Nurse Retention in Workplace Adversity

Practice Problem: Nurse turnover rate and lack of retention are issues that have an impact on safe patient care, patient mortality, quality outcomes, and patient experiences in the acute care units at the identified project setting. Turnover leads to excess labor utilization of overtime and increased hospital costs. PICOT: The PICOT question that guided this project was (P) In acute care hospital nurses, how do (I) nurse retention strategies (C) compared with no nurse retention strategies (O) reduce nurses’ intention to leave and increase job satisfaction over (T) eight weeks? Evidence: Twenty-one articles were reviewed that identified autonomy, recognition, acknowledgement, communication, and transformational leadership as nurse retention strategies, which contributed to a positive workplace environment and led to improved job satisfaction and nurse retention. Intervention: The intervention consisted of focused communication that included staff recognition and acknowledgement by the nurse leaders of each unit, which had a positive effect on the workplace environment and job satisfaction. Outcome: The results indicated a statistically insignificant change in job satisfaction and intent to stay yet did show a clinical significance. Conclusion: The benefit of the project was that there was a clinically significant change in behaviors including: verbal expressions of increased job satisfaction, notable positive attitudes and hopefulness, as well as staff resilience. Consistent leadership and a larger sample size may produce statistical significance in a future study. NURSE RETENTION IN WORKPLACE ADVERSITY 3 Nurse Retention in Workplace Adversity Nursing retention and high turnover rates, impact health care on many levels (Tang & Hudson, 2019). There are substantial pressures on health care workers and facilities to provide quality care in a cost-effective manner to patients, in an effort to yield outcomes of satisfaction with both patients and staff (Bowles et al., 2019). Finding the balance with these pressures is a challenge. Nursing retention should be a priority across the globe, as many registered nurses (RN) are often found leaving their positions when conditions and pressures becomes undesirable (Laschinger et al., 2016; WHO, 2010). Turnover is expensive for health care facilities and often takes an emotional toll on nurses (Tang & Hudson, 2019). Nursing turnover affects staff satisfaction, disrupts productivity, and impacts patient care. Patients are turned away due to inadequate staffing numbers, which in turn decreases revenue for the facility (Vardaman et al., 2018). In addition, nurses often feel disenfranchised and stressed, which has an impact on job satisfaction. Many nurses have left the profession because they felt that this challenge does not allow them to care appropriately for patients (Aiken et al., 2017; Spence Laschinger & Fida, 2015). This paper discusses how positive workplace environment and job satisfaction have a significant role on nurse retention. The strategies implemented for increased retention of nursing staff were focused on improving the workplace environment and included direct communication, supportive management, and nurse autonomy with involvement in decision making. As the work environment improved through the implementation of interventions, a clinical significance was noted. Significance of the Practice Problem Surveys of nurses in different countries indicate turnover is a global issue and is a particular concern in rural and remote areas (Brook et al., 2019; Mbemba et al., 2013; WHO, NURSE RETENTION IN WORKPLACE ADVERSITY 4 2010). The extent and impact of nurse turnover has been noted in countries with developed healthcare systems. Furthermore, 20 – 50% of nurses surveyed in eight countries intended to leave their jobs, these countries included Belgium, France, Germany, Greece, Ireland, Poland, Spain, and Switzerland (Brook et al., 2019). Nursing turnover “has significant impact” on the provision of safe, quality care and patient mortality in those countries (Zander et al., 2016, p. 5). In 2020, the vacancy rate of RNs climbed 9% nationally; a full point higher than 2019 (NSI Nursing Solutions, 2021). The Bureau of Labor Statistics projected the nursing labor shortage will reach 1.13 million by 2024 (O’Donnell, 2020; Hogan & Roberts, 2015). The rising rate of nursing shortages directly impacts patient quality outcomes and experiences. In addition, low nurse retention rates leads to excess labor utilization in both overtime and onboarding. Nationally, only one in five hospitals (19.3%) reported an RN vacancy rate of < 5% in 2020, and in 2019 the national bedside RN turnover rate was 15.9% (NSI Nursing Solutions, 2021). The average cost of one bedside nurse is $44,400 annually, with an average hospital loss of $3.6m $6.1m/yearly (NSI Nursing Solutions, 2021). The cost of turnover can have a profound impact on hospitals, and needs to be managed. Over 32% of newly hired RNs do not reach their first-year anniversary. For those nurses that surpassed the first-year anniversary, the turnover rate before reaching their second year of employment is 20.5% (O’Donnell, 2020). The northern California RN turnover rate in 2017 was 10.7%, with a southern California turnover of rate 12.1% (Hospital Association of Southern California, 2017). It is estimated that hospitals lose between $4 and $7 million per year because of nurse turnover, and each percent change in RN turnover cost the average hospital an additional $306,400 each year (NSI Nursing Solutions, 2021).


