Why Do Nurses Quit?

[Nurse Beth]

Jamie looked at the framed group photo on the wall of Cohort 22, the 24 new grad nurses who started a year ago in 2015. They all look so happy and eager. Where are they all now?

Of the 24, 16 remain employed. Christina returned to the Bay Area and Shelby is in an NP program. Lindsay went on LOA and never returned. Alex worked ICU for one year, then left to work in State Corrections for better benefits and pay.

Is this an exodus? A revolving door? Lynda, the nurse recruiter complains "I bring nurses in the front door, but they bleed out the back door"

Every year the hospital hires in two new cohorts of 25 nurses. Every year, at least 50 nurses leave the facility.

Just one of the downstream effects is that preceptors become burnt out on precepting new grads because of the turnover "You put your heart and soul into training them..then they leave!"

In the United States, nursing workforce projections indicate the registered nurse (RN) shortage may exceed 500,000 RNs by 2025.

It's estimated that 30%-50% of all new RNs elect either to change positions or leave nursing completely within the first 3 years of clinical practice.

Here's a few answers to commonly asked Why are nurses leaving? questions :

Why do nurses leave after transitioning from school to clinical bedside?

Reality Shock: Some new grads do not survive the shock. Nursing school is insufficient preparation for nursing. Often there is an overwhelming lack of support for nurses in their first year.

Passing meds on two patients with an instructor available does not prepare a new grad for passing meds on six patients with doctor and family interruptions, Lab calling with critical values, and ED calling report on a new patient.

Is stress a factor in nurses leaving?

Nursing school is exhausting, but working as a nurse is a different kind of exhaustion. Nursing demands constant vigilance. Nurses are always "on" - there is no cubicle to hide in, no office in which to decompress and escape. This proves more exhausting for some than for others.

The sheer intensity of nursing comes as a huge shock.

Is staffing levels a contributing factor in nurses leaving?

Caring for four ICU patients or eight high-acuity Med-Surg patients is simply unsafe and untenable. Across the nation, California is the only state with mandated nurse-patient ratios.

Is mandatory overtime a reason for nurses leaving?

New nurses either:

• Come in to work extra shifts. How does working three twelve hour shifts on, one day off, four on sound? (as relayed to me yesterday by a nurse with less than one year experience in ED)
• Learn to say "No", a boundary many struggle with

Is floating to other units a concern for nurses?

Floating to other units is a major stress. Care is not always taken to ensure competency-based assignments, or to support the newbie floater.

What do some non-nursing tasks push nurses away?

An inordinate amount of time is spent on tracking down supplies, ordering forms, screening calls, ordering diets ...all tasks that could be handled by non-licensed support staff.

Nurses need to focus their energy on critical thinking- how do I get the patient from Point A to Point B along the continuum of recovery/wellness during my shift?

How do new nurses react to the additional responsibilities?

Realization that the buck stops here. New grads experience the fear of making a mistake and possibly harming a patient. This can literally be paralyzing for the new nurse.

How does poor management lead to nurses leaving?

Nurse managers are strongly linked to job satisfaction. Managers who are not trained lack the necessary communication and leaderships skills. Favoritism abounds and poor performance is tolerated. Poor performers are not eliminated.

Poor management ultimately results in turnover.

What are some reason why new nurses struggle?

Lifting patients and other physical demands take their toll. Work hazards such as exposure to hazardous drugs are a safety concern.

Nurses are subject to physical assault/verbal abuse which causes job distress.

How challenging is the nursing work environment for new nurses?

I think what happened to me is what they call "nurses eating their young". Yesterday I couldn't get my patient's IV re-started before shift change. I tried but missed and the patient didn't have any meds due. It was so busy and I had SO many other things to do. During handoff, the other nurse loudly humiliated me in front of everyone. "You left the patient without IV access?" Everyone got quiet and I didn't know what to say. Even some family members heard. I thought it is a 24-hour job, that's what they said in orientation. Did I do something wrong?" As seen on social media

How can nursing turnover be reduced?

