The state of nursing turnover and key nurse retention strategies

Coauthored by Nora Warshawsky, Ph.D., R.N., NEA-BC, CNE, FAAN, Nurse Scientist; and Milissa Eagle, MA, Director of Workforce Analytics.  

America’s nurses are making their voices heard. Increasing nurse turnover and collective bargaining activity have loudly demonstrated that the status quo needs to change—significantly—to keep the nursing workforce healthy and happy in their roles. What do they want? Better work environments, adequate staffing, and increased pay top the contract lists.

In short: Nurses are demanding respect.

This isn’t a new problem. It’s an amplified problem. Nursing shortages have waxed and waned over the years. The current situation has been partially predicted for a while now—but the COVID-19 pandemic added fuel to the fire. Many nurses suffered from moral distress and burnout. Still today, 56% of nurses report symptoms of burnout. Gen Z nurses are voting with their feet and heading for the exit. And what’s most alarming is many are leaving the nursing profession altogether.

Basically, the idea that there will always be another nurse waiting for a job opportunity is no longer valid. Healthcare leaders must retain and develop their existing nursing workforces to continue to deliver high-quality care and stay competitive.

Registered nurse turnover trends and key nursing recruitment and retention strategies

These recent trends have been concerning. We, at Press Ganey, turned to our data for greater insights. We analyzed a sample of 123,000 RNs within our database whose organizations conducted an employee engagement survey in 2022 and 2023 (data collected through September 30, 2023). Turnover was estimated by comparing those who were invited to take the survey in 2022 and 2023; those who were on the invitation list in 2022 but not in 2023 were assumed to have turned over.  

And our data shows that RN turnover should still concern us all:

• Nearly 1 in 5 RNs left their organization between 2022 and 2023. For RNs in their first two years at an organization, this increased to 1 in 4.
• Disengaged RNs are 2.2x more likely to turn over, compared to those who are highly engaged.
• Facilities with the highest engagement scores have RN turnover rates 5.6 percentage points lower than facilities with the lowest engagement scores. Facilities with higher engagement scores also save $260k in turnover cost for every 100 RNs.

Reduce nurse turnover through connection, leadership, training, and growth

Next, we turned to Press Ganey workforce data for insights into key drivers of RN turnover to help identify where people can focus to retain talent.

Consistent with the published literature¹, we learned:

1. Nurses seek meaningful connection to their work. When RNs don’t feel connected to their work, they are 1.6–1.7x more likely to turn over than RNs who do feel connected to the work. Leaders should start by asking nurses what barriers prevent them from practicing at the top of their license, then work to remove the barriers. Leaders should also make an active effort to ensure RNs feel like they belong and are contributing to the organization’s mission, vision, and values.
2. Nurses want effective leaders. When RNs don’t have effective leaders, they are 1.5x more likely to turn over than RNs who feel like they have effective leaders. The most critical leader is their nurse manager. Are your nurse managers respectful, are they genuinely concerned about their team, and do they encourage a culture of teamwork?
3. Nurses want to advance their skills and have career growth. When RNs don’t feel they have training/development opportunities they are 1.4–1.5x more likely to turn over than RNs who feel like they do. Leaders should assess the availability of additional professional development for front-line nurses. Is there investment in training, upskilling, and career pathways for RNs? 
4. Nurses who have been at an organization for less than two years are particularly seeking psychological safety. For these RNs, it’s critical that they’re part of a team where they feel comfortable speaking up and discussing how to prevent errors. Leaders should assess their organizational cultures for civility and respect. Do you have mechanisms for nurses to voice their concerns and ideas for improvement? Do leaders listen and take action? Segmenting your data is key to understanding what is important to different groups, so you can then tailor action plans accordingly. 

A path forward: Focusing on selection, onboarding, and developing nurse leaders

Organizations that we see improving are doubling down on taking an employee-first approach. Knowing there’s a high risk of turnover for RNs—especially early in their tenure—it’s important to focus on hiring the right people and the experience in the first few years of employment. You need to engage them from the beginning.

We recommend organizations should focus heavily on the selection process. That is, you want the right people in the right roles—people who will contribute to not only your patients, but to your culture, too. During the pandemic, the selection process became very rapid due to social distancing and the need to fill roles quickly. For a more robust selection process, we recommend a three-hour interview, give or take.

While this sounds lengthy, it’s well worth the time to make sure you’re making the right hiring decision. This interview process starts with about 45 minutes with the hiring manager who is conducting a behaviorally based structured interview to understand the candidate, their skills, and how well they’d fit with the culture. This process also includes a structured peer interview in which the peers can evaluate the candidate in an objective way.

The last piece of the process is a more immersive experience. This is an opportunity for the nurse to join in their scrubs and then observe the unit(s) or team(s) that they’d potentially join. This gives them a realistic preview of the day-to-day job functions—and it gives your team an opportunity to get to know the candidate. This approach can start to instill a sense of belonging, as candidates can see how they’d fit in and contribute. An immersive on-the-job experience lets you see someone in their natural element and how their behavior aligns with what you learned during the interview.

Once you’ve selected the right person for the role, giving them an exceptional onboarding experience, along with a continuous listening strategy through the 24 months of employment, is the linchpin helping organizations reduce turnover at the one- and two-year mark. Nurses should be paired with a preceptor to support them during their onboarding experience. Along with this, having a visible and supportive manager is critical.

Organizations can approach continuous listening in several different ways. At a minimum, you should be capturing the new nurse experience at 30 days and 90 days—ensuring they feel engaged and empowered. Mixed in should be in-person discussions with their leader—30-, 60-, 90-day rounds focused on building a relationship with the new nurse, as well as ensuring they’re connected to purpose and have what they need to be successful in their job. Intentional six-month and one-year stay interviews between a new nurse and their leader also ensure any issues are identified and addressed early. These constant touchpoints make new nurses feel connected and supported.

All of these listening modes are important—but they are most effective when a leader is being authentic and supportive. Sometimes this requires an additional investment in developing your nurse leaders to help them create that sense of purpose and belonging among their people, and fostering a nurturing, collaborative environment. When you can anchor the new nurse in your organization’s mission, vision, and values, they will be more likely to stay.

Though the work ahead may seem daunting, the ROI of tackling nurse turnover is huge. And we’d like to help. We have some of the top technology and dedicated consultants to help organizations develop robust RN retention strategies. Get in touch with our nursing team, and we’ll work with you to address your specific challenges.  

1. Keith, A. C., Warshawsky, N., & Talbert, S. (2021). Factors That Influence Millennial Generation Nurses' Intention to Stay: An Integrated Literature Review. The Journal of nursing administration, 51(4), 220–226. https://doi.org/10.1097/NNA.0000000000001001