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An Evidence-Based Protocol for Nurse Retention

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 JONA
Volume 38, Number 10, pp 441-447
Copyright B 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins
THE JOURNAL OF NURSING ADMINISTRATION
An Evidence-Based Protocol
for Nurse Retention
Ericka Gess, MS, RN, PCCN
Milisa Manojlovich, PhD, RN, CCRN
Sharon Warner, BSN, RN
Registered nurse turnover can drastically affect the
quality of patient care while costing more than 1
billion dollars. The ongoing nursing shortage
makes it hard to replace nurses, necessitating a
novel approach to reduce nurse turnover. The
authors discuss an evidence-based protocol that
improves organizational commitment among
nurses as a way to retain nurses through facilitating
autonomy, improving communication, and offering
recognition and rewards to nursing staff.
Nursing turnover is a dysfunctional human re-
source issue when an institution loses nursing staff
whom it would rather retain. Nursing turnover has
negative consequences when it occurs at high rates,
resulting in diminished continuity of care, de-
creased productivity, and increased risk for patients
and nurses.1 The ongoing nursing shortage is a
magnifying issue for nursing turnover because,
although the shortage is not necessarily the root
cause of people leaving the profession, it does make
replacing those nurses increasingly difficult, thus
worsening both situations. High rates of staff nurse
turnover are detrimental not only to nurses and
healthcare economies but also to the safety and
well-being of patients.
Nationwide, the average registered nurse turn-
over rate is estimated to be approximately 15% to
Authors’ Affiliations: House Supervisor (Ms Gess), Univer-
sity of Michigan Health System, and Staff Nurse, Telemetry
Unit, Veterans Affairs Ann Arbor Healthcare System, Michigan;
Assistant Professor (Dr Manojlovich), University of Michigan
School of Nursing, Ann Arbor; and Staff Nurse (Ms Warner),
Pediatric Intensive Care Unit, Children’s Healthcare of Atlanta,
Egleston Hospital, Georgia.
Corresponding author: Ms Gess, University of Michigan
Health System, C108 Med Inn 1500 E Medical Center Dr, SPC
5804 Ann Arbor, MI 48109 (egess@med.umich.edu).
JONA  Vol. 38, No. 10  October 2008
Copyright @ 2008 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
36% per year.2 Current literature estimates eco-
nomic costs of nursing turnover to be 4 to 5 times
higher than what hospitals typically calculate. There
are hidden, indirect costs that account for 79% of
losses including a 4% loss during predeparture, a
15% loss while the position is vacant, and an 81%
loss while the new hire reaches a productive level.1,3
Others claim that in addition to the decreased
productivity of a new employee, indirect costs also
include the cumulative effects of turnover, such as a
decrease in staff morale and group productivity.4,5
Guidelines for calculating turnover costs are avail-
able in the literature.6 High costs of turnover can be
crippling in a healthcare industry where the cost of
care is skyrocketing and insurance company reim-
bursement rates are dropping.
As nurse leaders, we are accountable for
ensuring that appropriate levels of competent staff
are available to provide safe and quality patient
care. To reach this goal, nurse leaders, human
resource, and other administrators have long
worked together to retain nurses. Although re-
search evidence exists to demonstrate the delete-
rious effects of nursing turnover and the value of
nurse retention, there is little guidance in the
literature on how to apply the research evidence
in a clinical setting. This article seeks to provide an
evidence-based protocol comprised of a compila-
tion of current evidence-based strategies for nurse
retention that nurse leaders can tailor to their own
needs and use within any healthcare setting. The 3
authors developed this protocol based on personal
and professional interest in finding ways to reduce
nurse turnover.
Focusing interventions on nurse retention can
be viewed as a cost-effective way to address the
high rates of nursing turnover, as this is an area
441
where implementation of evidence-based strategies
can generate immediate results. The protocol
described within this article was derived from
interventions identified within current published
research. The authors chose nurse leaders as the
focus group to target for this protocol, as current
and previous research on nurse leaders and
employee relationships has identified a positive
correlation between nurse leaders’ behaviors and
employee satisfaction and retention.7,8
Much of the research on organizational com-
mitment and nursing turnover occurred during the
1970s and 1980s, with further clarification and
expansion of the associated constructs occurring
throughout recent years.8 Organizational commit-
ment has received most of its attention in research
because of its consistent relationship to turnover.8
Organizational commitment may be seen as part
of a larger cluster of constructs describing the
individual-organizational relationship and includes
organizational identification, job loyalty, job
attachment, and job involvement.9 Previous re-
search findings on organizational commitment
have identified positive correlations between ante-
cedents of organizational commitment (ie, autonomy,
recognition, and communication) and nurse reten-
tion.8,9 Therefore, this protocol for nurse retention
focuses on development of these 3 areas: autonomy,
recognition, and communication to increase organi-
zational commitment.