• Increasing staffing and limiting nurses' work hours. Flexible work schedules and job sharing help nurses with children stay in the workforce
• Creating a culture of safety
• Providing strong, supportive nursing leadership
• Creating a Just Culture
• Including nurses in decision-making related to patient care delivery and practice

It's honestly been so tough transitioning from a nursing student to new grad nurse. I have good preceptors, and coworkers, but I wonder if I'll ever be fast enough to keep up. The patients are very sick and I get worried about the protocols and everything I might be forgetting. But yesterday my patient's wife hugged me at the end of my shift and said how much she appreciated my care. I felt good and it reminded me why I wanted to be a nurse and that I can make a difference. I know I'm still learning and not up to speed yet. I totally needed that hug. As seen on social media

As a nurse, I love nursing and promote my chosen profession. At the same time, I'm well aware of the dissatisfiers that drive nurses away from nursing and the bedside.

What is driving nurses away from nursing?

References

Aiken, L. H., Sermeus, W., Van den Heede, K., Sloane, D. M., Busse, R., McKee, M., ... & Tishelman, C. (2012). Patient safety, satisfaction, and quality of hospital care: cross sectional surveys of nurses and patients in 12 countries in Europe and the United States. Bmj, 344, e1717.

ANA 2011. Health & Safety Survey Hazards of the RN Work Environment. Retrieved December 8, 2016. 

Jones, C. B. C. B., & 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).

[Leonardo Del Toro, RN]

Nurses have a serious problem saying NO. And that is a problem too.

[Ruby Vee, BSN]

Daisy4RN said:

What are the reasons nurses quit?? All of those stated in the article and then some. Bottom line is that job satisfaction (at least in the hospital setting) has steadily declined as workloads and stress has steadily increased. Bedside nurses are held accountable for EVERYTHING. It used to be that the nurse was responsible for the nursing care. Now everything is the nurses responsibility/problem (ie lab didn't come/blood draw, meds not delivered by pharmacy, PT/OT didn't come, Doctor didn't come, lunch/the right lunch didn't come, no supplies on hand, no working equipment, no CNA, family wants to speak to you again, pain meds every 2 hours, routine meds 5 times on your shift etc etc etc). And don't forget the endless charting. The hospitals cut back while at the same time the patients are requiring more time, either because of (medical) acuity, or because the pt/family is demanding (even though medical issues don't require that much time, but you know, customer service..). Bottom line is that nurses are running around attempting to get everything done but it is always a loosing battle and someone is always complaining because its never enough! Do we really need to ask why nurses are quitting??

I have been a nurse for nearly 40 years, and nurses have ALWAYS been held accountable for the lab not coming, meds not being delivered by pharmacy, PT or OT didn't come, the physician didn't round, the meal wasn't what was ordered, the physician made the patient NPO without explaining it to the patient, the blood isn't ready, the interventional lab is backed up, surgery was delayed, the TV doesn't have the channel I want to watch, my family isn't here . . . The difference is that people used to be more polite and understanding about it. Now they're not. If you think that there was some particular "golden age" of nursing when nurses weren't accountable for everyone else's job, please be advised that there wasn't.

[Ruby Vee, BSN]

Nurse Beth said:

I don't believe articles perpetuate the behavior. I think some nurse's treatment of new nurses perpetuates the behavior.

I think you're way off base there. I think all of the articles about nurses eating their young, horizontal violence, lateral violence and bullying convince students and new nurses that this is what they're going to find in the workplace. Then, SURPRISE! They go out and find such things in the workplace. Even if they're not there. It's easier to blame your problems getting along with your new coworkers on bullies and NETY than it is to admit, even if only to yourself, that you may be partially (or even mostly) to blame for your difficulty getting along with others.

The fact that people believe they're being picked on, bullied, eaten or subjected to lateral or horizontal violence does not mean that they have been. And there would not be so many people believing in such things if there weren't so many articles out there about it.

[Ruby Vee, BSN]

Kate_Peds said:

I would encourage everyone to remember what it is like to be a new graduate. Hopefully that way the line of communication will remain open. The issue of new grads leaving is not just the topic of a popular gossip session, it's a very real problem.

I think the best way to find out why new graduates are leaving is to communicate with them about their experiences. I commend Nurse Beth for asking those direct questions, and, as unpopular as the terms may be, saying what needs to be said. We can sit around with our eyes shut and our hands over our ears because we don't like a particular phrase, but in the end, if this is what new grads are saying is causing them to move on, we would be foolish to assume that syntax is the cause.

