Reducing Nurse Turnover

Abstract

In hospitals, the cost to replace 1 registered nurse (RN) can be quantified by considering costs in recruitment, hiring, and onboarding processes. Though the mean replacement cost of 1 RN will vary depending on geographic location and professional specialization, some have estimated this cost at $56 000. In addition to these direct costs, high turnover also contributes to broader organizational challenges, including disrupted communication, teamwork, and patient care. These challenges can contribute to adverse quality outcomes, such as increased inpatient falls. This article examines the organizational cost of RN turnover by analyzing its relationship to inpatient fall rates as an indicator of quality care.

INTRODUCTION

Nurse turnover is a major challenge for hospitals across the country, negatively impacting patient care, staff burnout and morale, and financial performance. Recent Workforce data from Press Ganey reveals the prevalence of this issue as nearly 1 in 5 registered nurses (RNs) left their role between 2022 and 2023.1 Data also show a clear connection between nurse engagement and RN turnover with facilities scoring in the top quartile of engagement outperforming those in the bottom quartile by 5.6 percentage points. Looking at financial implications and cost related to the replacement of 1 RN, lower turnover rates would translate to $313 K in cost savings per 100 RNs.2

Further review of the data from the National Database of Nursing Quality Indicators (NDNQI)3 brings another concern to light. Based on 191 responding facilities, there was a statistically significant association between higher RN turnover rates and an increase in patient falls with subsequent higher costs. In this article, we will explore the organizational cost of RN turnover through the lens of in-patient fall rates as an indicator of quality care.

Turnover

Nursing turnover occurs when a nursing position becomes vacant due to a nurse leaving or being removed from their position within an organization.2 According to a systematic review conducted by Bae, the replacement cost of 1 RN, in U.S. dollars, varied from $21 514 to $88 000 per nurse, or approximately 1.3 times the average annual salary of the nurse.4 In addition to the tangible costs of replacement and onboarding, there are noneconomic impacts as well, including negative employee morale and patient outcomes.4 Research has demonstrated that patient outcomes may be negatively affected by nurse turnover.5 Sawada et. al6 identified 6 organizational factors that were negatively affected by nurse turnover: “quality of nursing care, the physical and mental health of nursing staff, workload and working conditions of nursing staff, relationships among nursing staff members, sense of responsibility among nursing staff, and cost and benefit of hiring replacement personnel.”

In-patient falls

The Centers for Medicare and Medicaid (CMS) regard in-patient falls as an adverse event and defines a patient fall as a sudden, unintentional descent to the floor, with or without injury to the patient.7 An adverse event in the inpatient hospital setting refers to any injury or harm that occurs to a patient as a result of medical care rather than the underlying condition for which the patient was admitted. These events can prolong the hospital stay and cause long-term disability.8 As of 2008 any health care costs associated with an adverse event are not reimbursed by CMS.9

According to CMS, patient falls are the most common adverse event in the hospital setting with 700 000 to 1 000 000 in-patient falls reported in the United States annually.7 Of those patients who fall, 30%-35% will sustain injuries and on average, add more than 6 days to the patient’s hospital stay.10 In a recent 2023 multicenter study, Dykes et al10, examined 10 176 patients who suffered a fall as acute care in-patient patient. The average total cost associated with the fall was $62 521 ($36 775 in direct care costs) with an associated cost increase of $36 070 among study participants. According to the CDC, approximately $50 billion ($29 billion Medicare) is spent annually in the U.S. health care system on falls-related care.11

As a means to compare the quality of care provided to patients, risk-adjusted in-patient fall rates can be a strong indicator for comparison. Risk-adjusted fall rates take into account factors that might influence the likelihood of falls, such as patient demographics, health conditions, and hospital characteristics. Thus, the study was limited to a sample of medical-surgical and step-down units. By adjusting for these factors, you can more accurately compare fall rates across different hospitals to determine the quality of care provided in the organization.12,13

METHODS

Press Ganey analyzed 2023 annual turnover rates for employed full-time equivalent (FTE) RNs and advanced practice registered nurses (APRNs) alongside patient fall rates per 1000 patient days using the NDNQI. Established in 1988 by the American Nurses Association and acquired by Press Ganey in 2014, NDNQI is a U.S.-based repository of nursing quality indicators submitted by participating Press Ganey client hospitals used for benchmarking and improving patient quality care. For a detailed description of NDNQI, refer to Montalvo.3 The NDNQI data management procedures were reviewed by the Advarra Institutional Review Board (IRB) and deemed exempt from IRB oversight.

This research study used a cross-sectional design to analyze data from 844 medical-surgical and step-down units across 191 facilities. Units were grouped into quartiles based on turnover rates, and the top 25% (highest turnover) and bottom 25% (lowest turnover) quartiles were selected for comparison (see Table 1 for descriptives of quartiles). An independent t-test was conducted to determine whether fall rates differed significantly between these 2 groups.

Table 1.

