EFFECTIVE CHANGE

STRATEGY: NURSE
RETENTION
Presented by: Nina Favor, Jody French-Sroka, Mary
Hefferan & Amy Herrington

EFFECTIVE CHANGE STRATEGY

Part One

Introduction
Improving Retention of Nurses

Literature Support
Nurse Retention Strategies
Kurt Lewin s Change Theory

Overview of Issue
Nursing shortage
Retention of nurses
Significant number of graduate nurses leaving the profession

Demographics of Population
Population is living longer

Healthcare needs are becoming more demanding

Baby Boomers make up more than a quarter of our population
Estimated by 2030, 1 in 5 Americans will be older than 65

Wold, G.H. (2012).

Basic Geriatric Nursing (5th ed.). St. Louis, MO: Elsevier.

Demographics of Nursing
The average age of a practicing nurse is 45 years old

55% of surveyed nurses reported their intention to retire between 2011 and 2020
RNs will have the greatest job growth through 2020
495,500 replacements needed by 2020

1.2 million nurse needed by 2020 r/t growth and replacement

American Association of Colleges of Nursing.

(2013).

Nursing Shortage. Retrieved from http://www.aacn.nche.edu/media-relations/fact-sheets/nursing-shortage

Specifics of Experienced Nurse Turnover

Relationships
Nurse/Nurse relationship
Nurse/Manager relationship
Nurse/Physician relationship

Staffing
Improper staffing levels
Unorganized units
Imbalanced assignments

Personal Reasons
Compassion fatigue
Glass ceiling

Punke, H. (2013).

3 biggest causes of nurse turnover. Beckers Hospital Review.

Retention of Graduate Nurses

30% turnover in first year

Up to 50% turnover in second year

Organizations report 22-60% turnover

Hillman, L., & Foster, R. (2011). The impact of a nursing transitions programme on retention and cost savings. Journal of Nursing Management, 19(1), 50-56.
http://0-dx.doi.org.libcat.ferris.edu/10.1111/j.1365-2834.2010.01187.x
Mills, J., & Mullins, A. (2008). The California Nurse Mentor Project: Every Nurse Deserves a Mentor. Nursing Economics , 310-315.
Orsini, C. (2005). A Nurse Transition Program for Orthopaedics. Orthopaedic Nursing , 240-246.

Specifics of New Graduate Turnover

Emotional Stresses
Transition from novice to expert
Converting knowledge to practice

New Environment
Fear
Apprehension
Insecurity

Inadequate Support
Preceptors
Nurse Educators
Managers

Role Adjustment
Student to Professional

Cottingham, S., DiBartolo, M. C., Battistoni, S., & Brown, T. (2011). Partners in nursing: A mentoring initiative to enhance nurse retention. Nursing Education Perspectives, 32(4), 250-255. http://0dx.doi.org.libcat.ferris.edu/10.5480/1536-5026-32.4.250
Nelson, J. L., Arjes, M., Bushman, K., Carlson, M., Czaplewski, L., Derby, K., Godman, K., Horton, D., Stansfield, T., & Tan, H. P. (2012). Correlating novice nurses perceptions of nursing orientation
and first-year support with direct preceptor interventions. Journal of Continuing Education in Nursing, 43(2), 59-64.
Welding, N. M. (2011). Creating a nursing residency: Decrease turnover and increase clinical competence. Medsurg Nursing, 20(1), 37-40.

Cost of High Turnover

Financial
$42,000-64,000 to replace a nurse

Time
Human Resources
Management
Staff Nurse Preceptors

Experienced Nurse Turnover

High new graduate turnover

Inadequate staffing and inconvenient scheduling
Burnout and increased physical demands of experienced nurses
Turnover of experienced nurses

Mills, J., & Mullins, A. (2008). The California Nurse Mentor Project: Every Nurse Deserves a Mentor. Nursing Economics , 310-315.

Need for Change

120,000 nurses work outside nursing profession (Wood, 2009)

National RN Vacancy rate of 8.1% (AACN, 2013)

Improved retention Decrease in nursing shortage
Improved retention Financial gains

American Association of Colleges of Nursing. (2013). Nursing Shortage. Retrieved from http://www.aacn.nche.edu/media-relations/fact-sheets/nursing-shortage
Wood, D. (2009). Why have nurses left the profession? AMN Healthcare. Retrieved from http://www.nursezone.com/nursing-news-events/more-news/Why-Have
Nurses-Left-the-Profession_29118.aspx

Effective Change Strategy

Communication Methods

Kurt Lewin s Change Theory

Marshall, E.S. (2011). Transformational leadership in nursing: From expert clinician to influential leader. (1st ed.). New York: Springer Publishing Company.

