Nurse Turnover and Retention Nursing CE Course

2.0 ANCC Contact Hours

Syllabus

Nursing turnover is a significant concern for most healthcare organizations. Given that a continued shortage of nurses is a focus worldwide, it is not surprising that the World Health Organization (WHO) noted in 2011 that nursing retention should be a priority across the globe. Certain geographical areas can have turnover rates as high as 60% within the first year amongst new graduate nurses, and in the US over one-third of new graduates reported that they considered leaving their job within the first year of practice. While the new graduate nurse is at highest risk for retention issues, all nurses can be found leaving their positions when conditions are undesirable. Factors that drive turnover or retention will be discussed in detail as we explore why nurses leave and what makes them want to stay (Laschinger et al., 2016; Van Camp & Chappy, 2017).

Studies have demonstrated that as many as 1.6 million job openings for nurses may exist during 2020, resulting in a deficit of almost 200,000 nurses based on current enrollment in schools. In 2018, the Nursing Solutions, Inc (NSI) National Healthcare Retention and RN Staffing Report suggested that nurse turnover rate in healthcare facilities was up to 18.2% in 2017 compared to 17.2% in 2014 (NSI, 2019). This increase in turnover is a significant concern to most healthcare facilities since each registered nursing (RN) position ranges from $38,000- 61,100, resulting in a total of $4.4-7.0 million dollars across the US. Further studies list individual healthcare facilities losing approximately 300,000 per year on each percent change of nurse turnover (Van Camp & Chappy, 2017).

A high turnover rate of RN staff can be directly correlated to poor patient outcomes due to nurses that are unfamiliar with their work environment and poor continuity of care. Experienced, skilled, knowledgeable RNs deliver a higher quality of care to their patients. There are also fewer negative experiences and adverse healthcare events with an experienced nurse that is familiar with a facility than with a new nurse, whether a new graduate or a nurse that is unfamiliar with a facility (Van Camp & Chappy, 2017).

Nurses serve as the primary source of care in both the inpatient and outpatient healthcare settings. The RN incorporates knowledge related to the patient’s care, the ever-changing healthcare system, reimbursement implications, and the patient’s satisfaction and response to the care delivered. There is an enormous amount of stress for an individual nurse as they deliver safe and effective care while navigating the social and cultural aspects of the healthcare environment, so there is little difficulty in understanding how quickly they can become discouraged and seek an alternative source of employment. Unfortunately, there appears to be little difference between organizations, leading to repetitive nursing turnover, where nurses are continuously in new roles and new environments. The constant change can produce less than desirable outcomes for both the nurse and the patients they care for (Brigham et al., 2018).

Issues Leading to Turnover

Nursing shortages have been forecasted and recognized for over a decade. The shortages continue in many areas of the US due to a lack of nurse educators to expand nursing programs, increasing patient populations due to baby-boomers aging and seeking healthcare at a higher rate, and high turnover rates of existing nurses. Nursing shortages can lead to negative work environments and heighten stressors placed on the nursing staff, causing frustrations that consequently lead to more turnover (Haddad & Toney-Butler, 2019).

Nurse staffing levels are noted by the American Nurses Association (ANA) as a significant source of job dissatisfaction and contribute to poor patient outcomes (ANA, n.d.b.). Both new graduate nurses and experienced nurses report similar frustrations with regards to nursing staffing inadequacies. For instance, experienced nurses report job dissatisfaction related to scheduling inflexibilities, staffing ratios, and shift assignments that are often due to shortages of staff. Experienced nurses most often report leaving the bedside to pursue employment elsewhere due to the scheduling demands, inflexibility of management with scheduling, lack of professional recognition, and the physical demands of bedside nursing (Ackerson & Stiles, 2018).

Job satisfaction is defined as “the personal positive perception toward work and work experiences” (Laschinger et al., 2016, p. 659). In contrast, dissatisfaction is associated with turnover, burnout, and patient dissatisfaction. Quality nursing care is central to positive patient outcomes and the ability to deliver quality care is paramount to nursing satisfaction. Literature shows a correlation between nurses who feel they can deliver care in a manner the patient deserves and heightened job satisfaction. The standard of nursing care can be impacted by staffing, resources, policies of an organization, or organizational leadership. The nurse's perspective on their ability to deliver the quality of care can lead to a desire to remain or leave not only the place of employment but, at times, the profession of nursing altogether (Laschinger et al., 2016).

