Leadership: A Key Strategy inStaff Nurse

Retention
Carol S. Kleinman, PhD, RN
MF1110

Nursing administrators are challenged to recruit and

retain staff nurses in the midst of increasing job vacancies
and staff nurse turnover rates averaging 21%. The prevailing issues related to staff nurse recruitment and retention
in the current healthcare environment are briefly reviewed
as introductory content. The article outlines the case from
nursing administration literature that effective leadership

In

the past decade, many studies focused on and

provided support for the relationship between

effective leadership style and job satisfaction, retention, and organizational productivity. Volk and Lucas
(1991) were among the first to work in this area and
identify a relationship between management style
and anticipated staff nurse turnover. Since that time, a
strong body of evidence has developed that includes
the work of McDaniel and Wolf (1992), Taunton,
Boyle, Woods, Hansen, and Bott (1997), research from
Magnet hospitals (Scott, Sochalski, & Aiken, 1999),
and work by Shobbrook and Fenton (2002). These
studies have indicated leadership behaviors that
include support and consideration of staff, high visibility, and willingness to share leadership responsibilities positively influence staff nurse retention.
Although it remains unclear how to best prepare
effective managerial leaders, evidence suggests that
graduate education may be an important precursor to
the development of effective leadership styles
(Dunham & Klafehn, 1990; Dunham-Taylor, 2000).
The feasibility of mandating graduate education
requirements for all practicing nurse managers is limited; therefore, continuing education strategies must
focus on nurse manager leadership training mechanisms that target the assimilation of effective leadership behaviors. Focused leadership training through
Dr. Kleinman is Associate Professor and Director, Health Systems
Administration Programs, Seton Hall University, College of Nursing,
South Orange, New Jersey.
Address correspondence to Carol S. Kleinman, PhD, RN, 18
ChristopherCourt, Matawan, NJ 07747.

128

styles of nurse managers and nurse administrators

enhance staff nurse retention. As nurse administrators
continue to struggle with staff nurse recruitment and retention, evidenced-based strategies are discussed that
address leader preparation and organizational leadership
structure including advanced education, leadership training, and shared leadership models.

continuing education should include content related

to the importance of visibility and communication,
collaboration, acknowledgment and empowerment
of staff, and a guiding vision for the organizational
unit.
According to the American Organization of Nurse
Executives (AONE), the average tumover rate for registered nurses working in hospitals in 2002 was 21.3%
(American City Business Journals, 2003). This high
rate of staff nurse tumover is costly to hospitals and
patients for several significant reasons. Suboptimal
staffing affects the quality of patient care, increases
patient waiting time for services, and reduces the
number of services (e.g., surgeries and emergency
room visits) the hospital can offer (Sufin, 2003). Staff
nurse tumover is also costly to hospitals from a monetary perspective. The Advisory Board Report (New
Jersey State Nurses Association, 2002) indicated that,
based on costs associated with replacing a resigning
nurse, an $800,000 savings could be realized by reducing the turnover rate from 13% to 10%.
As nurses resign, hospitals have tried to address
the problem by offering attractive sign-on bonuses
and other recruitment incentives. However, Nevidjon
and Erickson (2001) assert these economic solutions
are not effective in recruiting more nurses but, rather,
they simply redistribute the current supply of nurses.
In actuality, sign-on bonuses have become a standard
recruitment strategy (Patrick, 2000) that may have little to do with where nurses choose to stay and work.
Nurse managers and administrators in the acute care
setting face a worldwide, ongoing challenge to recruit
and retain staff nurses (Foley, 2001).

The Journal of Continuing Education inNursing May/June 2004 Vol 35, No 3

.

