The 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. And as the nursing shortage worsens, employers and nurses across the nation will 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 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.²

At What Price?

The cost of replacing a staff nurse is estimated to run as high as $50,000.³ Replacing a nurse with additional training, such as critical care or labor and delivery, may cost even more. High turnover gives rise to 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 exact 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 when vacancy rates reach 8% or greater, consider it a crisis that must be rapidly addressed.⁴ Otherwise, 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 traveler arrives to fill a temporary staffing need, time and energy are redirected away from patient care to orienting all personnel on the unit.

So 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 leave 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? With today’s shortage, 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, and research shows that the most frequent reasons fall into five categories: intense workload, lack of scheduling flexibility, low compensation, no access to continuing education, and minimal opportunity for career growth.^6,7

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 today’s high value placed on family, recreation, and time away from work, health care employers need to provide scheduling options that are both worker- and family-friendly.

Provide competitive compensation and benefit packages. Employers should, however, pay their staff fairly and review compensation levels at least twice a year to make sure they are remaining 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 hold on to nurses, employers will 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 will need to develop strategies that encourage nurses to develop personal and professional growth and expertise.

While workload, scheduling, compensation, continuing education, and career growth may be determined by their employer, nurses can use a variety of strategies to directly influence the workplace. 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 that 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. Pair new employees with seasoned nurse preceptors with 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. They’ll remember what it felt like to be a novice. Go ahead and tell them where the hidden supplies are located, and describe the different 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 being left undone, talk with them 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 place to work. 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. They 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 place 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 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.⁸

Help administration develop compensation methods that reward productivity. Request that the human resources department provide 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 evolving clinical challenges nurses face as acuity levels rise. Also include suggestions on education topics that improve the workplace, such as communication, teamwork, and the like. 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 to obtain offerings, such as professional journals and online courses.

Nurse-physician communications and work relationships are reported as a retention issue in a number of agencies.⁹ Many facilities have developed and implemented nurse-physician policies that outline unacceptable behavior, a process for reporting that behavior, and recourse for correcting it. But not only will you want to promote a culture of trust and respect with physician: You’ll also want to discuss the need to value each employees’ unique contribution in nurse-to-nurse communications and also in nurse-to-nurse assistant communications. 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. 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 different can be a great thing. Health care requires all types of “differences” 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-on 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 will 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 healthcare 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 nurse workforce, including age, disability, ethnic or national origin, gender, race, religion, sexual preference, and a number of other attributes. There is diversity in marital status, values, and beliefs. There is 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 more 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 to remain 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’ point of view.

Agree to disagree. You don’t always have to agree with colleagues’ ideas and opinions. But 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.

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.