Interpersonal relationships are shown to be a factor in turnover. People are happiest in an environment where they get along with their coworkers, and nurses and healthcare workers have a long-standing reputation of conflict. There was once a saying that "nurses eat their young" and incivility among nurses and other healthcare workers is well documented. It is much easier to walk away from a position in an environment with strained or poor interpersonal relationships than one of a cohesive nature (Kaiser, 2016; Smith et al., 2017). Personal reasons are yet another cause of turnover and may vary from compassion fatigue to personal obligations such as caregivers for minor children. Increasing the use of technology and a lack of empowerment are other commonly noted reasons for turnover. Women disproportionately hold the title of nurse, and their further obligations to childrearing and family care can add stress to an already stressful environment. Coupled with staffing and scheduling conflicts, the working mother often chooses to leave the profession in order to care for her children (Haddad & Toney-Butler, 2019).

In addition to turnover from one workplace to another, is the risk of career turnover by nurses. Career turnover refers to the intention of a nurse to leave the overall profession and is caused by job dissatisfaction that seems to be unmanageable even with a change in employer. New graduate nurses seem to be overwhelmingly at risk for job dissatisfaction as they question not only their current employment but also the choice of nursing as a profession altogether. This may lead to the nurse moving on for further education to get out of the clinical setting and away from bedside care as a nurse educator, nurse leader, or other advanced practice nursing role (Laschinger et al., 2016).

Nursing management has been noted as another source of turnover. The phrase, "people do not leave a position; they leave a manager" holds true in healthcare as well. Nurse Managers often have little to no formal training, and this can lead to dissatisfaction amongst those working for them (Ackerson & Stiles, 2018). Other cultural issues for leaving a position may be salary issues, uncomfortable work environment, communication barriers, insecurity related to the patient load and responsibilities, lack of opportunity or recognition, and a lack of appreciation (Dewanto & Wardhani, 2018).

Implications of Turnover

The cost of turnover is a significant concern as it contributes to the cost of healthcare overall. Studies have shown that new graduate nurses are often unprepared for patient care and their inexperience can lead to increased patient falls, pressure ulcers, medication errors, or other poor patient outcomes. Teamwork is necessary for effective patient care, and it requires trust and effective communication, which is difficult to achieve with constant turnover. Patients have difficulty developing trust with nurses that are visibly unprepared to manage their care such as a new graduate nurse, or a new hire unfamiliar with the environment. A high number of inexperienced nurses also creates a higher workload demand and stress for the experienced nurses within an organization and can lead to patient dissatisfaction. Patient dissatisfaction leads to lower reimbursement and poorer survey scores on the Hospital Assessment of Healthcare Providers and Systems survey (HCAHPS), which can directly affect the income to an organization (Strate, 2018).

A recent survey of 3,000 hospitals across the US estimates the average cost of turnover for each nurse is $52,000, and that an institution can save or lose over $300,000 each time they adjust their turnover rate up or down by just a single percentage point. The average hospital loses between $4,400,000 and $6,900,000 annually on turnover of bedside nurses. Each travel or agency nurse costs the organization over $70,000 annually, thus for each 20 travel RNs eliminated, the average annual savings is $1,435,000. The average reported timeline was 90 days to hire a new nurse, and 24% of hospitals surveyed reported over a 10% vacancy rate amongst nurses, driving up the need for travel or agency nurses to fill in the staffing gaps (NSI, 2019). The group previously known as the Institute of Medicine (IOM, 2000), now the National Academy of Medicine, published their report, To Err is Human. This report highlighted the problems with patient safety and reported that tens of thousands of patients die each year due to the delivery of health care. In 2004, the Centers for Disease Control and Prevention identified serious implications for infectious diseases related to nursing staffing patterns and nurse turnover including methicillin-resistant Staphylococcus aureus (MRSA) outbreaks in a neonatal intensive care unit due to understaffing, Enterobacter cloacae outbreaks related to understaffing, central venous catheter associated sepsis due to understaffing, and nosocomial infections related to a high nurse to patient ratio in a pediatric unit (Stone et al., 2004). In 2005, Hall noted that patient infections increased by approximately 30% with the loss of each nurse. These infections ranged from pneumonia, urinary tract infections, and sepsis. Even two decades ago, the notion of nurse retention and its positive impact on patient outcomes were known, and yet, the problem continues today. Turnover is not limited to acute care settings, as it is also a problem within long-term care facilities. Turnover may be indicative of greater systemic issues stemming from management or corporate concerns within healthcare organizations, and not only about nursing implications alone. Direct causality between high turnover and patient outcomes is difficult to establish; however, a review of California long-term care facilities found that a 10% increase in nursing turnover equated with a 19% increase in deficiency citations (i.e., violations) on their annual survey (Antwi & Bowblis, 2018).