Current projections within the United States estimate more than 100,000 staff nurse vacancies, with
future shortages estimated at more than 800,000 by
2020 (Martin, 2003). These disturbing forecasts are
compounded by the reality that fewer young people
are pursuing nursing education (Foley, 2001) at a time
many nurses are nearing retirement age (Buerhaus,
Staiger, & Auerback, 2000). Without educators, the
number of new graduates needed will not be achievable. The 2000 National Sample Survey of Registered
Nurses estimates more than 500,000 nurses-18% of
the nursing workforce-maintain active nursing
licenses but do not work in nursing (Foley, 2001).
Public and private sector businesses are competing
for nurses in the marketplace. Most important, national trends identifying an increased need for nurses are
significantly augmented by the many nurses leaving
the profession as a consequence of reduced nurse-topatient ratios, unsafe working conditions, lack of
autonomy, inadequate pay (Martin, 2003), and other
workplace issues. The dilemma relates not only to the
need to have a sufficient number of nurses to provide
quality care, because nursing is the backbone of the
healthcare system, but also to the need to attract and
keep the best and brightest within the profession.
RECRUITMENT AND RETENTION FROM A
LEADERSHIP PERSPECTIVE

Several professional organizations have developed

executive statements addressing the national nursing
shortage and high turnover rate among staff nurses
(American Nurses Association [ANA], 2002; AONE,
2002). More than 60 professional nursing organizations participated in the development of a strategic
implementation plan entitled "Nursing's Agenda for
the Future" (ANA, 2002). The plan outlined ten focus
areas in which to improve the future status of nursing
by the year 2010. One vision for the nursing profession involved developing leadership behaviors that
promote collaboration with colleagues. Another focus
area included developing work environments that
recognize nurses as stakeholders in decision making
and to provide appropriate staffing to meet patient
safety needs.
In testimony before the Work Environment and
Patient Safety Committee of the Institute of Medicine
(AONE, 2002), the AONE reported hospitals that have
successfully recruited and retained staff nurses have
leaders who demonstrated competency in their role,
are trustworthy, and value and support the contributions of their employees. Magnet hospitals were also
discussed in the AONE report as an example of the
Leadership in Staff Nurse Retention- Kleinman

The dilemma relates not only to the

need to have a sufficient numbeir
of nurses to provide quality care,
but also to the need to attract ancd
keep the best and brightest
within the profession.
type of hospital organizations that possess effeclive
leaders (AONE, 2002). Magnet hospitals demonstrated the ability to attract nurses during a nursing shortage in the early 1980s (McClure, Poulin, Sovie, &
Wandelt, 1982) and have significantly lower turnover
rates (Kramer, 1990; Kramer & Schmalenberg, 1991;
Scott et al., 1999). In their summary of Magnet hospital research from 1983 to 1991, Scott et al. (1999) identified several effective leadership characterist:ics
reported within Magnet hospital organizations. These
previously documented leader behaviors included
being visionary, being supportive and responsive to
staff, having high performance expectations, and
being visible.
The relationship between types of effective leadLership styles and staff nurse retention is supported by a
body of scientific evidence (McDaniel & Wolf, 1992;
Shobbrook & Fenton, 2002; Taunton et al., 1997; Volk
& Lucas, 1991). Volk and Lucas (1991) conducted one
of the first studies in nursing to focus on the lead.ership and retention relationship. Results from their
study indicated that a participatory management
style was associated with less anticipated turnover.
Further analysis revealed management style was the
only predictor of anticipated turnover and explained
32% of the variance in turnover. These findings were
consistent with studies in business and industry that
identified increased employee satisfaction and productivity resulting from a participatory management
style.
McDaniel and Wolf (1992) examined transforraational and transactional leadership characteristics of
nurse administrators to evaluate the relationship
between leadership style, turnover, and job satisfaction. Transformational leadership characteristics
include being able to articulate a shared vision of [he
future of the organization and encourage creative
problem solving that demonstrates support and
encouragement of staff (Bass & Aviolo, 20C00).
Conversely, transactional leaders focus on day-to-cLay
operations in which rewards are contingent on performance (Burns, 1978). Nurse administrators more
129