Nurse Retention in Workplace Adversity
Nursing retention and high turnover rates, impact health care on many levels (Tang & Hudson, 2019). There are substantial pressures on health care workers and facilities to provide quality care in a cost-effective manner to patients, in an effort to yield outcomes of satisfaction with both patients and staff (Bowles et al., 2019). Finding the balance with these pressures is a challenge. Nursing retention should be a priority across the globe, as many registered nurses (RN) are often found leaving their positions when conditions and pressures becomes undesirable (Laschinger et al., 2016;WHO, 2010).
Turnover is expensive for health care facilities and often takes an emotional toll on nurses (Tang & Hudson, 2019). Nursing turnover affects staff satisfaction, disrupts productivity, and impacts patient care. Patients are turned away due to inadequate staffing numbers, which in turn decreases revenue for the facility (Vardaman et al., 2018). In addition, nurses often feel disenfranchised and stressed, which has an impact on job satisfaction. Many nurses have left the profession because they felt that this challenge does not allow them to care appropriately for patients (Aiken et al., 2017;Spence Laschinger & Fida, 2015). This paper discusses how positive workplace environment and job satisfaction have a significant role on nurse retention. The strategies implemented for increased retention of nursing staff were focused on improving the workplace environment and included direct communication, supportive management, and nurse autonomy with involvement in decision making. As the work environment improved through the implementation of interventions, a clinical significance was noted.

Significance of the Practice Problem
Surveys of nurses in different countries indicate turnover is a global issue and is a particular concern in rural and remote areas (Brook et al., 2019;Mbemba et al., 2013; WHO, Synthesis of the literature identified autonomy, recognition, communication, organizational commitment, evidenced-based education/training, and transformational leadership as useful interventions to improve the workplace environment and job satisfaction. A summary of the primary articles (Appendix A) and systematic reviews (Appendix B) include the evidencebased nurse retention interventions.
The strength and quality of the evidence was evaluated by using the Johns Hopkins Nursing Evidenced Based Practice Synthesis Process and Recommendations (JHNEBP) Tool (Dang & Dearholt, 2017). The resulting articles were a mix of level II evidence levels (n=9) with quasi-experimental and explanatory mixed method design studies, as well as, level I (n=9), level III (n=1) and level IV (n=1). Quality ratings were A or B indicating high quality and/or good quality representing strong, compelling and consistent evidence for the evidence search (Appendix H & I).

Themes with Practice Recommendations
Themes that had an effect on nurse retention included: managers who created a positive workplace environment, using direct communication, staff recognition and acknowledgement, and nurses' inclusion in decision-making.

Effective Leaders
Effective leadership includes: staff empowerment, team-work, harmonious collaboration, inter-staff caring relationships, ethical practices, and support for fellow staff. Direct communication by acknowledging and recognizing nurses' work by management had an effect on job satisfaction and nurse retention (Nurdiana et al., 2018).