We used a 3-component definition of organiza-
tional commitment because this core definition has
essentially remained the same over time.8,10,11 We
define organizational commitment as consisting of
identification with the goals and values of the
organization, a willingness to focus strong effort
toward helping the organization achieve its goals,
and a strong desire to maintain membership in the
organization.11,12 By increasing organizational
commitment, our goal is to foster the development
of a workforce committed to organizational goals
and mission, decrease nurse turnover, increase staff
morale, and increase productivity.
Description of Protocol and
Evaluation Tools
The recommendations in this retention protocol
are based solely on an extensive review of the
literature. Interventions addressed in the protocol
focus on autonomy, recognition, and communica-
tion. These variables were selected because they
positively influence job satisfaction, organizational
commitment, and retention.8,9,13 Most of the
literature on nurse retention focuses on the con-
442
Copyright @ 2008 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
tributing factors but has offered few tested solu-
tions to address the problem of nursing turnover.
The interventions within this protocol were identi-
fied as potential solutions to the identified prob-
lem, but to our knowledge, the efficacy of these
interventions has not yet been tested. Therefore, we
also provide evaluation tools to be used in con-
junction with the protocol, which will measure the
effectiveness of these interventions in increasing
nurse retention.
Accurate measurement of turnover is impor-
tant for effective turnover management and evalu-
ation. To calculate the rate of turnover within an
organization, raw data from employees’ person-
nel records should be obtained. Duxbury and
Armstrong,14 Hoffman,15 and Price16 developed
turnover indicators that have been validated. These
instruments were combined to create the Nursing
Turnover Measurement Form. This evidence-based
retention protocol is designed to help nurse man-
agers measure turnover in an easy and consistent
manner over time (Table 1). The self-reported
Anticipated Turnover Scale developed by Hinshaw
and Atwood17 is a validated tool that is also
helpful for managers in understanding staff nurses’
perceptions and intentions to quit. Items on the
Nursing Turnover Measurement Form are shown
in Table 2.
These tools should be used in conjunction
with the strategies to increase autonomy, recog-
nition, and communication. These tools will
assist in identifying areas of weakness within
organizations where increasing organizational
commitment by focusing on these areas could
be beneficial to decreasing staff turnover. These
tools, when used together, will create a protocol
for nurse leaders to be able to easily implement
and then measure the outcomes. Preintervention
and postintervention data should be collected to
assess the effectiveness of the protocol and
whether there was any impact on staff turnover
with its initiation. For staff members who
choose to leave, exit interviews should also be
conducted, as they are an invaluable source of
information regarding areas of improvement
within organizations.
Protocol Implementation
The first step toward implementing the evidence-
based protocol requires the nurse leaders who will
be using it to conduct an assessment of their
organization to identify what is currently being
done to increase staff autonomy, recognition, and
communication. Items on this assessment are
JONA  Vol. 38, No. 10  October 2008
 Table 1. Evidence-Based Retention Protocol
Organizational
Commitment
Components Retention Goals
Autonomy Encourage staff members to seek
learning experiences both within
the organization and on their own
Encourage and support creative
freedom in practice
Support and develop a participative
management structure with shared
governance
Recognition/ Acknowledge a job well done
rewards
Provide positive feedback
Communication Listen to what nurses are saying
about patient care
Implement shared governance
models and increase collaborative
communication
shown in Figure 1. A baseline assessment using the
evaluation tools should then be done to determine
what is working well and what could be done
differently. Once this is done, nurse leaders should
then examine the strategies discussed below and
set forth in the evidence-based protocol for increas-
ing autonomy, recognition, and communication
to identify which would be good tools for them
to implement to fill the identified needs. This
would then allow for maximum utilization of the
organization’s resources and reduce redundancy in
repeating activities that are already in place or have
been found to be ineffective. The evaluation tools
should then be used to measure the effectiveness
of interventions by being conducted at 6-month
intervals during the first year for new hires and
JONA  Vol. 38, No. 10  October 2008
Copyright @ 2008 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Strategies to Achieve Goals
Provide time during monthly staff meetings for educational
in-services by staff members
Dedicate a resource binder to staff in-services to ensure they
are available to all staff members at any time
Provide a bulletin board in the staff break room where staff
members can post an educational material that they
have developed or obtained from internal or external
learning opportunities that could provide support for
evidence-based practice
Encourage staff members to share information gained from
their experiences in organizationwide conferences or
related skill competency activities
Include staff on committees where patient care policies and
critical care pathways are developed
Be open to changes in current practice and fostering a culture
where this is encouraged and promoted
Give incentives for and then implement nursing suggestions
for better patient care
Empower staff nurses to use their clinical knowledge and
expertise to develop, direct, and sustain their own
professional practice through participating n decision
making within the organization
Start an e-mail Bkudos line[
Arrange a night out for staff
Use media within the organization to publish thank you’s
and acknowledgements
Charter a celebration team
Let staff members know through an e-mail or hand-written
note about their positive accomplishments
Place a spotlight in the internal newsletter on recognizing
employees who are Bcaught[ doing something right
Provide time during staff meetings for employees to discuss
their concerns
Maintain an open door policy with staff
Be visible on the units and rounding frequently with
staff members
Encourage nurses to network with colleagues and
collaborate among other units and departments
Dedicate key positions on committees where patient care
policies and procedures are decided by staff nurses
where effective communication is essential.