Effective leadership has been

demonstrated to be an integral
component of retention and should
be an important part of any
multidimensional recruitment and
retention strategy.
frequently demonstrated transformational behaviors
compared to transactional behaviors; staff nurse job
satisfaction was found to be significantly associated
with transformational behaviors. The researchers correlated low staff nurse turnover (10%) with predominantly transformational leadership style.
Researchers funded by the National Institutes of
Health and the National Center for Nursing Research
examined the causal relationship of staff nurse retention (Taunton et al., 1997). Their work described relationships between leadership and staff nurse retention. Study results indicated a direct relationship
between retention and a leadership style that is considerate of staff. Considerate leadership behaviors
include being fair, facilitating staff skill development,
and valuing and supporting staff contributions.
Although nurse managers must attend to budget and
staffing issues, on the basis of this evidence they must
also develop interpersonal relationships with each
staff member to effectively mentor staff. Unit contributions by staff and excellent patient care must not go
unnoticed by managers.
A recent study examining the relationship between
effective leadership and staff nurse retention was conducted by Shobbrook and Fenton (2002). The
researchers reported a reduction in turnover from 36%
to 13% within the emergency department of
Southampton University Hospital's NHS Trust in
London. The basis of the recruitment and retention
plan provided a flattening of the leadership structure
that allowed greater sharing of responsibilities and
professional development opportunities for staff.
Other components of the plan included an educational plan to provide equitable staff development, protected time to participate in continuing education, and
contractual arrangements to promote career development. The researchers identified and capitalized on the
desire for professional development among nurses.
Within the context of nursing shortages, it remains
imperative for nurse managers to allow and budget for
professional development activities for staff.
The large scale study recently reported by Aiken,
130

Clarke, and Sloane (2002) revealed a strong association between job satisfaction and staff nurse retention.
The study was funded by both the National Institute
of Nursing Research and the Agency for Healthcare
Research and Quality and was conducted in the
United States, Canada, England, and Scotland with
10,319 nurses in 303 hospitals. Managerial support for
nursing was identified as having a pronounced effect
on diminishing nurse job dissatisfaction and burnout
and improving the nurse retention problem.
An anecdotal case study of the Tenet Healthcare
System within the United States represents an example of a multidimensional approach to address
recruitment and retention of staff nurses. Staff nurses
within one regional Tenet hospital system were asked
to identify job likes and dislikes (Patrick, 2000). The
nurses identified their relationship with the manager
as an important contributor to job satisfaction and
expressed that working conditions were optimized by
a caring and fair manager. Patrick (2000) reported the
parent company, Tenet Health Systems, planned to
have 12,000 managers participate in a leadership
training program during the subsequent 3 years. The
leadership training programs are part of the Employer
Choice Initiative, a company-wide program that provides employee-focused support in an effort to
increase employee satisfaction and decrease turnover
(Tenet Healthcare Corporation, 2003). A press release
by the Tenet Healthcare Corporation (2003) reported
nationwide turnover within the Tenet Healthcare
System declined from 21.4% in 2002 to 21.0% in 2003,
and nationwide employee satisfaction increased from
78.6% in 2001 to 80.8% in 2002. These percentages
indicate a positive trend in employee satisfaction and
retention and suggest a relationship to the staff development initiatives.
EVIDENCE-BASED STRATEGIES TO PROMOTE
STAFF NURSE RETENTION
As is evident from the preceding review of literature, effective leadership has been demonstrated to be
an integral component of retention and should be an
important part of any multidimensional recruitment
and retention strategy. Several evidenced-based
strategies are proposed to enhance staff nurse retention. These strategies emphasize the importance of
leader preparation and organizational structure.
The work of Dunham and Klafehn (1990) and
Dunham-Taylor (2000) identified the importance of
graduate education for nurse managers. Study findings suggested effective leadership characteristics
were associated with nurse leaders who possessed

