed through medical dominance and gender dominance of a predominately female profession [29].

Incivility was one of the factors correlated with nurses’ turnover intentions [4,30]. Several studies have identified that the leadership relationship can have a strong impact on reducing the risk for incivility on the nursing units [31-33]. Authentic leadership can have a direct negative effect on bullying and an indirect effect on lower turnover intention, burn out and emotional exhaustion [34]. Good leaders can reduce the incidence of nurse incivility and create a safe work culture. Good leaders should set the expectation early that incivility and disrespectful behaviors will not be tolerated.

Another type of safety/ security may be related to job security and benefits. In Jordan, nurses who worked in public hospitals as government employees with permanent contracts reported a significant higher intent to stay than nurses who worked in for profit, private sector hospitals with yearly contracts [35]. Similarly, in Mainland China, nurses who worked in tertiary hospitals, which tended to have higher pay and better retirement benefits, had a greater intent to stay than nurses who worked in primary and secondary hospitals [36]. In addition to type of hospital, older nurses reported a much higher intent to stay in nursing profession than younger nurses in China and in Canada [36,37]. Support employees in obtaining a secure retirement with benefits for their families is a leadership strategy that can promote nurse retention.

Support

According to the Oxford Dictionary, support can be defined as to bear the weight; to give assistance; and to give approval, comfort or encouragement [17]. Support is particularly important to employees who are carers [38]. Husbands advocate that carers are often the “forgotten community”, because the person who is ill often gets the attention [38]. Providing support for employees during this period of time when they are carers for ill family members at home can promote a sense of loyalty and commitment [38]. The same is true within nursing. When a nurse is caring for ill family members at home and caring for patients at work, finding balance can be very difficult. The supervisor who supports a nurse through a very difficult time is not forgotten. Although Cowden and Cummings (2012) did not include external factors outside the organization as a component of their model, extended family issues can be a factor that affects a nurse’s decision to leave the workplace. Support that goes beyond the immediate organization can foster a stronger sense of loyalty from the employee.

I have found that little acts of kindness such as flexibility with shift work, sending a card, or just listening to a nurse talk about the loss of a loved one can make all of the difference in building a supportive relationship that ultimately results in nurse retention. When I have invested my time and efforts into supporting nurses who have been going through a difficult time, I have discovered that they bounce back stronger and more willing to invest and contribute to the organization. Feeling valued by an organization must come through the people. Supervisors who demonstrate caring support for their nurses can make all of the difference in nurse retention.

There are many articles that discuss the importance of leadership support. For example, in a study of 514 Thai nurses, high strain was associated with low intent to stay at work. Using multiple regression analysis, intent to stay was significantly and positively correlated with supervisor support among the nurses with high-strain jobs and with coworker support in nurses with active jobs [39]. Rod well and others [16] discovered that nurses who felt like they contributed within the leader-member exchange were more engaged and intended to stay in their current employment. Nei, Snyder, and Litwiller [40] found in a meta-analysis that supportive and communicative leadership are two of the strongest predictors of nurses’ intent to stay. The key is to provide the support and to communicate the support in a manner that is meaningful to the nurse.

Appreciation for contribution

Appreciation is basically creating in an environment where employees feel that others care about them. Some precursors for creating a work environment where people feel “cared for” involves a management style that stimulates trust, a spirit of teamwork and safety, structured times to be heard, managers who listen, a drama-free positive attitude, collaboration and autonomy [41]. But creating a healthy environment is only one part of the puzzle to helping a nurse feel appreciated. The appreciation must be communicated in a manner that the nurse values. In order to know how the nurse wants the appreciation to be expressed, the supervisor must first know and understand the nurse.

According to White (2012), there are 5 components for employees to feel appreciated. The first is that appreciation must be communicated individually and personally. Secondly, the language of appreciation chosen by the communicator must fit the desired language of appreciation of the employee [42]. The five basic languages of appreciation include words of affirmation, quality time, acts of service, tangible gifts, and appropriate physical touch [43]. The third component for the employee to feel appreciated is that the actions of the supervisor must be valued by the recipient [42]. In order to understand what the employee values, the supervisor must assess the employee’s preference. The fourth component is that appreciation needs to be communicated regularly and not just once a year. And finally, the communication of appreciation needs to be done so in a way that is perceived as genuine and authentic [42].

There are many ways that appreciation may be demonstrated, such as in praise and recognition, staff development, and professional advancement opportunities. Appreciation is a positive affective experience that is felt by the nurse. Therefore, it is the nurse employee interpretation of the action intended to communicate appreciation that determines the psychological experience. In order to communicate appreciation effectively, nurse leaders must know their subordinates and understand which forms of demonstrated appreciation work best for the individuals in order to produce a positive experience. Positive affective experiences are associated with positive nurse intent to stay [4] and reduced nurse turnover intention [5].

Conclusion

Nursing for most is not just a profession, but a call of service. Nursing is consistently one of the most respected and trusted professions. Nurses promote the health of others. Nurse leaders should strive to create environments that promote the health and well-being of nurses. Choosing the right type of nurse leader is crucial to this process. It is important that a nurse leader demonstrates integrity to create an atmosphere of trust. Loyalty should go both ways between the nurses and the nurse leader. Nurses should be able to work within an environment in which everyone is treated with respect and appreciated for their contribution to patient care. The workload for nurses needs to be manageable so that the patient does not suffer because of staffing inadequacies. Finally, the nurses should feel supported and empowered to grow as individuals and to provide a significant contribution to healthcare. Creating a healthy work environment requires leaders who are willing to listen, take a strong moral stance, and stay connected to the needs of the nurses on the unit.

There are multiple areas within Cowden and Cummings’ Model where nurse leaders can positively impact nurses’ intent to stay. Nurse leaders can modify the way they interact with other nurses to promote team building and cohesion. Nurse leaders can facilitate positive changes within the organization and work environments, such as promoting professional development, effective staffing ratios, and a safe work environment. Nurse leaders can support nurses when external events occur, such as having to act as caregivers for their own families.

No nurse leader ever arrives; it is a constant process of learning and developing. Nurse leaders should reflect on their actions, decisions, and impact on others. An effective nurse leader is one of the strongest tools for promoting nurse retention. Nurse leaders are in a position to be the change agents for creating environments where nurses want to stay. I challenge you to be the nurse leader that you would love to have as a supervisor. All nurses are leaders. All leaders will make an impact. What type of impact will you choose to make as a nurse leader?

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