Hospital managers describe turnover as disrupting the hospital service delivery. Consequences range from workload increases on the nurses that are left behind to patient complaints about nursing services that are delivered. Nurse turnover increases the cost of recruitment and training. New nurses require time for adaptation to the work environment and orientation, a learning period which may be associated with decreased quality and quantity in the delivery of services during this time. Senior nurses become distrustful of new nurses as they have to reteach and adapt to new personalities and new nurses repeatedly. Doctors perceive the new nurses as lacking skills and feel unwilling to teach the new nurses, as evidenced by an increase in complaints by doctors with the hiring of new nurses. Patients perceive a lack of professionalism when a recently hired nurse is not yet familiar with their environment or skills. The trust of both patients and families is decreased with new nurses, and satisfaction surveys reflect this shift. Hospitals have increased challenges with recruitment when staff leaves their organization, and turnover increases the overall hospital costs and interrupts their revenues. Ultimately, the loss of nursing staff increases the workloads of those left behind, causing fatigue and lowering their morale, and in turn, deteriorates the patient care within an individual organization (Dewanto & Wardhani, 2018).

Retaining Nurses

In a study on healthy work environments and nurse retention, it was noted that up to 63% of nurses were very satisfied with their choice of nursing as a career, but less than 29% were satisfied with their current workplace. The nurses surveyed mentioned leaving their current job for other positions in nursing, returning to school, or retiring. Of those desiring to leave their positions, they further noted they might reconsider the choice to leave if conditions in their current workplace were to improve. The areas identified as needing improvement were staffing, leadership, and respect from administration. The same study noted that healthcare environments lacked joy for employees (Kennedy, 2019).

The Institute for Healthcare Improvement (IHI) released a white paper that focused on restoring joy in the healthcare workplace to improve both the morale of employees and patient outcomes by changing the culture. The focus of this white paper was to present joy into the workplace and make a positive focus rather than negative connotations of discussing incivility, burnout, etc. Of particular interest was the notion of changing the dialogue in the workplace to one of "What can we do today?" and "What do we need today? " This style of dialogue places focus on the workforce as a team and inspires the notion that working together is a possibility. Reshaping the workplace culture to focus on positivity and helping nurses look at their work from a perspective of joy is a start to changing the overall clinical environment. Nurses spend a significant part of their life at work, and this suggestion of joy s becoming the standard can impact the profession of nursing overall (Perlo et al., 2017).

In addition to creating a positive working culture that values all employees within the organization, new nurses particularly need support as they transition from the academic setting and into their initial clinical roles. Much literature has been written on this period of transition and the value of implementing structured programs to facilitate a successful transition to clinical practice. Hospitals are recognizing the value of a nurse residency and the support offered for new nurses in these programs. With key aspects similar to a new physician residency program, a nurse residency program supports new nurses entering practice through the use of didactic and hands-on educational support, mentors, preceptors, and other structured roles to offer psychosocial and transitional support to the nurse graduate. This transitional period can be very stressful for new nurse graduates with the disparities between the professionalism and ideal work environment taught in most nursing schools in direct comparison to the reality of clinical practice. This reality can lead to early job dissatisfaction, and a strong mentor can help bridge this gap. Nurse mentors can also be used as the experienced nurse transitions from one area of practice to another to offer resources during the transitional period. Mentorship, coaching, or other support roles help to enculturate nurses entering new areas of practice and have been identified as useful tools for retention (Horner, 2017).