The Journal of Continuing Education in Nursing May/June 2004 . Vol 35, No 3

graduate degrees. Additionally, findings suggested

nursing leaders with master's degrees in nursing may
have better transformational leadership preparation
compared to those with master's degrees in other disciplines.
Attracting nurse managers who possess graduate
degrees and supporting the attainment of advanced
education among current nurse managers may be a
worthwhile investment when compared to the significant organizational costs associated with staff
nurse turnover. An effective continuing educational
program should consider providing monetary incentives and an organizational commitment that allows
sufficient time to be spent on course work in addition to managerial responsibiLities. Developing a
relationship with a specific academic provider of
registered nurse to bachelor of science in nursing
programs and graduate education in nursing administration may facilitate nurse managers' returning for
advanced education. Onsite and distance education
programs may offset obstacles of scheduling and
geography.
Focused leadership training may be a more costeffective approach to the development of effective
leadership characteristics in nurse managers compared to the investment in graduate education and
may represent an alternative strategy. Furthermore,
the lack of baccalaureate preparation of many nurse
managers may preclude the rapid acquisition of a
graduate degree. There is no evidence in the literature
regarding the most effective way to train leaders;
therefore, it will be necessary for nursing and healthcare administrators to evaluate the costs and benefits
associated with different types of continuing education mechanisms. Leadership training programs
should be focused, specific, and targeted to required
competencies.
Another organizational strategy involves a reevaluation of the nursing management structure to identify ways leadership may be shared among nursing
staff. In their efforts to develop strategies to improve
staff retention, Shobbrook and Fenton (2002) reviewed
exit interviews indicating leadership and organizational culture were the primary factors influencing
staff nurse turnover. Through flattening of the nursing organizational leadership structure, an improved
mechanism was developed for sharing leadership and
enhancing professional development.
From an organizational perspective, the implementation of nursing practice models has been reported to
empower staff nurses and thus indirectly enhance job
satisfaction. As previously discussed, a participatory
Leadership in Staff Nurse Retention . Kleinman

The current state of knowledge does;

not reflect a systematic study ol
strategies for enhancing the
leadership characteristics among
those in nursing management..
management style based on a transformational lead ership model encourages staff nurse retention (Volk &
Lucas, 1991) and is clearly related to staff nurse
empowerment. Based on a summary of findings from
several shared governance interventional studies
(Upenieks, 2000), staff nurse retention was found to be
significantly related to the use of practice models.
Importantly, Upenieks (2000) indicated that effective
leadership skills are required for the successful organizational implementation of a nursing practice model.
RECOMMENDATIONS
Research is needed to foster understanding of
how to promote effective leadership behaviors.
Although the relationship between effective leadership styles and staff nurse retention has been widely
studied, it remains unclear how to fully develop
effective leadership characteristics of nurse executives and managers. The current state of knowlec[ge
does not reflect a systematic study of strategies for
enhancing the leadership characteristics among
those in nursing management. It is not clear how to
intervene to further develop those leaders with. positive leadership characteristics and how approaches
should differ to develop those managers with ineffective styles. General correlations have been identified, but specific approaches to leadership development, approaches that may be offered and supported
by healthcare organizations, are lacking and should
be developed through research efforts.
The evidence is clear that effective nursing leaders
enhance staff nurse retention. Strategies for healthcare
organizations that have been identified as having a
significant impact on staff nurse retention and organizational effectiveness involve supporting advanced
educational preparation for nursing leadership personnel and developing an organizational structure
that fosters sharing leadership. Nurses who are in
leadership positions, or who aspire to be, must avail
themselves of development opportunities, formally
and informally, through degree-based educational
programs, continuing education, inservice instruction,
mentoring experiences, and other self-development
approaches. It is imperative for nurses in continuing
131

education and staff development roles to promote

leadership skills through such initiatives as content
presentations, availability and dissemination of relevant reading material, role playing activities, roundtable discussions, leadership support groups, and
ongoing 360 evaluation.
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The Journal of Continuing Education in Nursing

May/June 2004 *Vol 35, No 3

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TITLE: Leadership: A Key Strategy in Staff Nurse Retention

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