1. Hill, Karen S. DNP, RN, NEA-BC, FACHE
  2. Cleary, Brenda L. PhD, RN, FAAN
  3. Hewlett, Peggy O. PhD, RN, FAAN
  4. Bleich, Michael R. PhD, RN, FAAN
  5. Davis, Kathleen MBA, RN, CNAA-BC
  6. Hatcher, Barbara J. PhD, MPH, RN, FAAN


The authors provide commentary on the article, "Experienced Nurse Retention Strategies: What Can Be Learned From Top-Performing Organizations," also in this issue by authors Hirschkorn, West, Hill, Cleary, and Hewlett.


Article Content

The case for action regarding the retention of the experienced RN workforce has been established. Retaining nurses is an imperative in providing the highest-quality nursing care possible and thus positively affecting patient outcomes. Few employers are addressing the issue of the aging workforce to any significant extent. To change workforce trends, 2 questions need to be asked: (1) Are nurses sufficiently satisfied with their jobs and careers within nursing to pursue redefinitions of roles as they age rather than retire? And (2) what can nursing leaders do to retain expertise among the nursing population as they look to impending retirements and, in many cases, exodus from the profession?


Shifts in the nursing workforce, including dramatic increases in the numbers of nurses older than 50 years, are a primary factor that is predicted to further increase the shortage of workers in the future.1,2 Buerhaus3 reported there were 100,000 nurses older than 50 years in 1980, with more than 400,000 noted in 2007.


"Wisdom at Work" White paper

Critical issues concerning an aging workforce, best practices and questions about the future, identified in the Wisdom at Work white paper,2 launched an international focus on the issue of the aging nursing workforce. This white paper contains perhaps one of the most extensive reviews of literature around selected aspects of the aging nursing population. Numerous studies forecasting a nursing shortage of varying degrees are cited in the literature; however, limited purposeful efforts have been launched to relate the practices identified in the Wisdom at Work document with longitudinal outcomes. True impact to workforce trends will be realized when proposed innovations and programs are associated with quantifiable outcomes resulting in an adequate supply of experienced skilled RNs in all areas of practice.


Data from the Wisdom at Work evaluation4 yielded new information regarding general categories of interventions requiring further exploration and those undergoing initial implementation and testing. Categories of interventions in the grant projects included initiatives involving (1) ergonomics, (2) staffing, and (3) technology. Inherent in the grant review process was an expectation for outcome measurements. However, a 24-month evaluation process is less than optimal to ensure that developments are sustained and supported over time within the framework of real-time workforce challenges. The imperative to launch innovative recommendations and practices beyond hospitals and other health agencies employing nurses necessitates continued rigorous evaluative criteria supported by evidence-based practice and research. In addition, outcomes realized through these programs and projects must be disseminated through publications and presentations for wide-scale adoption.


Key Indicators

Common key indicators including nursing turnover, workplace injuries, RN satisfaction, and intent to stay in the profession of nursing should be stratified by age cohort and practice setting and reported for trending. By drilling down these data, future efforts to increase satisfaction and intent to stay can be developed for global applications or targeted for unique settings such as academic practice roles. Other key indicators including organizational cost, cost avoidance, and impact on quality must be monitored to support the business case for retention of expertise and can be applicable across all practice settings.


The impact on culture and the influence of leaders on the success of workforce initiatives must not be underestimated. The implementation of programs and projects in a variety of healthcare settings and care delivery models is necessary to create a cadre of best practices with wide application.