Nurse residencies are strong indicators of role transition for the new graduate nurse across the literature. Graduates of nursing schools enter the workforce with anticipation of a supportive and caring environment and a somewhat altruistic view of patient care and instead, may find discord and dissatisfaction. There is a distinct incongruence between the real-world practice and the preconceived notions that were formulated during school in the ideal educational environment. Within the literature base, this transition is referred to as "culture or reality shock" at worse, or role transition at best. Since the transition time is a crucial one for long-term role satisfaction, success, and safety of patient care, the value of nurse residency programs is evident (Price & Reichert, 2017).

Mentoring is a long-term and mutually beneficial relationship where the experienced professional supports, teaches, mentors, and encourages the less experienced individual to foster professional and personal growth as they adapt to their new role. A mentor should be confident, have effective communication skills, good listening skills, maturity, and a nurturing nature. They should not be judgmental or impatient. Early mentoring focuses on clinical competence and basic nursing skills that may be adapted in a particular facility versus the way they were taught in school. Over time, the mentor may focus on the development of advanced nursing skills and higher levels of problem-solving, clinical judgment, and even emotional intelligence. New nurses who have been part of a mentoring program report increased satisfaction, competence, and confidence with their new roles; enhanced communication and leadership skills; and the development of close interpersonal relationships with other nurses on the unit as well as their mentor, all leading to improved retention. Hospitals with mentoring programs and nurse residencies report improved retention, with turnover rates dropping to less than 10%. The annual cost of a mentoring program can cost $50,000 to $100,000, which is much less than the cost of nurse turnover (Horner, 2017).

Coaching is a more time-limited and structured relationship between a skilled facilitator and an individual or group of learners. For instance, a coach may work with a particular hospital unit to improve morale or teach leadership behaviors. Goals are agreed upon prior to the coaching, and the coach promotes the development of the desired skills to reach those goals. Knowledge, skills, and attitudes are focused on to develop new behaviors that will enhance the learner's performance and role effectiveness. Coaching can have higher up-front costs than other types of mentoring that may be primarily volunteer, but the tradeoff is a higher impact on job satisfaction and organizational or cultural improvements. Studies have demonstrated improved relationships, higher intention to remain in a position, and increased job satisfaction by nurses where coaching has been initiated (Horner, 2017).

Role adjustment is not limited to the new graduate nurse entering practice but can also impact newly hired advanced practice RNs (APRNs). Mentors can be a vital source of support and aid in adjustment to the role of the healthcare provider. A study of 37 new APRNs reported that positive relationships with their mentors contributed to high job satisfaction and a decrease in stress. The article noted that the new APRNs held recognition, potential advancement, and career growth as key intrinsic factors driving job satisfaction and retention. Mentors were reported to validate those intrinsic factors and aid in the retention of the new APRNs (Horner, 2017).

Nursing empowerment has been identified as a major source of nurse retention and the lack of empowerment as a key indicator of turnover. Professional practice behaviors go above and beyond nursing tasks and skills and include development of therapeutic relationships with patients, evidence-based practice, exercising clinical judgment, and collaborating with the healthcare team. RNs have the knowledge, skills, and attitudes to deal with and adapt to complex and unpredictable situations yet must have the autonomy to practice at their highest scope of practice. Without sufficient support from administrators, the RN may not feel empowered to extend themselves to meet the full potential professional practice. Nurses want autonomy to deliver quality patient care. As previously noted, research indicates that a nurse's perception of patient safety and quality of care delivered through their institution is directly linked to their turnover intentions. Not surprisingly, nurses perception of the quality of care is directly correlated to objective hospital quality indicators, including patient satisfaction, failure to rescue, and infection or mortality rates (Laschinger et al., 2016).

Ongoing training and opportunities for attending educational summits or conferences are important aspects of nurse satisfaction as well. These training's expand a nurse's knowledge of current evidence, allow networking with peers, and encourage professional development. In a study of 185 nurses that included students, early-career nurses, and mid-to-late career nurses, professional development was identified as an expectation and an expressed need across the lifespan of a nurse's career. Students require sufficient training to deliver safe and effective care. Further, the graduate nurse must have sufficient training for role transition and skill mastery. Mid-to-late career nurses (over the age of 50) understand the need for lifelong learning, maintaining competency within their nursing role, and understanding the latest evidence-based care to ensure they are delivering optimal care; these nurses cited professional development opportunity as essential for job retention. Despite this, only 12% of late-career nurses surveyed reported that their institution supported or provided educational opportunities. This study noted that nurses across various stages of their career felt that ongoing education was critical to a healthy work environment. They further noted that healthy work environments directly weighed on their job satisfaction and the desire to remain in the nursing profession (Price & Reichert, 2017). Provision 5 of the ANA Code of Ethics (2015) discusses the nurse’s responsibility to maintain competence through professional development. The ANA states that this continued competence and professional growth affect the quality of patient care as well as the nurse’s “self-respect, self-esteem, and meaningfulness of work” (ANA, 2015, p.22). The IOM published The Future of Nursing in 2011, which confirmed the importance of lifelong learning in nurses and tied the retention and recruitment of nurses to educational and professional development opportunities from their employers to hone skills and master competencies, which also improves patient care and outcomes (IOM, 2011).