Communication, Acknowledgement, and Recognition
Job satisfaction was influenced through open and direct communication, collaboration, and decision making (Jackimowicz et al., 2018;Van den Bulcke et al., 2020;Moisoglou et al., 2020;Coundounaris et al., 2020;& Brown et al., 2018). The nurse managers who made a point to be active listeners with their health care staff, to share information, and use consistent follow up, improved communication on the unit, which may lead to increased nurse retention (Tang & Hudson, 2019).

Leadership Styles
Leadership styles have a direct impact on a nurses' intent to stay, and indirectly affect the quality of health services provided to patients. Transformational leadership is a style that includes a defined nurse manager role, positive management support styles, supportive hospital management, and supportive organizational climates, to increase nurse retention (Labrague et al., 2020;Adams et al., 2019;Genly, 2016;Hussein et al., 2019;Jakimowicz et al., 2018;Moisoglou et al., 2020;Nurdiana et al., 2018;Putra et al., 2020;Ke & Hung, 2017;Semachew et al., 2017;& Brook et al., 2018). Positive, encouraging, visible and available managers have increased nurse retention on their units versus those managers not engaged with their staff (Labrague et al., 2020).

Setting, Organizational Structure and Organizational Need
The setting was a 400-bed acute care facility located in the southwestern part of the United States. It is one of the largest hospitals and the largest employer in the area. The leadership team consisted of the chief executive officer (CEO), the chief nursing officer (CNO), the chief operating officer (COO), the chief financial officer (CFO), the chief strategy officer (CSO), and the chief human resources officer (CHRO). Organizational need and support were determined by the CNO, as well as, the acute care directors and nurse managers. Nurse retention has become a high priority to the organization, due to the increased turnover rate, which has the consequence of high costs to the organization and impacts the quality of care provided to patients. The volunteer participants in this pilot project were acute care nurses, totaling 20 participants, who were given surveys pre-and post-intervention implementation.

Stakeholders and Organizational Support
Due to the nursing turnover, there was a shortage of nursing staff, which was felt by other professionals in the organization, such as respiratory therapists, physical therapists, pharmacists, technicians, who were all supportive of this project. The stakeholders with active involvement were those from the leadership team, the PM, and the nursing staff for the selected units.
Turnover is disruptive to nursing productivity, and with inadequate staffing this directly affects patients and their families, who are also important stakeholders in nurse retention efforts (Vardaman et al., 2018).

Organizational Need and SWOT Analysis
The SWOT analysis of the hospital identified the following strengths for this project, core experienced staff, adequate resources, and a busy unit with high census. Additionally, when the hospital offered a new graduate program, they had full capacity due to hospital outreach. The weaknesses noted for this project were the nursing shortage and high turnover rate. The opportunity is that the hospital is the largest employer in the area and is able to pilot this project.
The threats were the negative media coverage, of nurses leaving the organization, and the nurses' negative perception of management. (Appendix G).

Interprofessional Collaboration
Interprofessional collaboration requires all stakeholders to take an active role in maintaining a positive workplace environment. The interprofessional staff have been impacted by the nursing turnover and low retention rates and have been doing their best to adjust to new, inexperienced nurses. However, the increase in the turnover rate not only affected patient care, but it also disrupted the collaboration among interprofessional staff.

Project Overview
Twenty volunteer nurse participants were randomly recruited from the acute care units.
Inclusion was any nurse willing to participate, exclusion was any nurse who had submitted a resignation pre-survey intervention. The demographic data (Appendix F), the Job Satisfaction Survey (JSS) (Appendix D) and McCain's Intent to Stay (ITS) (Appendix E) were tools used for data collection and evaluation of both pre-and post-interventions via the Survey Monkey online tool. The comparison was made by using the data collected pre-intervention versus the data collected post-intervention.