The mitigation of lost knowledge in the nursing workforce was the focus of the third aspect of the Wisdom at Work initiative. Bleich et al5 established a common understanding of the impact to the nursing profession in all practice settings when expert nurses leave the profession. Two primary areas of concern emerged from this work: (1) What are the platforms to preserve complex (tacit) knowledge in the nursing workforce? And (2) how can organizations extend the careers of nurses with expertise beyond the normal age of retirement? Interrelated programs including the creation of flexible roles and simulation of knowledge among generations of nurses are identified; however, few organizations have strategically prioritized this issue. Fundamentally, capturing the contribution and impact of expertise that senior nurses bring to the clinical setting is still undefined, and have organizational experience-based nursing knowledge has yet to be quantified within the profession.5


The Business of Nurse Retention

Still, the business case for nurse retention in relation to patient quality is compelling. Research supports that for every increase of a year in average RN experience over 10 years, the hospital-acquired pressure ulcer rate was 1.9% lower, and a higher percentage of experienced RNs were related both to lower fall rates and lower hospital-acquired pressure ulcers rates.6(p9) An upper ceiling for this effect was not identified. In addition to years of experience, multiple factors that contribute to nursing quality include staffing ratios, patient acuity, and levels of education.6,7 Further research is indicated to quantify the factors and interventions differentiating the practice of experienced nurses to facilitate the transfer of this type of critical information and decision-making to others.


In making the business case for the retention of older workers, few employers have yet to experience the reality of a shortage to make this a "burning issue."8 In healthcare, not only will employers "feel the pain," but patients will as well. Initiatives to create a safer system of healthcare delivery must take into account the realities of workforce issues as action plans are identified. A multitiered approach including ergonomics (safety), staffing (workforce and policies), and technology (applied toward both the worker and the patient) is indicated. The focus on human capital within the Robert Wood Johnson Foundation highlights the retention of seasoned and experienced nurses as a call to action. Workplace and organizational interventions must be developed and tested with input from nursing constituents at all levels. The focus of the Magnet(R) accreditation program highlighting empirical outcomes is one mechanism to enable systematic exploration of these and future interventions. Unfortunately, the impact of Magnet recognition is currently limited to hospital practice settings and offers less benefit for nurses working in other practice settings.


Educating nurse leaders in all areas of practice to prioritize the retention of experienced nurses must be accomplished through partnerships between organizations including Sigma Theta Tau, the American Nurses Association, the American Association of Colleges of Nursing, the National League for Nursing, and the American Organization of Nurse Executives. Collaboration among these professional nursing organizations and others will enable the communication of processes and outcomes to be widely disseminated as research unfolds.


Large numbers of nurses, many of whom have delayed retirement based on economic changes, will soon leave the workforce. Nurses in the baby-boomer generation are recreating a vision of the journey to retirement. It is critical, however, to note that nursing leaders cannot afford to ignore this temporary reprieve in the retirement exodus. Creative and nurse-friendly practices and programs will enable the profession to retain the expertise and knowledge of these professionals to benefit our patients and our communities. Strategic priorities must incorporate innovative methods to identify, capture, and transfer the knowledge wisdom that comes only from experience and time. This issue is far reaching beyond hospital-based nursing practice and mirrors trends in other disciplines and practice settings within healthcare professions including our medical staff colleagues as well as the aging nursing faculty.



The lessons learned from hospitals in these initiatives and other outcomes can and should be adapted to other industries and beyond. All aging workers can benefit from human resource, technological, and ergonomic adaptations to prolong productive careers. The time to act is now before the looming and predicted retirement of the baby-boomer generation affects the quality of healthcare in all sectors. It is not too late to put programs and services in place to retain the knowledge, skills, and expertise of this generation.




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3. Mattson J. Nursing shortage update: a conversation with Peter Buerhaus. Reflect Nurs Leadersh. 2007;33(4). Available at Accessed July 14, 2010. [Context Link]


4. The Lewin Group, Inc. Evaluation of the Robert Wood Johnson Foundation Wisdom At Work: Retaining Experienced Nurses Initiative final report. Available at Accessed July 13, 2010. [Context Link]


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7. Aiken L, Havens D, Sloane D. The Magnet nursing services recognition program: comparison of two groups of Magnet hospitals. J Nurs Adm. 2009;39(7/8):5-14. [Context Link]


8. Piktialis D. Adaptations to an aging workforce: innovative responses by the corporate sector. Generations. 2007;31(1):76-82. [Context Link]