Health care organizations are complex and face a myriad of challenges. Maintaining a cadre of well-qualified, dedicated employees is one of the greatest challenges faced by an organization. All organizations experience both voluntary and involuntary turnover, which, for the most part, will have a negative effect on the organization. This is particularly true in health care—and especially in the nursing profession, which has experienced very high rates of turnover, historically and cyclically.

Turnover is a voluntary process where an employee decides for whatever reason that he or she no longer wants to be employed at a particular organization. In the book The 7 Hidden Reasons Employees Leave, author Leigh Branham defines turnover as a process of disengagement that occurs over a period of time and that ends with voluntary termination. This definition is significant, giving the organization an opportunity to stop the process if they can figure out what is causing the person to want to leave. Although there are many reasons why individuals leave their jobs, Laureen J. Hayes and colleagues identified job satisfaction as being a significant factor for nurse turnover in their 2006 literature review published in the International Journal of Nursing Studies.

Because there are many factors that influence a person’s job satisfaction—such as leadership support, autonomy, and positive work environment—it is quite challenging to develop a comprehensive retention program. However, knowing the most common factors and what nurses value can be very helpful for the nurses and the organization. The journey to becoming a nurse is challenging, and once you become a nurse the challenges remain, but the rewards often outweigh the challenges. Certainly, no one goes into nursing believing that they will eventually become disenfranchised to the point where they want to leave their position, or in some cases, the profession. Unfortunately, this is exactly what happens to many nurses, especially new nurses.

Why is Turnover So High?

Turnover has been particularly problematic in nursing. In 2007, Christine T. Kovner and colleagues reported in the American Journal of Nursing that within the first year of transition turnover rates were as high as 50%. New nurses face countless challenges as they transition into practice. Reality shock affects all new nurses to some degree, with some leaving their organization and others leaving the profession altogether. It’s very overwhelming to leave the cocoon of support in nursing school and suddenly be on your own. Being autonomous, developing time management, critical reasoning, and organizational skills, and becoming clinically competent are just some of the challenges faced by new nurses.

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Experienced nurses often leave due to a negative work environment, which leads to job dissatisfaction and burnout. Not only does turnover have a negative effect on patient outcomes, but it may result in more turnover as units become understaffed and more nurses experience burnout. Furthermore, turnover costs to society are estimated to be between $1.4 and $2.1 billion, according to a 2013 study published in the Journal of Nursing Management.

Turnover has been the subject of multiple studies since the mid-1900s—several theories and models have been developed to explain why turnover occurs. For example, William H. Mobley and colleagues developed a conceptual model in 1979 that considered individual, organization, and environmental factors. Another model was developed in 1994 by Thomas W. Lee and Terrence R. Mitchell—the “unfolding model” of turnover, which has four paths. The first path describes a “shock,” which leads to the second path where the employee evaluates his or her fit. In the third path, the employee analyzes his or her fit within the organization, and in the fourth path, the employee leaves the organization.

More recently, Amy L. Kristof-Brown and colleagues described how person-environment fit has been utilized to explain organizational turnover in a 2005 article published in Personnel Psychology. The general premise being that when an employee’s (person) needs are met by the organization they will have a good fit, which will result in greater job satisfaction and lower turnover. The model has been further developed into categories of person-supervisor, person-organization, person-group, and person-job fit. In my doctoral dissertation on job satisfaction and turnover, I utilized person-supervisor fit and found a relationship between value congruence on leadership support and job satisfaction in registered nurses. Although there were several different antecedents of job satisfaction, leadership support was a significant factor. It is helpful to have a basic understanding of turnover and the various theories, especially when developing orientation and retention programs.

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Why Job Satisfaction Matters

Interestingly, salary was not identified as a significant factor in job satisfaction in many studies, yet job satisfaction is one of the most common factors that influence an employee’s decision to leave an organization. Some of the most common predictors of job satisfaction are: autonomy, work environment, supervisor support, and work stress. Nurse-physician collaboration, nurse-patient ratios, ability to deliver safe patient care, interpersonal relationships, and recognition can also have an effect on job satisfaction.

Although very few studies have been conducted on job satisfaction and minority nurses, Ying Xue published a study on job satisfaction among racial and ethnic minority nurses in the International Journal of Nursing Studies in 2015. The results revealed that a majority of nurses were satisfied with their jobs; however, black, American Indian/Alaska Native, and multiracial nurses had lower job satisfaction in comparison to white nurses. Xue recommends further studies be undertaken in order to develop programs to improve job satisfaction and decrease turnover in minority nurses.