References
American Association of Colleges of Nursing. (2013). Nursing Shortage. Retrieved from http://www.aacn.nche.edu/media-relations/factsheets/nursing-shortage
Cottingham, S., DiBartolo, M. C., Battistoni, S., & Brown, T. (2011). Partners in nursing: A mentoring initiative to enhance nurse retention. Nursing
Education Perspectives, 32(4), 250-255. http://0-dx.doi.org.libcat.ferris.edu/10.5480/1536-5026-32.4.250
Hillman, L., & Foster, R. (2011). The impact of a nursing transitions programme on retention and cost savings. Journal of Nursing
Management, 19(1), 50-56. http://0-dx.doi.org.libcat.ferris.edu/10.1111/j.1365-2834.2010.01187.x
Marshall, E.S. (2011). Transformational leadership in nursing: From expert clinician to influential leader. (1st ed.). New York: Springer Publishing
Company.
Mills, J., & Mullins, A. (2008). The California Nurse Mentor Project: Every Nurse Deserves a Mentor. Nursing Economics , 310-315.
Nelson, J. L., Arjes, M., Bushman, K., Carlson, M., Czaplewski, L., Derby, K., Godman, K., Horton, D., Stansfield, T., & Tan, H. P. (2012). Correlating
novice nurses perceptions of nursing orientation and first-year support with direct preceptor interventions. Journal of Continuing Education in
Nursing, 43(2), 59-64.
Orsini, C. (2005). A Nurse Transition Program for Orthopaedics. Orthopaedic Nursing , 240-246.
Punke, H. (2013). 3 biggest causes of nurse turnover. Beckers Hospital Review.

Welding, N. M. (2011). Creating a nursing residency: Decrease turnover and increase clinical competence. Medsurg Nursing, 20(1), 37-40.
Wold, G.H. (2012). Basic Geriatric Nursing (5th ed.).

St. Louis, MO: Elsevier.

Wood, D. (2009). Why have nurses left the profession? AMN Healthcare. Retrieved from http://www.nursezone.com/nursing-news-events/morenews/Why-Have-Nurses-Left-the-Profession_29118.aspx

EFFECTIVE CHANGE STRATEGY

Part Two

Nina Favor, Jody French-Sroka, Mary Hefferan & Amy Herrington

Administrator Role
Financial

Safety

Outcomes

Satisfaction- Patient and Staff

Nurse retention
Estimated that 55% of nurses plan to retire between 2011-2020

Replacement cost per RN w/hidden costs ~$65,0000 (2)

Nation could face major public health crisis
Multi-factorial
Lack of nurse residency programs

(3)

(1)

Strategy
Kurt Lewins Change Theory

3 stages
Unfreezing
Moving to new level or Changing
Refreezing

Unfreeze
Shifts

Benefits
Staffing
Schedules

Education
Work-life balance
Governance

Change
Flexible shifts

Variable benefits
Flexible schedules
Staffing ratios (acuity systems)

Increased educational offerings

Advancement
Accountability and ownership

Refreeze
Improved morale

Improved communication

Improved orientation/mentor program

Culture of safety

Improved satisfaction scores

Policy change- organizational

Why

Who

How

Barriers

Policy change- professional

Evidence

Process
Support
Enactment

Compliance

References
intention to stay among Saudi nurses. Journal of Nursing

Abualrub, R., & Alghamdi, M. (2012). The impact of leadership styles on nurses' satisfaction and
Management, 20, 668-678. doi:
10.1111/j.1365-2834.01320.x

Brewer, C.S., Kovner, C.T., Greene, W., Tukov-Shuser, M., & Djukic, M. (2012). Predictors of actual
turnover in a national sample of newly licensed registered
nurses employed in hospitals.
Journal of Advanced Nursing, 68(3), 521538. doi: 10.1111/j.1365-2648.2011.05753.x

Bryant-Hampton, L., Carroll, T., Walton, A., & Strickler, L. (2010). Recognition: A Key Retention

Strategy for the Mature Nurse. The Journal of Nursing

Collins-McNeil, J., Sharpe, D., & Benbow, D. (2012). Performance potential. Aging workforce: retaining
from CINHAL

valuable nurses. Nursing Management, 43(3), 50-51. Retrieved

Cowden, T., Cummings, G., & Profetto-McGrath (2011). Leadership practices and staff nurses intent
19(1), 461-477.

to stay: a systematic review. Journal of Nursing Management,

Force, M.V. (2005). The relationship between effective nurse managers and nursing retention. Journal

of Nursing Administration, 35(7), 336 341

Furtado, L., Batista, M., & Silva, F. (2011). Leadership's impact in turnover and career abandonment
intention: The Azorean hospital nurses case, Hospital Topics,
89(3), 51-58. Retrieved from
ttps://fsulearn.ferris.edu/courses/1/XLIST_10370.201301/groups/_6497_1//_244103_1/a

Administration, 40 (3) 121-123.

zorean.pdf

Gardner, B. (2010). Improve RN retention through transformational leadership styles. Nursing

10.1097/01.NUMA.0000384003.09214.ed.

