Nursing Turnover and Retention in Healthcare Organizations

Introduction

The process of recruiting and training, particularly in high-impact fields like healthcare, has become increasingly complex and expensive. Turnover is the rate at which an organization gains or loses employees. High turnover means that more employees are leaving more rapidly, which can be harmful to productivity and finances.

The real costs of hiring include recruitment time, opportunity costs, and investment in both the new employee and the staff in Human Resources. Indirect costs include training, loss of production, reduction of performance levels, and overtime due to inexperience. In fact, this issue is so important that in for-profit organizations, the cost of employee turnover is estimated to be about 150% of the total payroll and benefit package (Rothwell, 2012). One must also understand the high costs of post-employment requirements, including drug screening, physical exams, orientation, learning curve, and coaching from others. Staff time is difficult to calculate, but in a busy medical facility, for example, more work tends to equal less attention to detail and may result in a decrease in customer satisfaction.

The issue of high turnover rates is particularly important in healthcare. At Community Health Center, there is a troubling trend of new graduate nurses leaving after one year. The problem is acute: there are tremendous fiscal losses that cannot be mitigated, quality of care is reduced during periods of low experience and high training demands, and public perception of care and management suffer due to turnover rates. In the United States alone, nursing colleges and universities continue to expand enrollment to meet the rising demands of care. These demand curves are influenced by demographics—an aging population requiring more healthcare—hospital budget cuts, and the high cost of educating and training new nurses. Compounded with demand for more experienced employees, it is easy to see why the market would attract nurses with at least a year's experience away from residency or training programs.

Turnover in Healthcare Context

However, one can view this issue in two ways: employee turnover, which is negative, and employee retention, which is positive. Employee retention focuses on keeping talent with the organization, reducing costs, and increasing quality of care and patient satisfaction. Research shows that the largest reason for employee turnover—and therefore the place to start with employee retention—is job satisfaction within the first few months of employment. However, this same research shows that it is not just monetary factors that cause turnover, but the manner in which employees perceive their value to the company. Twenty-first century employees want to be valued, and they expect their company to be honest, transparent, and secure with a long-term view of utilizing their talents in a mutually beneficial situation (Chen et al., 2011).

In the healthcare context, high turnover rates have been associated with poor patient care, patient and employee dissatisfaction, and in some cases, actual quality concerns in clinical medicine. In modern nursing theory, one of the more important components revolves around the combination of ethical behavior, patient advocacy, and communication within a busy healthcare environment. Losing employees after one year puts the organization into a continual mode of catch-up, without ever really getting ahead. The conundrum is complex, and one must balance the needs of the organization with the overall patient care paradigm, which means balancing nursing care with fiscal demands, the ability of the nurse to provide appropriate care, and the creation of a robust learning environment for employees' educational and career needs (Glazer & Alexandre, 2009).

Turnover accounts for about 30% of all healthcare employee separations and about 25% of all nurses. The same reports show that 88% of all healthcare organizations view turnover as a "key strategic imperative," yet most do not focus on it in the strategic and tactical planning process. Research demonstrates the critical relationship between staffing stability and clinical outcomes, making this a quality-of-care issue as well as a financial one.

Budgetary and Fiscal Impact

Nationally, the impact of nursing turnover is staggering. Looking at turnover by tenure, those who leave in the first twelve months account for about 50% of the hospital's total turnover. The actual cost of turnover is difficult to measure but probably amounts to about 20–25% of the organization's final net income. The higher the turnover ratio in departments with a high degree of patient impact—and thus fiscal impact—the greater the cost. Further, the higher the qualifications required for the new employee, the higher the cost if they resign within one year.

This has further economic implications not only for the healthcare market but for the ability of workers to find new jobs, what new geographic locations become available, and where and how they spend their money. To illustrate the scale: the average hospital loses about $300,000 per annum for each percentage increase in annual nursing turnover (Cottingham et al., 2011). These figures underscore why retention initiatives, even if they require upfront investment, represent a sound financial strategy for healthcare organizations.

Retention Solutions and Change Management

Patient Care. Shortages caused by turnover are proven to cause a decrease in the length of stay, the general quality of care, and a greater number of hospital-acquired illnesses that do not qualify for Medicare or Medicaid reimbursement, thus shifting the fiscal responsibility to other patients or insurers.

Loss of Patients. A high yearly turnover might result in needing to turn away patients to other facilities, particularly in states that mandate certain patient-to-care ratios.

Staffing Costs. Contract personnel or increasing the workload on existing employees places high demand on those remaining staff in terms of excess workload, lack of perceived worth, and high stress.

Support Staff. High levels of turnover create a disruptive environment that impacts other medical service providers, both in-house and external. This also impacts Human Resources, who often find it more difficult to recruit top talent because of a reputation for higher than average turnover.

Accidents and Absenteeism. High turnover tends to increase hurried behavior and the likelihood of accidents, as well as burnout, stress, and higher levels of absenteeism among current staff (Hunt, 2009; Bittner et al., 2012).