The need to be autonomous is something most nurses value, but this increases as a nurse becomes more experienced. Experienced nurses value their autonomy and ability to use their knowledge, critical reasoning, and expertise when caring for their patients. New nurses, on the other hand, recognize their limitations and the need for support by their peers, mentors, and supervisors during their transition into professional practice. Unsurprisingly, both new and experienced nurses want to be supported by their manager—just in varying degrees.

Nurse-physician collaboration varies among organizations, and even nursing units. Although there are many supportive physicians that have developed positive working relationships with nurses, there are some physicians who are very disrespectful to nurses, unfortunately. Suzanne Gordon wrote extensively about this issue in her book, Nursing Against the Odds: How Health Care Cost Cutting, Media Stereotypes, and Medical Hubris Undermine Nurses and Patient Care. Still, physicians are not the only ones who are problematic. Many nurses, especially new nurses, are victims of workplace bullying by their peers and supervisors. This issue is so serious that the Joint Commission issued a Sentinel Event Alert in 2008 requiring organizations to have a “zero tolerance policy” against “intimidating or disruptive behavior.” Your organization is required to have policies to address this issue, so please reach out to the appropriate people if you are experiencing any type of bullying. There is no need to suffer in silence.

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A negative work environment is among the top reasons why nurses leave their jobs. Although there are many factors that influence the work environment, the nurse manager plays a pivotal role in creating a positive work environment. Many nurse managers are promoted from within and may not have the experience and/or education required of an exemplary leader. There are many different styles of leadership, and a true leader knows when to use the various styles. For example, in an emergency situation one might have to take an authoritarian approach; however, in most other situations, a democratic or participatory approach might be best. Transformational leadership, which is often seen in Magnet hospitals, has frequently been cited as the preferred style of leadership by many nurses.

Leadership support plays a significant role in turnover and is frequently cited as an antecedent of job satisfaction. Furthermore, value congruence on leadership support is positively related to job satisfaction among staff nurses. I measured the difference in scores of nurse managers and their staff nurses by using Kouzes and Posner’s Leadership Practices Inventory®, and the results were published in the Journal of Nursing Management. Notably, when value congruence increased, job satisfaction also increased. This is an important finding as it supports the influential role of the nurse manager and can be used to develop training programs for nurse managers so they can become expert leaders.

Nurse-patient ratios have recently been a major topic of debate among staff nurses, administration, professional organizations, and the collective bargaining units. There are compelling arguments for both sides of this issue, and the main goal is to enable nurses to provide safe and quality care. The American Nurses Association (ANA) recommends legislation that empowers nurses to collaborate on staffing plans and that is flexible to allow for changes in acuity and census. They also posit that establishing a minimal state staffing level could be beneficial. According to ANA, only 14 states currently have laws or regulations on staffing. Although there is a lack of consensus on whether or not to mandate nurse-patient ratios, nurses want to work in an environment that allows them to provide patient-centered care. Nurses also value recognition from patients and administration in the form of letters or just a simple “thank you.” Naturally, nurses expect to be paid at a level commensurate with their education and experience; however, these other factors are more important to many nurses. It is important to note that job satisfaction is different for each individual, so it is best to have each employee complete a questionnaire on job satisfaction and tailor retention programs accordingly based on the individual needs of the nurse, unit, and organization.

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Improving Your Work Environment

There are many things you can do to improve your work environment and job satisfaction. Finding the right “fit” can take time, so it is very important to learn as much as you can about an organization when applying for a new position. It is helpful to visit your potential unit and meet the nurse manager and the staff during the interview process. Be sure to inquire about the orientation program, mentor/preceptor programs, and staff development. Communication and interpersonal relationships are key to a positive work environment. Completing a self-assessment of your skills and developing a self-improvement plan can be quite helpful. Being proactive will also serve you well.

If you are having difficulties, be sure to reach out to your manager for support. And if you are having difficulties with your nurse manager, follow your chain of command and seek assistance from his or her superiors. Cultural differences can often lead to miscommunication and misunderstanding; therefore, it is of the utmost importance to continue to learn as much as you can about the various cultural beliefs and values of your colleagues and patients.

Stress is another common issue that can lead to burnout and job dissatisfaction. Engaging in self-care is very important, especially when caring for others. There are many strategies for dealing with stress—yoga, meditation, aromatherapy, healthy eating, exercise, and deep breathing exercises, just to name a few. If your organization offers a program, be sure to take advantage. If not, perhaps you can make a suggestion that a program be created. Moreover, if you feel that your particular nursing unit is having any of the issues discussed in this article, you might want to explore the possibility of a task force comprised of various staff members to identify strategies for improving the work environment.

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In summary, job satisfaction is related to turnover. While there are many factors at play, taking a proactive approach can make a major difference in lowering turnover rates. Create a positive work environment and it will benefit patients, employees, and the organization alike. 

Deborah Hunt
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