Management,41(8), 8-12. doi:

Hirschkorn, C.A., Wes, T.B., Hill, K.S., Cleary, B.L., & Hewlett, P.O. (2010). Experienced Nurse Retention
Organizations. The Journal of Nursing
Administration, 40 (11) 463-467.

Strategies What Can Be Learned From Top-Performing

Kleinman, C. (2004). The relationship between managerial leadership behaviors and staff nurse
Healthcare, 82(4). Retrieved from
http://business.ollusa.edu/leadership/LEAD9310/MLQ2.pdf

retention. Hospital Topics: Research and Perspectives on

References (cont)
Marshall, E.S. (2011). Transformational leadership in nursing: From expert clinician to influential
Publishing Company, LLC

leader. (1st ed.). New York: Springer

Michigan Center for Nursing Survey of Nurses. (2012). Survey instrumental and response frequencies for
registered nurses employed
in Michigan. Retrieved from
http://www.michigancenterfornursing.org/docs/Report%20on%20Survey%20of%20Nurses%22012%
20FINAL%2010-12-12%20(2).pdf
Spence Laschinger, H. K., Wong, C. A., & Grau, A. L. (2012). Authentic leadership, empowerment and burnout:
a comparison in
new graduates and experienced nurses. Journal of Nursing Management. Advanced online publication. doi:10.1111/j.13652834.2012.01375.x
Wallis, A., & Kennedy, K. I. (2012). Leadership training to improve nurse retention. Journal of Nursing
online publication. doi: 10.1111/j.1365-2834.2012.01443.x

Management. Advanced

Weberg, D. (2010). Transformational leadership and staff retention. Nursing Administration Quarterly, 34(3), 246-258.
Wieck, K. L., Dols, J., & Landrum, P. (2010). Retention priorities for the intergenerational nurse workforce.

Nursing Forum, 45(1), 7-17.

Salt, J., Cummings, G. G., & Profetto-McGrath, J. (2008). Increasing retention of new graduate nurses. The
Administration, 38(6), 287-296.

Journal of Nursing

Stroth, C. (2010). Job embeddedness as a nurse retention strategy for rural hospitals. The Journal of Nursing

40 (1) 32-35

Wong, C., Cummings, G., & Ducharme (2013). The relationship between nursing leadership and patient
review update. Journal of Nursing Management. 21 (5). 709-724

Administration,

outcomes: a systematic

EFFECTIVE CHANGE STRATEGY:

NURSING RETENTION

PART THREE: EFFECTIVE STRATEGY TO CHANGE BEHAVIOR IN A PROFESSIONAL

ENVIRONMENT

Nina Favor, Jody French-Sroka, Mary Hefferan, and Amy Herrington

INTRODUCTION
Nursing Educators have facilitated staff adaptation to new or changing roles with
strategies such as

Preceptor models
Mentoring programs
Internship courses
NURSE RESIDENCEY PROGRAMS

These strategies have been effective in ensuring that new grad nurses as well as
experienced nurses possess the attitude, skills, and knowledge needed to embark
on a new journey into the health organization.
(Lampe, Stratton & Welsh, 2011)

RESEARCH
Research has shown that individual needs such as

Cognitive learning
Stressor perception
Coping styles
Self-esteem
Socialization

ARE NOT MET

spectrumcenter.umich.edu

(Lampe, Stratton & Welsh, 2011)

Translation to Advanced Nursing Educators in

Surrounding Areas
An assessment of these intervention strategies to implement change
will provide organizational changes by using a four-step approach,
consisting of guiding
questions to direct the choice of the most appropriate
implementation which are straightforward and efficient means of
identifying and addressing nurse retention issues at local and global
levels within a complex system
(French et al., 2012)

Translationsolutions.org

STEP 1

Who needs to do what, differently? (p. 2)

Identify the evidence-practice
Residency Program Curriculum
(Goode, Lynn & McElroy, 2013)
Specify the behavior change needed to reduce the evidence-practice gap
Mentorship Models
(Jacobson & Sherrod, 2012)
Specify the health professional groups whose behavior needs changing
Collaborative Relationships
(Laschinger, Wong & Regan, 2013)