Magnet status has been associated with nurse satisfaction and nurse retention for some time, and it is well known that hospitals with the Magnet designation attract and retain nurses. Magnet facilities hold high standards of care and promote professional practice through control over the practice environment, clinical autonomy, and healthy nurse/physician relationships. Further values held by Magnet facilities are adequate staffing, decisional involvement, leadership, and nursing as the foundation of care. Lower burnout, greater job satisfaction, and a strong desire to remain in the profession of nursing are identified in nurses working in Magnet facilities (Laschinger et al., 2016. The ANA (n.d.a.) notes the following in relation to Magnet status: "to nurses, Magnet Recognition means education and development through every career stage, which leads to greater autonomy at the bedside. To patients, it means the very best care, delivered by nurses who are supported to be the very best that they can be."

A focus on manager training and leadership succession can be a vital part of retention. A strong leader will be an advocate for those they lead. This includes ensuring adequate staffing and resources, recognition of employee performance, and empowering nurses. Professional recognition can include financial awards such as bonuses or raises for performance, clinical excellence appreciation programs, and retention awards for years of service; these recognition's act as incentives to remain at an organization. Employee retreats, continuing education support, higher education opportunities, and clinical ladder programs can be positive aspects of an organization that entice the employees to remain in place (Ackerson & Stiles, 2018).

Nurses of advanced age (greater than 45 years) are both entering practice and remaining in practice due to financial constraints, yet the role of a clinical nurse can be challenging for the most physically fit individual. Evidence has been introduced that many older nurses would remain in the clinical setting much longer if they could have adaptations to current scheduling, including shorter work days, patient loads that are less physically demanding, increased pay based on their experience, and more support from management. While this may not eradicate the current shortage, retaining experienced nurses can improve the overall patient outcomes and improve the morale of individual units where each person is valued (Ackerson & Stiles, 2018).

Value of Retention

When workplace issues are addressed and resolved, positive outcomes for nurses and patients result. Many states have recognized the value of retention and have made attempts to actively slow down turnover through legislation that controls nurse/patient staffing ratios. The California Nurses Association proposed and advocated for ratios based on the nurse's experience, and eventually, the California Ratio Law was passed. The law, known as Title 22, states that “Nurse Administrators, Nurse Supervisors, Nurse Managers, and Charge Nurses, and other licensed nurses shall be included in the calculation of the licensed nurse-to-patient ratio only when those licensed nurses are engaged in providing direct patient care. When a Nurse Administrator, Nurse Supervisor, Nurse Manager, Charge Nurse or other licensed nurse is engaged in activities other than direct patient care, that nurse shall not be included in the ratio.” See Table 1 for the ratios required by the state of California (Southern California's Registered Nurse Union [SEIU], 2018).

Table 1

California Law Staffing Ratio Requirements 


                                                                                                                                                                                 (SEIU, 2018)

In addition to passing this law, several studies have focused on its success or lack thereof. While there has been no absolute evidence that mandatory staffing ratios are associated with less turnover, there have been reports of improved patient outcomes with many of the studies. In a 2015 systematic review and meta-analysis, the following conclusions were drawn:

  • Higher RN staffing was associated with a lower hospital-related mortality rate. With each additional RN full time equivalent per day, there was a 9% decrease in the mortality rate in the ICU; a 16% decrease in the mortality rate in the surgical unit setting; and a 6% decrease in the mortality rate in the medical unit setting.
  • Higher RN staffing was associated with a decrease in healthcare associated pneumonia, failure to rescue, and healthcare-associated bloodstream infections (Clendon & Gibbons, 2015).