then during the annual performance review
process for the duration of their time with the
organization.
Autonomy
As nurses encompass the largest segment of health-
care workers today, empowering them and creating
a practice environment where they are able to
make decisions and be supported in their actions
are very important. Autonomy is a job character-
istic that has been identified in the literature as
being a fundamental component of both job
satisfaction and organizational commitment for
many nurses13,17,33 and also significantly related to
turnover.18-20 In general, autonomous and satisfied
443
 Table 2. Items on the Nursing Turnover Measurement Form
Indicator Definition
Accession Percent of new nurses who stayed during a
rate specified period of time
Separation Percent of nurses who left at a specified
rate period of time
Stability Percent of nurses employed at the beginning
rate of the period and who still stayed at the
end of the period of time
Instability Percent of nurses employed at the beginning
rate of the period but who left at the end of the
period of time
Survival Percent of newly hired nurses who stayed
rate during a specified time of year
Wastage Percent of newly hired nurses who left during
rate a specified period of time
nurses are likely to retain their jobs. Moreover,
autonomy is reported to be the most important
factor that increase nurses’ productivity and
improves the quality of nursing care.20
The following strategies to develop and pro-
mote autonomy in practice are based on the
literature. One strategy to enhance autonomy in
practice is for management to encourage staff
members to seek learning experiences both within
the organization and on their own.18,20 By encour-
aging and supporting staff in this way, nurse
leaders recognize the value of further staff develop-
ment and education. Nurse leaders should also
provide opportunities for staff members to share
information that they obtain through these experi-
Figure 1. Anticipated turnover scale.
444
Copyright @ 2008 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Formula Calculation Rate
(No. of new nurses hired/average no.
of staff nurses employed)  100
(No. of nurses who quit/average no. of
staff nurses employed)  100
(No. of nurses at the beginning who
remained/total number of nurses at
the beginning)  100
(No. of nurses at the beginning who
quit/total no. of nurses at the
beginning)  100
(No. of new nurses remained/total no.
of new nurses)  100
(No. of new nurses who quit/total no.
of new nurses)  100
ences with other members of the organization and
be open to implementing changes in current
practice based on the evidence obtained through
these learning experiences. Some examples of this
are providing time during monthly staff meetings
for educational in-services by staff members and
dedicating a resource binder to staff in-services to
ensure that they are available to all staff members
at any time, providing a bulletin board in the staff
break room where staff members can post an
educational material that they have developed or
obtained from internal or external learning oppor-
tunities that could provide support for evidence-
based practice, or encouraging staff members to
share information gained from their experiences in
JONA  Vol. 38, No. 10  October 2008
organizationwide conferences or related skill com-
petency activities.
Nurse leaders should also do more to en-
courage and support creative freedom in prac-
tice.13,20,21 Instead of focusing on maintaining the
status quo, management should support staff
members in developing new and innovative ways
of providing care.22 By allowing employees to
develop methods of providing care based on evi-
dence and their own unique knowledge base and
experiences, staff members will be more empowered
and able to function independently. Examples of this
would be staff inclusion on committees where
patient care policies and critical care pathways are
developed, managers and hospital leaders being
open to changes in current practice and fostering a
culture where this is encouraged and promoted, and
giving incentives and then implementing nursing
suggestions for better patient care.