(French et al., 2012)

STEP 2

Using a theoretical framework, which barriers and

enablers need to be addressed? (p. 2)
Select a Theory(s)/ Theoretical Framework(s), to initiate change from Advanced Practice
Registered Nurse Team (Team 3)

Use Change Theory-Informed Behaviour Change to identify the pathway(s) of change and to
address possible barriers
Burnout (Laschinger et al., 2012)
Use qualitative methods to identify barriers and enhance nurse retention in regards to behavior
change
Harming patients; Teamwork , quality care, liking the job, relationship with colleagues = decreased
turnover (Goode et al., 2013)

(French et al., 2012)

STEP 2 continues
Using a Theoretical Framework

blog.girishm.in

Using a Change Theory

Kurt Lewins Change Theory

Theory-informed Behaviour Change

Flexible shifts

University Health System Consortium

(UHC)/American Association of Colleges of
Nursing (AACN) Residency Program Curriculum

Variable benefits
Flexible schedules
Staffing ratios (acuity systems)
Increased educational offerings
Advancement
Accountability and ownership

(Goode, Lynn & McElroy, 2013)

Nurse Residency Program Curriculum

Accreditation by Commission on Collegiate Nursing Education (CCNE)
3 Core areas
Leadership
Patient safety and outcomes
Professional Role
Delivered in monthly seminars or face-to-face

stdavids.com

Requirements to complete individually/team

Evidenced-based project
Simulations inter- professional exercises
(Goode et al., 2013)

STEP 3

Which intervention components (change behaviour

techniques and mode(s) of delivery) could overcome the
modifiable barriers and enhance the enablers? (p. 2)

Create New Roles

Intern Development Specialist (IDS)
____________________________________________________
Use theory or framework to identify potential behavior change

Techniques and barriers to overcome to enhance nurse retention

Identify evidence to in conjunction to potential behavior changes/techniques
Identify what is likely to be achievable
Identified components into an acceptable competencies AEB: intervention that can be delivered BY
the new graduate nurse
(French et al., 2012)
(Guthrie, Tyrna & Giannuzzi, 2013)

STEP 4

convertunitsnow.com

How can behaviour change be measured and

understood? (p. 2)

The Casey-Fink
Quantitative scoring
Identify mediators of change to investigate the proposed pathways of change
Transformational Leaders
Select appropriate outcome measures
Determine feasibility of outcomes to be measured
(Goode et al., 2013)

REFERENCES
French, S. D., Green, S. E., OConnor, D. A., McKenzie, J. E., Francis, J. J., Michie, S., ... &
Grimshaw, J. M. (2012). Developing theory-informed behaviour change interventions to
implement evidence into practice: a systematic approach using the theoretical domains
framework. Implementation Science, 7(1), 38. doi:10.1186/1748-5908-7-38
Goode, C., Lynn, M., McElroy, D. (2013). Lessons learned from 10 years of research on a postbaccalaureate nurse residency program. The Journal of Nursing Administration, 43(2), 73-79.
doi: 10.1097/NNA.0b013e31827f205c

Guthrie, K., Tyrna, J., & Giannuzzi, D. (2013). Transitional orientation: A cost-effective
alternative to traditional RN residency program. Nursing Economic$, 31(4) 172-175.
Jacobson, S. & Sherrod, D. (2012). Transformational mentorship models for nurse educators.
Nursing Science Quarterly, 25(3) 279-284. doi: 10.1177/0894318412447565

Lampe, K., Stratton, K., & Welsh, J. (2011). Evaluating orientation preferences of the generation Y
new graduate nurse. Journal for Nurses in Staff Development, 27(4) E6-E-9. doi:
10.1097/NND.0b013e182236646
Laschinger, H., Wong, C., & Grau, A. (2013). Authentic leadership, empowerment and burnout: A
comparison in new graduates and experienced nurses. Journal of Nursing Management, 21, 541552. doi: 10.1111/j.1365-2834.2012.01375.x
Laschinger, H., Wong, C., & Regan, S. (2013). Workplace incivility and new graduate nurses mental
health. Journal of Nursing Administration, 47(7/8), 415-421.
doi: 10.1097/NNA.0b013e31829d61c6

PICTURE REFERENCES
Slide 3
spectrumcenter.umich.edu
Slide 4
Translationsolutions.org
Slide 5
gapevologicconcepts.com
Slide 7
blog.girishm.in
Slide 8
stdavids.com
Slide 10
convertunitsnow.com

EFFECTIVE CHANGE STRATEGY:

NURSING RETENTION
Part Four: Leading Change in a Professional Environment
Nina Favor, Jody French-Sroka, Mary Hefferan, & Amy Herrington

Objectives

Outline the attributes of the nursing profession

Understanding the profession to enable change
Transformational leadership traits

Who are we accountable to?