Retention holds value at many levels, including that of improving the shortage of nurses across our country. Additionally, retention of nurses within an organization allows nurses to become more comfortable with their work environment and facilitates an expert caregiver (Laschinger et al., 2016). Patricia Benner's theory of clinical competence stages identifies the importance of experts caring for our patient population. In her classic work, From Novice to Expert, Dr. Benner noted the need for professional growth at the different stages of a nurse's career. She further identified that nurses move through levels of competence driven by experiences within the clinical setting, and the movement from novice to expert is a process that takes an extensive amount of time. Retention of nurses can foster the development of these expert skills as the nurse is allowed to flourish and grow in their depth of knowledge in the role and hone their nursing skills (Benner, 1982).

Several hospital systems increased their wages in 2019 with the intent to decrease costs. Since hospitals employ nearly six million people across the US, increasing wages could seem incongruent to saving money, yet executives within some of the largest healthcare organizations in the country, including but not limited to Cleveland Clinic, Advocate Aurora Health, and Atrium Health, advocated to increase wages to encourage retention. While their balance-sheet in the short-term may not have shown cost-saving benefits, administration and other levels of leadership believe an increase in wages can improve efficiency and care quality for the patients, thus increasing their overall economic health in the long-term. The rising wages for permanent nursing positions limits temporary agency hires that can cost a premium to the organization through retention. Despite the potential upside, smaller hospitals may have more difficulty making such determinations to increase wages. However, with a broad look at long-term outcomes, the sacrifice to the budget is one that needs to be considered for the positive collateral implications (Kacik, 2019).

Healthy Nurse, Healthy Nation

At the end of the day, nurses give everything they have physically, mentally, and socially for their profession. It is no wonder that burnout and a desire to walk away from the profession can occur. The ANA recognizes the need for nurses to care for themselves while caring for others. In 2017, the ANA launched the Healthy Nurse, Healthy Nation (HNHN) Grand Challenge.

This initiative was designed to transform the health of the nation’s four million RNs, allowing them to “live life to the fullest” just as they seek for their patients. Poor health outcomes for nurses are often due to the long hours of work, stress, and exposure to workplace hazards. Further, nurses who practice positive health habits can be of great influence on their patients as role models, educators, and advocates (ANA, 2020). The HNHN initiative begins with an online survey that identifies the nurse's risk for health, safety, or wellness concerns. The question categories in this online survey include demographics, occupational health habits, employee and personal wellness, individual safety, and overall health. This survey takes about 15 minutes to complete, and the user is guaranteed confidentiality. Both nursing students and nurses are encouraged to take the survey and join the path to living healthier. After all, we can't care for others if our own cup is empty (ANA, 2020).

Conclusions

Have you worked in a place where you were excited every day to go into work? Or, have you worked in a place where you started dreading your next shift before even going to bed the day before? Have you thought about what was different in the first? Was it a manager who respected you? Was it a co-worker who seemed to value you? Was it increased accessibility to resources? Was it staff that worked together for the good of the patient? Was it a well-oiled organization with policies and procedures that were up-to-date and based on evidence, not profits? Was it your salary? Think about the things that are positive in those workplaces that you loved. Those are the aspects of retention that we all seek. What is your part in making your current workplace one that others value and want to be a part of?

                                                                                                  References

Ackerson, K., & Stiles, K. A. (2018). Value of nurse residency programs in retaining new graduate nurses and their potential to affect the nursing shortage. Journal of Continuing Education in Nursing, 49(6), 282-288. https://doi.org/10.3928/00220124-20180517-09

American Nurses Association. (2015). The code of ethics for nurses with interpretive statements. https://www.nursingworld.org/practice-policy/nursing-excellence/ethics/code-of-ethics-for-nurses/

American Nurses Association. (2020). Healthy nurse healthy nation. https://www.healthynursehealthynation.org/

American Nurses Association. (n.d.a.). ANCC magnet recognition program. Retrieved on January 29, 2020 from https://www.nursingworld.org/organizational-programs/magnet/

American Nurses Association. (n.d.b.). Nurse staffing. Retrieved on January 29, 2020 from https://www.nursingworld.org/practice-policy/nurse-staffing/

Antwi, YA, & Bowblis, J.R. (2018). The impact of nurse turnover on quality of care and mortality in nursing homes: Evidence from the great recession. American Journal of Health Economics, 4(2), 131-163. https://doi.org/10.17848/wp15-249.

