Why do experienced ward nurses leave acute settings? This is a timely question during the COVID-19 pandemic with the additional pressure it has put on hospital nurses, and many others in the profession.
This issue is near to my heart, as I produced an integrative review on this topic as part of my master’s studies and this article has been produced from that research. The search terms used in my review were: tertiary, in-patient, acute, RN, nurse, leave, retention, stay, turnover and attrition, and the timeframe for the search was 2009-2019. Electronic databases searched included CINAHL Complete, Cochrane Library, ProQuest, PubMed, MEDLINE Complete, Clinical Key, Science Direct, Health Business Elite and Nursing Reference Center Plus. Thirty-six primary studies were evaluated and 16 met the selection criteria for inclusion in the integrated review.
Junior staff in majority
Also, I have been employed by a large tertiary hospital for the last 16 years, the majority of that time as a staff nurse working in various acute wards. Reflecting on the past 16 years, I realise I have lost many experienced and knowledgeable colleagues from the acute setting and I have worked as a staff nurse in areas with up to 75 per cent junior staff as a result of nurse attrition.
Rising nurse turnover has become a major concern globally, with the World Health Organization (WHO) urging countries to institute policies to stem the attrition of nurses.1
High experienced-nurse turnover in acute hospital wards and units affects the quality of patient assessment and care, as these nurses perform assessments and recognise patient deterioration quickly.2, 3
New Zealand has some of the worst statistics for nurse retention in the developed world. A New Zealand study carried out between 2004 and 2006 revealed a nurse turnover rate of 44.3 per cent – nearly three times higher than Australia.4 It is important to know why experienced nurses are leaving acute settings, as nurses are the largest workforce in health care and most of the nursing workforce is employed in acute settings.1, 5, 6 Retaining experienced nurses in acute care hospital settings is important because patient safety is linked to adequate staffing and skill mix.7
Adverse patient events and medication errors increase in areas of high experienced-nurse turnover. This turnover leads to inadequate staffing, potentially increasing length of hospital stay and contributing to patient mortality or delayed recovery.8, 9, 10, 11
Each experienced nurse lost to acute care in New Zealand is equal to half the salary of a nurse – approximately $30,000 – due to the costs involved in replacing them. These costs include advertising, training, temporary staffing and orientation periods,12 which are additional costs for district health boards (DHBs). With current DHB debt, and the cost of nurse turnover, retaining nurses in the workplace is important.
Implementing retention strategies for experienced nurses could save organisations substantial amounts of money.13
The three themes that emerged from my integrative review were:
- workload; and
- professional development.
The first theme of support included factors such as organisational and manager support, appreciation and relationships with co-workers. A perceived lack of support or recognition from the employing organisation and its management was a major reason why nurses intended leaving their workplace.
Nurses felt ‘unappreciated’
Nurses felt unappreciated and their skills and knowledge unrecognised at a direct manager and organisational level. Having a manager who didn’t offer help when staff were busy, was not visible on the ward, or was insensitive to staff needs were also identified as reasons staff intended to leave.14, 15, 16, 17
Unapproachable managers who didn’t listen to staff needs or support staff when there were complaints, led many respondents to voice an intention to leave.
Unapproachable managers who didn’t listen to staff needs or support staff when there were complaints, led many respondents to voice an intention to leave. Lack of support from colleagues, along with bullying, mistrust, fault-finding, and disrespect among colleagues led to dissatisfaction with work and intent to leave. 14, 16, 17, 18, 19, 20
The second theme related to workload, including patient acuity, poor staffing, and high nurse workload. Coupled with this was the perception that health was treated as a business and was no longer patient-centred. Nurses suggested patients’ needs were getting more complex, but the nurse-to-patient ratio remained the same, and working short-staffed was becoming more common.
More paperwork and documentation with less time for patient care left nurses feeling dissatisfied and with a sense they had not provided quality care.