What drives leaders in professional
health care organizations

Objectives
Explain how credibility contributes to a
change process
Nursing roles contributing to change

Using leaders strengths to promote change

Professional Nursing
Hoffart and Woods (1996) Professional Practice Model for Nursing

Source: http://umm.edu/~/media/UMM/Images/For%20Health%20Professionals/Nursing/prof%20practice%20model.ashx / Edited by M. Hefferan

Professional Nursing
Hoffart and Woods (1996) Professional Practice Model for Nursing

Source: http://umm.edu/~/media/UMM/Images/For%20Health%20Professionals/Nursing/prof%20practice%20model.ashx / Edited by M. Hefferan

Professional Nursing
Hoffart and Woods (1996) Professional Practice Model for Nursing

Source: http://umm.edu/~/media/UMM/Images/For%20Health%20Professionals/Nursing/prof%20practice%20model.ashx / Edited by M. Hefferan

Transformational Leadership

Source:
http://www.developmentsolutions.org.uk/images/tr
ansformational_leadership_table_3.gif

Accountability, Credibility and Change

Personal and team accountability
Leading by example
Credible and honest

Ethical and moral values

Driving force for leaders

Personal mission statement
Commitment to a goal

Nursing Leaders
Nurse Administrator (Jody)
Financial incentive
Conflict resolution skills
Balancing staffing concerns

Nurse Educator (Nina)

Commitment to education
Skills of curriculum development and evaluation

Nursing Leaders
Nurse Practitioner (Amy)
Committed to patient safety and quality patient
care
Advanced knowledge

Education and confidence building

Charge Nurse (Mary)

Workplace environment associate with trust, good communication and quality patient care
Matching preceptor personalities
Remain visible as a leader

Conclusion
Nursing Profession
Many aspects to understand to facilitate change

Transformational Leadership
Better commitment to change

Accountability, Credibility, and Change

Required to drive long term results

Nursing Leaders
Utilize strengths of nursing leaders within the organization

Conclusion of Group Presentation

Nursing shortage as a healthcare issue
Nursing turnover
Inadequate support, emotional/physical stresses, and role adjustment
High costs associated with turnover

Nursing retention
Lewins Change Theory: Unfreezing, change, refreeze

Conclusion of Group Presentation

Theory-informed behavior change
Evidence based practice, identify barriers, include key stakeholders, identify measureable goals

Leading in a professional environment

Professional Practice Model for Nursing
Transformational leadership
Accountability and credibility
Nursing leadership roles

References
Carroll, L. T. (2005). Leadership skills and attributes of women and nurse executives: Challenges for
Nursing Administration Quarterly, 29(2), 146-153.

the 21 st century.

Chiu, L. Y., Chung, G. R., Wu, S. C., & Ho, H. C. (2009). The effects of job demands, control, and social support on hospital clinical
nurses intention to turn over. Applied Nursing Research, 22, 258-263. Retrieved from:
http://www.medscape.com/viewarticle/714327
Herold, M. D., Fedor, B. D., Caldwell, S., & Liu, Y. (2008). The effects of transformational and change leadership on employees
commitment to change: A multilevel study. Journal of Applied Psychology, 93(2), p. 346-357. doi: 10.1037/0021-9010.93.2.346
Hoffart, N. & Woods, Q. C. (1996). Elements of a nursing professional practice model. Journal of Professional Nursing, 12(6), 354364. Retrieved from: http://dx.doi.org/10.1016/S8755-7223(96)80083-4
Jones, B. C. & Gates, M. (2007). The costs and benefits of nurse turnover: A business case for nurse retention. The Online Journal
of Issues in Nursing, 12(3). doi: 10.3912/OJIN.Vol12No03Man04
Marshall, E. S. (2011). Transformational leadership in nursing: From expert clinician to influential leader. New York, NY: Springer.
National League for Nursing. (2012). The scope of practice for academic nurse educators. New York, NY: National League for
Nursing.
Twibell, R., St. Pierre, J., Johnson, D., Barton, D., Davis, C., Kidd, M., & Rook, G. (2012). Tripping over the welcome mat: Why new
nurses dont stay and what the evidence says we can do about it. American Nurse Today, 7(6). Retrieved from:
http://www.americannursetoday.com/article.aspx?id=9168