Benner, P. (1982). From novice to expert. American Journal of Nursing, 82(3), 402-407.

Brigham, T., Barden, C., L. Dopp, A., Hengerer, A., Kaplan B., Malone, C., Martin, C., McHugh, M., & Nora, L. M. (2018). A journey to construct an all-encompassing conceptual model of factors affecting clinician wellbeing and resilience [NAM Perspectives Discussion Paper]. National Academy of Medicine. https://doi.org/10.31478/201801b.

Clendon, J., & Gibbons, V. (2015). 12 h shifts and rates of error among nurses: A systematic review. International Journal of Nursing Studies, 52(7), 1231-1242. https://doi.org/10.1016/j.ijnurstu.2015.03.011

Dewanto, A. & Wardhani, V. (2018). Nurse turnover and perceived causes and consequences: A preliminary study at private hospitals in Indonesia. BMC Nursing, 17(52), 1-15. https://doi.org/10.1186/s12912-018-0317-8

Haddad, L.M. & Toney-Butler, T.J. (2019). Nursing shortage. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK493175/

Hall, L. M. (2005). Quality work environments for nurse and patient safety. Jones & Bartlett.

Horner, D. (2017). Mentoring: Positively influencing job satisfaction and retention of new hire nurse practitioners. Plastic Surgical Nursing, 37(1), 7-22. https://doi.org/10.1097/PSN.0000000000000169

The Institute of Medicine. (2000). To err is human: Building a safer health system. National Academy Press.

The Institute of Medicine (2011). The Future of Nursing: Leading change and advancing health. National Academy Press.

Kacik, A. (2019). Health systems look to boost employee retention through minimum wage hikes: Modern healthcare. https://www.modernhealthcare.com/article/20190126/NEWS/190129958/health-systems-look-to-boost-employee-retention-through-minimum-wage-hikes

Kaiser, J. (2016). The relationship between leadership style and nurse-to-nurse incivility: Turning the lens inward. Journal of Nursing Management, 25(2), 110-118. https://doi.org/10.1111/jonm.12447

Kennedy, M.S. (2019). Improving the work environment, step by step. American Journal of Nursing, 119(4), 7. https://doi.org/10.1097/01.NAJ.0000554527.47868.3f

Laschinger, H.K., Zhu, J., & Read, E. (2016). New nurses’ perceptions of professional practice behaviors, quality of care, job satisfaction, and career retention. Journal of Nursing Management, 24, 656-665. https://doi.org/10.1111/jonm.12370

Nursing Solutions Inc. (2019). 2019 NSI national healthcare retention and RN staffing report. https://www.nsinursingsolutions.com/Documents/Library/NSI_National_Health_Care_Retention_Report.pdf

Perlo, J., Balkik, B., Swensen, S., Kabcenell, A., Landsman, J. & Feeley, D. (2017). The IHI framework for improving joy in work. The Institute for Healthcare Improvement White Paper. http://www.ihi.org/resources/Pages/IHIWhitePapers/Framework-Improving-Joy-in-Work.aspx

Price, S. & Reichert, C. (2017). The importance of continuing professional development to career satisfaction and patient care: Meeting the needs of novice to mid- to late-career nurses throughout their career span. Administrative Sciences, 7(17), 1-13. https://doi.org/10.3390/admsci7020017

Smith, J.G., Morin, K. H., & Lake, ET (2017). Association of the nurse work environment with nurse incivility in hospitals. Journal of Nursing Management, 26(2), 219-226. https://doi.org/10.1111/jonm.12537

Stone, P., Clarke, S., Cimiotti, J., & Correa-de-Araugo, R. (2004).  Nurses’ working conditions: Implications for infectious disease. Emerging Infectious Diseases, 10(11), 1984-89. https://doi.org/10.3201/eid1011.040253

Strate, C. (2018). How does patient satisfaction impact reimbursement? https://www.accessefm.com/blog/how-does-patient-satisfaction-impact-reimbursement

Van Camp, J., & Chappy, S. (2017). The effectiveness of nurse residency programs on retention: A systematic review. AORN, 106(2), 128-144. https://doi.org/10.1016/j.aorn.2017.06.003