Another strategy to enhance autonomy in
practice is through the support and development
of a participative management structure with
shared governance.13,20,23 Nursing shared gover-
nance is a managerial innovation that legitimizes
nurses’ control over practice while extending their
influence into administrative areas that were pre-
viously controlled only by managers.24,25 Some
examples of a participative management structure
with shared governance are empowering staff
nurses to use their clinical knowledge and expertise
to develop, direct, and sustain their own profes-
sional practice; encouraging nurses to network
with colleagues and collaborate among other units
and departments; and dedicating key positions on
committees where patient care policies and proce-
dures are decided by staff nurses.25,26
Recognition
Recognition of the value and meaningfulness of
one’s contribution to an organization’s work is a
fundamental human need and an essential requisite
to personal and professional development. People
who are not recognized feel invisible, underval-
ued, unmotivated, and disrespected. Most nurses
are dissatisfied with the recognition they receive
from their employer.27 This lack of recognition
leads to discontent, poor morale, reduced produc-
tivity, and suboptimal care outcomes. Inadequate
recognition is cited as a primary reason for turn-
over among employees and is linked to decreasing
nurse satisfaction.27-29
Recognition can be embodied in many forms,
both tangible (ie, monetary rewards or medals) and
intangible (ie, verbal praise or acknowledgement).
JONA  Vol. 38, No. 10  October 2008
Copyright @ 2008 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Effective reward and recognition programs are
vital to retaining well-qualified hospital employees,
actively engaging them in satisfying patients,
managing scare resources, and improving the
organization’s performance.29 Recognition is an
oftentimes overlooked way of showing apprecia-
tion and commitment within an organization. The
following strategies can be implemented to recog-
nize the staff members’ work and accomplishments
in a healthcare organization.
One strategy to further recognition within an
organization is nursing leaders doing more to
acknowledge a job well done.28-30 By providing
acknowledgement of positive staff work and
accomplishments, nursing leaders will be fostering
a positive practice environment where staff mem-
bers feel valued and appreciated. This will also
lend toward achieving the positive outcomes of
decreased turnover and increased organizational
commitment. Some examples of staff recogni-
tion from nursing supervisors and managers are
starting an e-mail Bkudos line,[ arranging a
night out for the staff, and using internal media
within the organization to publish thank you’s
and acknowledgments.
Another strategy in staff recognition is
providing positive feedback.22,30,34 By providing
positive feedback, management is focusing on
what was done right and celebrating these posi-
tive accomplishments. This helps create a culture
that is not punitive but is focused on celebrating
the positive outcomes. Some examples of this
strategy are chartering a celebration team, manage-
ment letting staff members know through an e-mail
or hand-written note when management notices
something positive they have done, and a spotlight
in the internal newsletter by nurse leaders on
recognizing employees who are Bcaught[ doing
something right.
Communication
Communication and openness to feedback are 2
very important concepts in any organization. Using
the right tools and techniques for various types of
communication is also critical. Leaders within an
organization can often adopt a specific style of
communication that may not always be understood
by staff members. Droppers31 states, Bone of the
most common communication mistakes leaders
make is to communicate with the same level of
complexity they’re comfortable working with.[(p62)
The following strategies have all been designed to
help facilitate more effective communication
between staff members and management.
445
 One strategy to develop a more effective
communication is when nurse leaders listen to
what nurses are saying about patient care.13 As
nurses are the primary caregivers at the bedside,
they are the most attuned to what is happening in
this arena. When nurse leaders actively listen to
what their staff nurses are saying about patient
care, they are demonstrating a true commitment to
their staff. Listening to staff also provides valida-
tion of staff concerns and conveys a greater sense
of commitment from hospital leadership to the
staff members. Examples of how management can
actively listen are through providing time during
staff meetings for employees to discuss their
concerns, management having an open-door policy
with staff, and managers being visible on the wards
and rounding frequently on the unit with staff
members.
Another strategy to facilitate better communi-
cation within the organization is implementation of
shared governance models and increased collabo-
rative communication.13,23,25 Shared governance
models based on participative management philos-
ophies have been implemented in nursing settings
to promote professional practice and subsequently
enhance the quality of work life of nurses.24,25,31
Some examples of how shared governance models
can facilitate communication are by encouraging
nurses to network with colleagues and collaborate
among other units and departments and dedicating
key positions on committees where patient care
policies and procedures are decided by staff nurses
where effective communication is essential.
Nurse leaders can also facilitate better commu-
nication by incorporating clear communication
systems.29,31,32,35 Keeping communication simple
and clear to ensure understanding is an important
strategy. According to Droppers,31 certain methods
are best used for specific types of information.
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