Solving the retention issue will likely have a drastic and synergistic effect on Community Health Center. Figures show that as high as 13% of all new nursing graduates will leave the profession entirely, causing a ripple effect on the stability of the healthcare market. In the short term, establishing a mentoring program for new graduate hires might seem an excessive expense. However, data shows that the use of qualified mentors significantly reduces the stress, communication barriers, and negative experiences associated with first-year positions.

This might mean adding additional hours for those who serve as mentors or bringing back retired professionals part-time. But if the new registered nurse has psychological support, a communications outlet, the benefit of experience, and an organization that shows it values their participation through a reward system, then additional costs would be unnecessary. This would have a positive impact on policy, budgets, employee satisfaction organization-wide, and particularly on patient perception and quality of care (Battistoni et al., 2011).

Change of any kind, and at any level, is difficult. Change and transformational management models focus on moving an issue from what it is today to what is desired. This is less formal sometimes and more psychological, but it requires research and attention to employees' perceived needs. For example, there may be new techniques, different styles or approaches, the use of ancillary skills to foster growth, or even a complete revamp of a program. The change or transformation is not just with the employee or employee program, but for management as well (Bass & Riggio, 2011).

In this case study, the use of draconian measures is certainly not viable. What is being done now does not seem to be working. Change management implies a shared vision—in this case, one in which the world of healthcare focuses on higher patient satisfaction, better quality of care, higher employee satisfaction, and cost control. Quality care is expected, and patient advocacy cannot be limited because of turnover. In this case, change would solve a problem and improve efficiency. In the long run, it would reduce unnecessary workload as well, due to training time and using employees in multiple roles simply because of need.

There are key steps that management at Community Health Center could take to improve this situation. First, an Employee Retention Committee should be instituted immediately, staffed with HR personnel and heads of major impacted departments, including 2–3 year employees. Second, a research stage should compile and cross-tabulate exit interview results; if exit interviews are not already being done, an immediate policy should be instituted. Third, an analysis stage using qualitative analysis from group members and hospital surveys should address the central question: What are the major reasons employees leave?

Fourth, based on qualitative and quantitative measurements, recommendations should be made on how to improve employee retention. Fifth, partnerships should be developed; research will most likely corroborate national findings about job satisfaction, and it is likely that a more robust residency program will provide the needed structure for retention. Finally, implementation should be ongoing, with the residency program including mentorship, monthly resident workshops and discussion groups, easily available stress and psychological counseling, rethinking resident schedules to address burnout, providing more opportunities to succeed, establishing a fund to pay a percentage of student loans after 18 months on the job, establishing fiscal and emotional rewards for tenure and retention, and providing more servant and participatory management for new hires.

Conclusion

The QSEN framework can be directly applied to improving employee retention at Community Health Center. Patient-centered care, which is central to modern medical ethics, allows focus on advocacy for the patient and enabling them to participate in all aspects of their care based on individual cultural, ethnic, and community values and needs. Increased retention of nurse graduates would provide more experienced staff and better patient-to-nurse ratios. Experience within the healthcare environment is often one of the tangible ways to understand individual differences, thus allowing more experienced staff to make better decisions.

Teamwork and collaboration involves shared collaboration with team members, support staff, and the entire healthcare team, both clinical and supportive. Turnover decreases teamwork because new individuals must be trained and require time to become part of the team. New employees are not as experienced and trusted in collaborating with others, and experience and time develop healthcare relationships. More consistent nursing staff would significantly improve this aspect.

Evidence-based practice focuses on using current research and knowledge to make more informed decisions. Research abounds and proves that high turnover has negative effects on all aspects of stakeholders' expectations and quality care. Quality improvement relates to the data collection, evaluation, and improvement of patient outcomes based on interaction. Decreased turnover and increased experience will allow for better evaluation and improvement of patient outcomes through clinical knowledge, advocacy, and carative philosophy.

Safety involves the prevention of harm to patients and staff. More experience translates into greater familiarity and comfort with safety issues, the ability to anticipate events, and experience to mitigate negative outcomes. Finally, informatics involves the use of technology to promote safety, quality, and comfort for all stakeholders. Increased experience provides a greater opportunity to integrate technology into daily practice, use it appropriately and safely, and provide clients with necessary information about the use of the technology (Hunt, 2012; Agency for Healthcare Research and Quality, 2013).

The integration of evidence-based retention strategies with the QSEN framework offers Community Health Center a comprehensive, theory-grounded approach to addressing nursing turnover. By implementing a structured mentoring and residency program supported by organizational change management, the center can reduce turnover costs, improve patient care quality, enhance employee satisfaction, and align local practice with national nursing excellence standards. This synergistic approach transforms retention from a cost-cutting initiative into a quality-improvement and professional development strategy, making it strategically valuable to all stakeholders.