Project Objectives
The project objectives proposed to increase nurse retention by improving the workplace environment, leading to increased job satisfaction and increased intent to stay:

1)
Increased communication between nursing management and staff through focused, directed daily fifteen-minute rounds (see Table 2). Managers recorded themes from daily rounds for further follow-up and set a goal to interact individually with all staff 2-3 times monthly.
2) Nurse managers led focus groups directed by themes from daily rounds monthly.
3) Recognition and acknowledgment by management of nursing staff achievements during meetings and huddles.

4)
Recognition by peers of a job well done in meetings and huddles.

5)
Hospital internal communication acknowledged and recognized staff accomplishments to include birthdays and educational achievements. This recognition was based on the staff's personal preference of allocation. Data collection and measurement of the intervention was achieved through email surveys, to assess effectiveness of recognition of achievements in one week.

6)
A 30 -60 second inspirational quote during meetings was used in an effort to begin the day with a positive outlook and to set the tone of the shift. Staff were encouraged to participate with their own quotes.

Schedule of Activities and Timeline
The schedule and timeline of activities were as follows: • Week 1-2: meetings were held with nursing staff to inform them of the project on the units and recruitment of 20 volunteer nurse participants. Pre-intervention tools (Demographics, JSS, ITS surveys) were given to nurse participants via email with an online link to the surveys. Increased visibility of managers on the units through focus groups and 15-minute walking rounds, as well as, daily huddles, which included a 30-60 second inspirational quote.
• Week 3: hospital internal communications were initiated for staff recognition of achievements, such as birthdays and educational achievements to be acknowledged during meetings, emails and/or cards, depending on employee preference.
• Week 4-6: Nurse manager led themed focus groups were generated from the daily walking rounds.
• Week: 7-9: Observation were conducted by the PM for the strategies used on the units and one-on-one interviews with nurses were held regarding the interventions and their effectiveness.
• Week 10: Evaluation and date collection of nurse participants occurred through post instruments of JSS, ITS and demographic surveys.

Resources and Budget
Resources required for the project included 40-50 birthday cards, Survey Monkey fees of $138 for six months, a positive quotes book, and gift cards of $5 for each of the 20 participants, which was part of the budget for nurse participation in the surveys. The statistician was an important resource in obtaining results that maintained the validity and reliability of the project.
Four hours was budgeted for the statistician, and a $150 was included for incidental expenses (see Table 1).

Project Manager
According to Harris et al. (2020) being an effective communicator will engage others, thereby, providing leverage to initiate and complete projects in a timely manner. Awareness of individuals processing information differently should be acknowledged and planned for in working with diverse workforces. Project managers should also possess planning and organizational skills to keep the project on schedule. The PM establishes the direction and ultimate outcomes of the project and then manages the project effectively to completion.
According to Carayon and Wood (2010) skills required for a PM include good communication, the ability to examine human behavior, and effectively interact with others in their surroundings.
The PM led the project with oversight by the CNO. The effect of the PM was evident through the improvement of communication skills such as one-on-one interactions with nursing staff, involvement in conflict resolution, maintaining interventions through leadership change, and the organization of scheduled huddles. The PM designed the acknowledgment and recognition materials for the nurse managers to distribute in the morning huddles, which not only improved morale but also validated to the staff nurses that their contributions were valued. These skills combined with the development of the appreciation materials, achieved the outcome of improving the work environment.

Process Measures
During the implementation phase, there was a change in nurse managers, which did impact the final results of the project. However, the nurse managers who were present with their staff nurses, showed better relationships and set the standard for the importance of respectful and engaging communication in the work environment. In this project, by the nurse managers asking questions, getting into the staff nurses' reality, and dialoging with them, it created a positive atmosphere for constructive criticism (see Table 2).

Statistical Analysis
Intellectus Statistics (2021) Table 3. A 10% increase in ITS and JSS post intervention survey data collection was noted as significant. Clinical significance was based on the interventions and their effects on ITS and JSS in the workplace environment.

