Practical evidence-based strategies for nurse retention allow front-line leaders to meet the needs of nurses on their units

Context

Nursing workforce shortages have gained global attention and concern, with surveys highlighting high rates of nurses who are burned out and want to leave their job¹ and health facilities reporting difficulties in attracting and retaining staff.² Nurse turnover, defined as leaving a job or organization, and retention, defined as staying in a job, have been urgent matters in healthcare for years, but lack of consistent reporting mechanisms make it difficult to quantify turnover outside of organizations. Instead, nurses’ job intentions are often used in place of the actual outcomes and both are attributed to factors including workplace features and leadership.³

Methods

This realist review⁴ drew on literature from Europe, North America, Australia and New Zealand that reported findings related to job intentions. Following literature searches and reviews, data from 48 research studies were extracted, coded, and synthesized. The authors visualized nurse retention and turnover as a process which included job intentions, with an underlying hypothesis that first-line leaders’ specific actions within a workplace can improve nurse retention. Data were categorized as supporting, refining, or refuting elements of a context-mechanism-outcome model and synthesized to deepen understanding of factors that can impact the process of turnover or retention.

Findings

Findings focused on four themes, termed ‘guiding lights’, shown to improve nurse retention: 1) fostering relational connectedness; 2) enabling professional practice autonomy; 3) cultivating healthful workplace culture; and 4) facilitating professional growth and development. Within each theme, multiple examples of strategies were linked with different desired outcomes. For example, in the ‘enabling practice autonomy’ theme, strategies such as encouraging nurse participation in planning and achieving unit quality objectives could improve satisfaction and engagement, both of which are linked to improved retention rates or intent to stay.

Commentary

This study provides a needed perspective on nursing workforce issues, acknowledging the pervasive and complex nature of turnover and highlighting pragmatic approaches to improve retention of nurses. While previous reviews have noted the difficulty in comparing intentions to leave with actual turnover,³ the model used in this review shows turnover as a process with known antecedents, including those specific to an individual’s workplace. By emphasizing the process and the context of turnover, the study provides multiple strategies that can be used to improve a given workplace without placing the onus on individual nurses to improve their resilience and without incurring the costs of additional resources or programming beyond support of frontline leadership to make change. This frontline approach emphasizes the locality of workplace issues and allows for direct intervention rather than a top-down or prescriptive approach adopted by administrators. With the diversity of strategies and targets, study findings apply to any and every nurse work environment and support an implementation science approach to projects that allows for contextualization of interventions, flexibility, and tracking of results that can be used to further develop the context-method-outcomes models in meaningful ways.

This study and its ‘guiding lights’ provide strategies to address a complex issue that has been worsened by the stress, demands, and trauma of working through the pandemic. The strategies presented here involve a person-centered approach of connecting with nursing staff to increase communication, support, and involvement of nurses to strengthen positive workplace features, promote retention, and improve patient outcomes. In addition to improving staff retention, the investment in targeted education and support of frontline nursing leaders helps develop their skills, improve their retention, and prepare them for promotion to larger leadership roles.⁵ Altogether, the study provides a hopeful and optimistic perspective on retaining a supply of engaged and satisfied nurses to meet the needs of patients and communities.

Commentary.

Implications for practice and research

• Frontline nursing leaders can choose from a variety of pragmatic strategies to improve the workplace and increase nurses’ desire to stay.

• Implementation science approaches to retention allow researchers to examine evidence-based strategies in different contexts and identify the skills needed by frontline leaders for effective implementation.