1. Fisher, Cheryl A. EdD, RN
  2. Jabara, Jennifer MSN, RN, CPN-BC, NC-BC
  3. Poudrier, Leslie BSN, RN
  4. Williams, Tamara BSN, RN
  5. Wallen, Gwenyth R. PhD, RN

Article Content

Retaining qualified nurses and reducing turnover are costly and chronic hurdles that many hospitals face. The need for organizations to retain their most talented and specialized nursing staff members continues to remain an organizational priority across the country. Hospitals are focusing efforts on increasing staff satisfaction and retention through the promotion of a healthy work environment, professional development, and meaningful recognition. Hospitals that have successfully achieved Magnet(R) recognition are known for fostering positive work environments for the nurses they employ.

Figure. No caption a... - Click to enlarge in new windowFigure. No caption available.

At the National Institutes of Health (NIH) Clinical Center in Bethesda, Md., a focused partnership developed through our well-established shared governance structure has become a conduit to explore new opportunities to impact retention. Within the shared governance structure, the recognition and retention (R&R) committee has historically had the primary responsibility of celebrating and recognizing nurses at departmental events. However, the committee sought to take an expanded role in addressing the issues surrounding turnover and recognition using an evidence-based approach guided by the department's National Database for Nursing Quality Indicators(R) (NDNQI(R)) survey data and current literature.


Can evidence support a culture change?

Much has been written about nursing retention and meaningful recognition; however, there are many factors and complexities that need to be considered to retain qualified nurses in highly specialized and demanding settings. A recent finding from the 2016 National Healthcare & RN Retention Report noted that the national nursing turnover rate is 17.1%, up from 16.4% in 2014, with costs to the institution averaging $37,000 to $58,400 per RN.1 This survey report further notes that although a majority of organizations (84.8%) view retention as a key strategic imperative, it isn't evident in their operational planning. Current evidence-based strategies for nurse retention focus on nurse leader behavior because of the positive correlation with employee satisfaction and retention.2 The three most notable nurse retention interventions identified include autonomy, recognition, and communication.2


At the NIH Clinical Center, an additional education and training investment is made in our clinical research nursing staff members to ensure that they're well versed in clinical care, as well as highly specialized in human subjects' protection for research participants enrolled in clinical trials. This additional investment makes it even more critical to focus on retaining such highly specialized and skilled staff. Although nursing turnover at the Clinical Center is below the national average (11% to 13%), the quest to continuously improve the work environment to retain highly qualified nurses is imperative.


Based on a strategic operational plan utilizing staff and manager input, the R&R committee developed a model to facilitate enhancement of the committee representative's role. The new role is designed to foster improved communication, cultivate meaningful recognition, and yield anticipated improved metrics on NDNQI scores, reflecting positive changes to the work environment.


Striving for a healthy work environment

The American Association of Critical-Care Nurses (AACN) Standards for Establishing and Sustaining Healthy Work Environments describes six essential standards that must be in place to support and foster excellence in patient care.3 These standards include skilled communication, true collaboration, effective decision making, appropriate staffing, meaningful recognition, and authentic leadership. The three most notable nursing retention interventions (autonomy, recognition, and communication) were mirrored in the healthy work environment standards. Our NDNQI data also exhibited that these key factors were opportunities for improvement in our current work environment. Recognizing that each source represented the same themes in areas for intervention, the committee was charged with the development of a strategy for impact. (See Figure 1.)

Figure 1:. Impact st... - Click to enlarge in new windowFigure 1:. Impact strategy

Within the context of striving for a healthy work environment, the R&R committee developed a new approach to committee functions to address the issues at hand. Open dialogue with the chief nurse and nursing executive team coupled with deliberate engagement of nurse managers was one of the first critical steps in the process to gather input and obtain support for the initiative. Nurse managers, in particular, are key to the retention of satisfied staff yet, all too often, they receive little preparation, education, coaching, or mentoring to ensure success.3 It's essential for nurse managers to work closely with their committee representatives to discuss retention issues and identify staff members most at risk for leaving the unit.


A model approach to engagement

Based on the AACN healthy work environment standards, a new framework was developed to guide the committee, along with manager engagement toward purposeful actions to achieve desired outcomes. Specifically, a monthly journal club was started to educate committee members about leadership, meaningful recognition, and other retention effort components, which they're empowered to influence.


A mentoring program for committee members is in development, with a focus on autonomy, leadership, and the skills necessary to serve as a resource and retention liaison at the unit level. Crucial Conversations training is being scheduled during committee time to enhance skills in communication strategies. An in-depth literature search was conducted to identify best practices and preferences for recognition to develop a department-wide recognition and awards program. Lastly, a resource site is in development to address requests for departmental services and opportunities for professional growth.


With these specific areas of focus, committee members will become a valued resource to patient care areas, with the specialized knowledge, skills, and attitudes necessary to facilitate retention. This new approach will serve as an opportunity for the R&R committee members to become fully immersed in the concepts of a healthy work environment. (See Figure 2.)

Figure 2:. New appro... - Click to enlarge in new windowFigure 2:. New approach to foster a healthy work environment

Sharing a vision

Increasingly, nursing is recognized as having a major contribution to patient care quality in acute and ambulatory care settings. Studies continue to evaluate the link between a culture of patient safety, quality, and the nursing work environment. Retaining highly specialized staff members in the context of a healthy work environment results in positive patient outcomes. In recent studies, Magnet hospital characteristics were significantly and positively related to a safe climate of patient care. The impact of the combined factors of nurse empowerment and a positive work environment that resulted in increased RN retention also translated into the perception of a safe patient care environment.4


By engaging frontline nurses through the shared governance structure, the opportunity for a paradigm shift has been available, but not yet maximized. Introduced to improve nurses' work environment, satisfaction, and retention, a shared governance model is designed to integrate core professional practice values and beliefs as a means of achieving quality care. Shared governance has served the NIH Clinical Center well for over a decade on many levels, including leadership development and the implementation of evidence-based practice through our clinical practice committee. For the success of this major transformation, a committed team of empowered staff members in tandem with supportive institutional leadership is necessary to lead and sustain change.




1. NSI Nursing Solutions, Inc. 2016 national healthcare & RN retention report. [Context Link]


2. Gess E, Manojlovich M, Warner S. An evidence-based protocol for nurse retention. J Nurs Adm. 2008;38(10):441-447. [Context Link]


3. American Association of Critical-Care Nurses. AACN standards for establishing and sustaining healthy work environments: a journey to excellence, 2nd edition. [Context Link]


4. Armstrong K, Laschinger H, Wong C. Workplace empowerment and magnet hospital characteristics as predictors of patient safety climate. J Nurs Care Qual. 2009;24(1):55-62. [Context Link]