Demographics
Frequencies and percentages were calculated for the demographic table (see Table 4) of gender, age, ethnicity, education, years of experience, relationship, and expertise split by time period. For the time period before the intervention (pre-test) to the time period post intervention (post-test), males and females were equally represented, each 4 (44%). For the pre-test data collection, the ages were 20-30 (n=4, 44%), ethnicity was White or Caucasian (n=3, 33%), and education was BSN (n-=5, 56%), experience was 6 months -1 year (n=5, 56%), relationship was married (n = 5, 56%), and expertise was proficient and competent, each 3 (33%). The post-test data collection consisted of age, ethnicity, education, years' of experience, relationship, and expertise were missing, each (n =4, 40%), education at BSN level (n=4, 40%), relationship was married (n= 4, 40%), expertise was proficient (n= 4, 40%). Some participants did not respond to post demographics if they participated in the pre-test. The demographic frequencies and percentages are presented in detail in Table 4.

Outcome Measures
A two-tailed independent samples t-test was conducted to examine whether the mean of "intent to stay" was significantly different between the pre-test and post-test categories of "time period." The Shapiro-Wilk tests was conducted to determine whether the variables "intent to stay" could have been produced by a normal distribution for each time period (Razali & Wah, 2011). The result for "intent to stay" in the pre-test category was not significant based on an alpha value of 0.05, W = 0.90, p = .248, suggesting that a normal distribution cannot be ruled out as the underlying distribution for intent to stay in the pre-test category. The result was not significant based on an alpha value of 0.05, W = 0.90, p = .345, suggesting that a normal distribution cannot be ruled out as the underlying distribution for intent to stay in the post-test category. The Shapiro-Wilk test was not significant for either the pre-test or post-test categories of the time period, indicating the normality assumption was met. The Levene's test assessed the data variances. The result for intent to stay was not significant based on an alpha value of 0.05, F (1, 14) = 0.75, p = .401. This result suggested it is possible that the variance of intent to stay is equal for each category of time period, demonstrating that the assumption of homogeneity of variance was met.
The result of the two-tailed independent samples t-test was not significant based on an alpha value of 0.05, t (14) = 1.54, p = .145, indicating the null hypothesis cannot be rejected.
This finding suggests the mean of intent to stay was not significantly different between the pretest and post-test categories of the time period (see Table 5). A bar graph of the means is presented in Figure 2 and did reveal clinical significance. Post-test results were a mean of 2.62 from a pre-test mean of 1.77, indicating a statistically insignificant result. Major changes in nursing management occurred after the implementation of the project that directly affected this acute care unit, and also impacted the implementation of the project. These changes played a role in the statistically insignificant results of this project, however, with consistent management and a larger sample size, the results may yield an outcome with statistical significance.
A two-tailed independent samples t-test was conducted to examine whether the mean of "job satisfaction" was significantly different between the pre-test and post-test categories of the time period. Shapiro-Wilk tests were conducted to determine whether job satisfaction could have been produced by a normal distribution for each category of the time period (Razali & Wah, 2011 The Levene's test was conducted to assess whether the variance of job satisfaction was equal between the categories of the time-period. The result for job satisfaction overall was not significant based on an alpha value of 0.05, F (1, 15) = 0.38, p = .545. This result suggests it is possible that the variance of job satisfaction is equal for each category of the time period, demonstrating that the assumption of homogeneity of variance was met.
The result of the two-tailed independent samples t-test was not significant based on an alpha value of 0.05, t (15) = 1.84, p = .085. This finding suggests the mean of job satisfaction was not significantly different between the pre-test and post-test categories of time period. The results are presented in Table 6. A bar graph of the means is presented in Figure 3 and did reveal clinical significance. The job satisfaction results were post-test mean of 3.10 from pre-test of 3.84, suggesting a statistically insignificant result. A larger sample size may produce results of statistical significance.