Increased patient acuity in the acute setting has been identified as the reason many nurses intended to leave their workplace.14, 19, 21, 22 Experienced nurses reported having the most complex patient load and being required to support their junior colleagues with their unwell/high acuity patients, leading to feelings of being overwhelmed.22, 23 More paperwork and documentation, with less time for patient care left nurses feeling dissatisfied and with a sense they had not provided quality care.15, 22, 24
In one New Zealand study, nearly half of nurses who had left said they would have stayed in their workplace if there had been more staff on the wards.25 Inadequate staffing leads to feelings of job dissatisfaction, emotional exhaustion and burnout, as staff have less time for patient care.14, 21, 22, 25, 26, 27
A perception that health care had become business-focused was a reason some nurses intended to leave 17, 27 because they perceived nursing was no longer patient-centred and this led to less personal satisfaction in their role. Nurses felt the real rewards in nursing were forming relationships with patients and providing quality care, which was no longer possible in the business-driven model of health care.17
The third theme related to professional factors, including career and professional development and participation in hospital affairs. Perceived poor education opportunities, along with limited possibilities to upskill, were reasons nurses left their workplace. The education nurses wanted was directly related to the job they were employed to do, so when they couldn’t access this learning, they felt dissatisfied and this led to an intent to leave.20, 24, 26, 28, 29 Some nurses felt their employing hospital made decisions without consulting nursing staff and some of these decisions made it difficult for them to give quality patient care.26, 27, 30
Recommendations from this integrative review included:
- educating nurse managers about leadership and strategies to support nurses;
- recognising the value of nursing staff;
- increasing manager visibility on the wards;
- improving communication with nurses;
- fostering collegial and professional relationships between nurses;
- involving nurses in decision-making and policy development at an organisational level;
- providing paid leave for professional development and education;
- instituting professional recognition and reward programmes,
- decreasing nurse-patient ratios; and
- managing workloads safely.
There was limited recent New Zealand research on this topic, so another recommendation was for further research involving New Zealand nurses.
With 2020 designated the International year of the Nurse and Midwife by the WHO and the crucial role of nurses in the COVID-19 pandemic, the value of nurses should be obvious to all those involved in health care. That does not appear to be the case in the initial DHB multi-employer collective agreement offer which has been roundly rejected by nurses. The offer did not appreciate or recognise nurses’ skills, flexibility or work ethic, especially in this uncertain time and is likely to exacerbate the exit of experienced nurses from the sector. If DHBs want to retain these nurses, then the offer needs to reflect the importance of the nursing workforce in health care.
Large numbers of experienced nurses are still leaving acute settings. To ensure quality care, nurse satisfaction and to increase the future nursing workforce, we must find strategies – and properly valuing nurses’ work is a key one – to stem this attrition.
Janine Ellison, RN, BN, MN, is a nurse educator in the professional development unit at Waikato District Health Board, with the older persons and rehabilitation service portfolio.
- World Health Organization. (2016). Global strategic directions for strengthening nursing and midwifery 2016-2022.
- Hirschkorn, C., West, T., Hill, K., Cleary, B., & Hewlett, P. (2010). Experienced nurse retention strategies: What can be learned from top-performing organisations. Journal of Nursing Administration, 40(11), 463-467. doi.org/10.1097/NNA.0b013e3181f88fd3
- Perkins, S. (2009, Oct). Ways to retain experienced nurses. Trustee, 62(9), 4.
- Hughes, V. (2017). Leadership strategies to promote nurse retention (PDF, 186 KB). Scientific Journal of Nursing & Practice, 1(11), 001-005.
- Huntington, A., Gilmour, J., Tuckett, A., Neville, S., Wilson, D., & Turner, C. (2011). Is anybody listening? A qualitative study of nurses’ reflections on practice. Journal of Clinical Nursing, 20, 1413-1422. doi.org/10.1111/j.1365-2702.2010.03602.x
- Nursing Council of New Zealand. (2017). The New Zealand Nursing Workforce: A profile of Nurse Practitioners, Registered Nurses and Enrolled Nurses 2016-2017.
- Menella, H. (2018). Retention of healthcare personnel: Retaining older nurses: Evidence-based care sheet CEU. CINAHL Nursing Guide.
- Buffington, A., Zwink, J., Fink, R., DeVine, D., & Sanders, C. (2012). Factors affecting nurse retention at an academic Magnet hospital. Journal of Nursing Administration, 42(5), 273-281. doi.org/10.1097/NNA.0b013e3182433812
- Fagerstrom, L., Kinnunen, M., & Saarela, J. (2018). Nursing workload, patient safety incidents and mortality: An observational study from Finland. BMJ Open, 8. doi.org/10.1136/bmjopen-2017-016367.