Descriptives of Highest and Lowest Turnover Quartiles

	Total Number of Units	%Compared for Top and Bottom	Total Units per Quartile	Highest Turnover Rate	Lowest Turnover Rate
Medical-Surgical and Stepdown Units	844	25%	211	64.54%	10.19%

Fall rates were measured per 1000 patient days, with the average fall rate calculated across 4 quarters. Turnover was calculated as the 4-quarter nursing unit turnover rate, expressed as percentage of FTEs for RN and APRN staff. The turnover rate in NDNQI is defined as the proportion of permanent, direct care nursing staff that leave their position during the quarter for any reason (eg, leaving the hospital, taking a position on another unit). Eligible staff for the turnover indicator in the current study are RNs and APRNs who are in permanent, unit-based FTE positions and who provide direct patient care (defined as 50% or more of their responsibilities).

To evaluate the financial impact of turnover, the difference in fall rates between units in the highest and lowest turnover quartiles was calculated. The difference informed the estimated cost of additional fall rates associated with higher turnover. The financial impact was determined by applying the average cost of an inpatient fall, using an estimate from a recently published article that found an average fall cost of $35 365.10 This cost was then multiplied by the reduction in the fall rate per 1000 patient days to estimate the annual savings per unit, providing a quantified financial impact of higher turnover in terms of increased fall-related costs.

RESULTS

Units with the lowest turnover have fall rates of 2.17, while units with the highest turnover have fall rates of 2.83, resulting in 0.66 significantly fewer falls per 1000 patient days for low-turnover units (t (419.34) = −5.06, P < .001). To calculate the average fall cost, the 0.66 reduction in fall rates was multiplied by $35 365, the average inpatient fall cost. This translates to approximately $23 341 in annual savings per unit for every 1000 patient days (see Figure 1).

Figure 1.

Bar chart represents average annual fall rates per 1000 patient days in units with the lowest (bottom quartile) and highest (top quartile) RN turnover rates. Units with lower turnover had 0.66 fewer falls on average, corresponding to an estimated annual savings of $23 341 per unit for every 1000 patient days.

Discussion and implications for nursing leadership

A significant association was observed between turnover rates and inpatient fall rates, with lower turnover units experiencing 0.66 fewer falls per 1000 patient days compared to higher turnover units. Consistent with current evidence, these findings suggest that RN turnover influences variation in patient safety outcomes and has implications in reducing avoidable organizational costs.

Nurse turnover is a major challenge at hospitals across the country, negatively impacting patient care, staff burnout and morale, and financial performance. Recent Press Ganey data reveal just how prevalent this issue is: Nearly 1 in 5 RNs left their role between 2022 and 2023 (link https://info.pressganey.com/e-books-research/nurse-resilience-2024). It also shows a clear connection between engagement and RN turnover: Facilities that score at the top in engagement outperform those at the bottom by 5.6 percentage points. Looking at the financial implications, lower turnover rates translate to $313 K in cost savings per 100 RNs.

To mitigate these impacts, organizations can implement targeted management strategies to improve retention and reduce RN turnover. Proven management strategies include building positive relationships among the nursing team, creating mechanisms for effective feedback, and coaching nurses for career progression and advancement.14 The evidence offers the following strategies for nurse managers to reduce turnover and support quality patient outcomes.

1. Nurse managers are critical to nurse retention and patient care quality.15 Since the nurse manager role is the first rung in the leadership ladder, nurse managers are typically promoted based on clinical excellence rather than leadership experience.16 It is critical to provide nurse managers with strong onboarding and role transition support.17 Nurse managers are more successful when they have the skills to perform the job.15,18

2. The evidence is clear: relationships matter! Regardless of which relational leadership style studied, consistent, positive outcomes are associated with nurse managers who establish positive relationships with their teams.14,19 Senior nurse leaders should mentor novice nurse managers in developing relational leadership styles. Collaborative relationships are critical to build trust and positive perceptions of work among the nursing team as well.14 Nurses want to work in environments that support cohesive teamwork.20

3. Authentic listening is an important tool nurse managers can use to build strong, cohesive teams.21 Authentic listening is when leaders use transparent communication that builds trust and promotes positive work climates.22 Nurse leader rounding21 and stay interviews23 are 2 strategies that promote regular collection of employee feedback. As changes based on nurse feedback are implemented, remember to conduct regular check-ins to assess progress toward goals and adjust as needed throughout the year. Using electronic surveys facilitates essential assessment and evaluation.

4. Career development and progression are critical to retaining today’s nursing workforce.20 Nurse managers should engage with their nursing team through regular check-ins. These check-in conversations should focus on understanding the career goals of individual nurses. The critical step is to develop action plans to help nurses develop new skills and knowledge to support their specific goals.

CONCLUSION

Lower RN turnover rates are associated with fewer falls and a subsequent reduction in avoidable costs of $23 341 per unit for every 1000 patient days. Units in the lowest turnover quartile reported significantly fewer falls compared to those in units with the highest turnover, demonstrating a clear association between RN turnover rates and patient fall rates. We have provided proven strategies to improve retention and decrease turnover contributing to improved patient safety, fewer falls, and reduced financial burden for health care organizations. These strategies can support organizations in reducing turnover and, in turn, drive retention. RN feedback is essential for improvement. It is important to understand what your RNs need and what their experience is like at your organization. Additionally, it is important to understand how these experiences and needs might differ across demographics and populations. Understanding the answers to these questions will drive strategies to decrease RN turnover, improve patient outcomes, and decrease avoidable costs.