Impact
The intervention increased communication between nurses and nurse managers, as well as the acknowledgement and recognition in the workplace environment. A larger sample size and more time, may impact the unit, with the aim to increase job satisfaction and reduced nurses' intent to leave. Nurse managers implemented the intervention of direct and focused communication that acknowledged and recognized staff performance. Certificates of recognition and acknowledgement (signed by nurse managers) were given to nursing staff, along with cards of appreciation. Within the implementation of 15-minute walking rounds, concerns were found regarding staffing, scheduling, and equipment, which provided areas of improvement opportunities to be addressed. Utilization of rounds several times a week is viewed as a continual important aspect and has remained a sustainable outcome. This practice change highlighted the importance of the availability and visibility of nurse managers being present on the units. The clinical significance noted was the resilience of the nurses and hopefulness towards the positive changes of nurse retention interventions.
The sustainability of the project was due to the new management's acceptance of the interventions. Certificates and cards samples were given to management, who stated they will continue to use them. The favorable attitude of the unit and overall environment improved as the nurses felt recognized and acknowledged, as observed by the PM. The ongoing effectiveness of the intervention can continue to be measured using the JSS form and continued rounding by the nurse managers.

Dissemination
The PM attended a round table discussion by the American Holistic Nurses' Association Practice Committee, which discussed the topic of nurse retention in the workplace. A powerpoint presentation was prepared for the weekly directors meeting, to share the project results with the CNO, preceptor, and other nurse leaders. The evidenced based interventions, methodology, results, strengths, and barriers that were encountered was presented and a video presentation link was sent to those who were unable to attend. An abstract for a poster presentation will be submitted to the American Nurses' Association conference and the American Association of Critical Care Nurses (AACN) conference. The journal manuscript guidelines for the AACN and the American Psychiatric Nurses Association were reviewed for an article submission, and a journal manuscript will be prepared for publication. In addition, an application will be submitted to the university's Sigma Theta Tau chapter meeting for consideration of project presentation.

Plans for Sustainability
The plans for sustainability consists of the nurse managers maintaining their visibility and availability in patient care areas, interacting with staff nurses, acknowledging staff, and giving feedback to staff through open and direct communication. The nurse manager will also continue to lead focus groups, as this became an asset in addressing nurse turnover and retention, as well as, other issues from the staffs' perspective. Another important aspect for sustainability is maintaining a positive workplace environment that values nurse suggestions and recommendations to patient care and increases the voice of nurses in the decision-making process.

Conclusion
The intention of this project was to evaluate the effect of the implementation of nurse retention strategies and the influence this had on a nurses' job satisfaction and intent to leave their position. This hospital setting did not have any nurse retention strategies in place prior to this project and their nursing turnover rate had significantly increased. Lewin's change model guided nurse management in creating a positive work environment using retention strategies.
Literature themes that promoted a positive workplace environment, identified this as having a direct impact on job satisfaction, improved nurse retention, and decreased nurse turnover. A workplace environment that consists of teamwork, effective and intentional communication between staff and management, nurse autonomy, and management who are visible and engaged in their staff, will experience a decrease in nurse turnover and an increase in the retention of nurses

Figure 3
The Description of nurse turnover pattern, as perceived by hospital managers.

Summary of Primary Research Evidence
Nurse turnover is higher than the acceptable level predicted by age, marital status and job tenure.
1) Common reasons nurses leave: personal reasons, job offers from hospitals or other organizations and working conditions. 2)Potential way to reduce turnover is to retain nurses in an organization more than three years. 3) Hospital management view turnover as a disturbance to hospital services, staffing practices, managerial processes, and hospital revenue which increases costs. 1) Pay rise, pay structure/administration and job satisfaction were significantly and negatively related to turnover intentions.
2) Effect of benefits on turnover intentions was nonsignificant. 3)Pay level, pay structure/administration and pay rise has the most important effect on nurses' satisfaction. 4) Age status had negative and significant effects on turnover intentions. 5) Gender status had nonsignificant impact on turnover intentions. Job Satisfaction Survey Permission -Conditions for Using These Assessments * All of the assessments in the Our Assessments section of paulspector.com are copyrighted.
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