- Hairr, D., Salisbury, H., Johannsson, M., & Redfern-Vance, N. (2014). Nurse staffing and the relationship to job satisfaction and retention. Nursing Economic$, 32(3), 142-147.
- Perrine, J. (2012). Strategies to boost RN retention. Nursing Management, 40(4), 20-2.
- North, N., Leung, W., Ashton, T., Rasmussen, E., Hughes, F., & Finlayson, M. (2013). Nurse turnover in New Zealand: Costs and relationships with staffing practises and patient outcomes. Journal of Nursing Management, 21, 419-428. doi.org/10.1111/j.1365-2834.2012.01371.x
- Lartey, S., Cummings, G., & Profetto-McGrath, J. (2014). Interventions that promote retention of experienced registered nurses in the health care settings: A systematic review. Journal of Nursing Management, 22(8), 1027-1041. https://doi.org/10.1111/jonm.12105
- Choi, S., Pang, S., Cheung, K., & Wong, T. (2011). Stabilizing and destabilizing forces in the nursing work environment: A qualitative study on turnover intention. International Journal of Nursing Studies, 48(10), 1290-1301. https://doi.org/10.1016/j.ijnurstu.2011.03.005
- Choi, S., Cheung, K., & Pang, S. (2013). Attributes of nursing work environment as predictors of registered nurses’ job satisfaction and intention to leave. Journal of Nursing Management, 21, 429-439. doi.org/10.1111/j.1365-2834.2012.01415.x
- El-Jardali, F., Merhi, M., Jamal, D., Dumit, N., & Mouro, G. (2009). Assessment of nurse retention challenges and strategies in Lebanese hospitals: The perspective of nursing directors. Journal of Nursing Management, 17(4), 453-462. doi.org/10.1111/j.1365-2834.2009.00972.x
- Tuckett, A., Winters-Chang, P., Bogossian, F., & Wood, M. (2015). ‘Why nurses are leaving the profession … lack of support from managers’: What nurses from an e-cohort study said. International Journal of Nursing Practice, 21(4), 359-366. doi.org/10.1111/ijn.12245
- Labrague, L., Gloe, D., McEnroe, D., Konstantinos, K., & Colet, P. (2018). Factors influencing turnover intention among registered nurses in Samar Philippines. Applied Nursing Research, 39, 200-206. doi.org/10.1016/j.apnr.2017.11.027
- Moloney, W., Gorman, D., Parsons, M., & Cheung, G. (2018). How to keep registered nurses working in New Zealand even as economic conditions improve. Human Resources for Health, 16(45). doi.org/10.1186/s12960-018-0312-x
- Van Dam, K., Meewis, M., & van der Heijden, B. (2012). Securing intensive care: Towards a better understanding of intensive care nurses’ perceived work pressure and turnover intention. Journal of Advanced Nursing, 69(1), 31-40. doi.org/10.1111/j.1365-2648.2012.05981.x
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- Hayward, D., Bungay, V., Wolff, A., & MacDonald, V. (2016). A qualitative study of experienced nurses’ voluntary turnover: Learning from their perspectives. Journal of Clinical Nursing, 25, 1336-1345. doi.org/10.1111/jocn.13210
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- Alasmari, H., & Douglas, C. (2012). Job satisfaction and intention to leave among critical care nurses in Saudi Arabia (PDF, 220 KB). Middle East Journal of Nursing, 6(4), 3-12.
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- Nantsupawat, A., Kunaviktikul, W., Nantsupawat, R., Wichaikhum, O., Thienthong, H., & Poghosyan, L. (2017). Effects of nurse work environment on job dissatisfaction, burnout, intention to leave. International Nursing Review, 64(1), 91-98.
- Abubakar, R., Chauhan, A., & Kura, K. (2014). Relationship Between Perceived Organizational Politics, Organizational Trust, Human Resource Management Practices and Turnover Intention Among Nigerian Nurses. International Journal of Business and Development Studies, 6(1), 53-82.
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This article has been reviewed by the associate director of nursing and operations manager, ambulatory care, at Nelson Marlborough District Health Board, Jill Clendon and the Kai Tiaki Nursing New Zealand co-editors.