Speaking as a crusty old bat, I certainly haven't forgotten what it was like to be a new graduate. I doubt anyone else has, either. I have actually communicated with new graduates about why they are leaving -- perhaps 10-15 of the 30 or so who leave our ICU ever year never intended to stay in the first place. They only wanted the minimum amount of ICU experience they could use to get into anesthesia school. Another 5 or so hadn't set their sights on anesthesia school when they applied to our unit, but since everyone else was going, they thought they should as well. Several leave every year because they miss their family back home, their boyfriend back home or because their new boyfriend is being transferred to Milwaukee. There are some who leave because they cannot do the job, don't want to do the job, or were very surprised to find out the job actually involved direct patient contact, responsibility and accountability. Some leave to go to graduate school to become CNS or NPs because they're shocked that they're actually expected to work nights, weekends and holidays at the bedside and they expect to have more prestige or better hours in an advanced practice role. (The nurses who go on to become CNS or NP because they understand that role and look forward to the new challenges don't seem to be new grads; they seem to be nurses with more than the minimum experience.)

The new graduate who felt she was being eaten because someone spoke to her about leaving a patient without IV access could possibly have been experiencing a senior nurse having a bad day. More likely, that same nurse had already explained to her, possibly more than once, that you don't leave your patient without IV access when they're on the monitor, or NPO, or when the next shift has an IV med due within an hour of their start of shift.

[sevensonnets]

Very well said, Ruby.

[WKShadowNP, DNP, APRN]

Quote

A few months ago our entire system went down for a few weeks and we had to paper-chart. Hallelujah! I was so happy.

A few years ago when one of many downtimes occurred a coworker freaked out and bemoaned her lack of ability to chart/pass meds. We had paper MARs again and she said, "What am I going to do?" in a high pitched and pitiful moan.

"I am going to actually go and take care of my patients." I passed my meds with nary a mistake and made notes on a notepad in my pocket as the downtime was to be short lived. I left on time too.

[WKShadowNP, DNP, APRN]

Ruby Vee said:

(The nurses who go on to become CNS or NP because they understand that role and look forward to the new challenges don't seem to be new grads; they seem to be nurses with more than the minimum experience.)

I agree with everything in your post but I kept this part of it in as a quote because that's me. I'm not as experienced as many here (to whom I look for insight and advice and whom I admire), but I've put in 15 years as a nurse and 3-4 before that in unlicensed assistive roles (lab, monitor tech, tech-retary, et al.). I love what I do and I am excited for the challenges to come as an advanced practice nurse.

I graduated nursing school and began work on the same floor as my pre-nursing peers, so I had that advantage but I remember the hazing type of behavior of some nurses, and the support of others. It came from all ages and backgrounds.

One had nothing to do with my role but my marriage. I'm in a very "old-fashioned" southern state and have a nontraditional union. (Which now is more traditional than what non-traditional means today.) One old biddy passive-aggressively asked, "And what did your parents think of that." I knew she was goading me because of my inter-racial marriage but I answered sweetly and honestly, "Well they didn't like that I was 18, but they love him."

The hardest time I had as a new nurse was time management and that was addressed. By some, the constructive feedback offered strategies to improve, from others it was like being yelled at everyday. And I mean yelled. I remember being on my 4th of 7 patients for med pass and the charge nurse opened the med room and in front of the two other nurses in there told me in a very loud and irritated, condescending tone that whatever patient has called out for the third time for his pain meds. I said, 'OK! OK! I heard you!" She, meanwhile, did not offer to help and sat back down at the desk.

I understood right then that she was the one not ok, not me. And instead of letting that resentment formulate my perspective of my profession I sat with the knowledge that people are people, the good, bad, and ugly, no matter where you go. That moment brought me to tears because of the embarrassment, and because I was so rattled she forced me to go and take a few minutes. (Thus further delaying my timely med pass.) I have only had two more moments where I needed a moment to decompress in the past 20 years of working in this field. That was the first.

From my observation the younger nurses leaving do so because of better opportunities or higher ambitions. The older ones of my acquaintance left for a variety of typical life reasons, the least of which are disillusionment of the profession, although that was present. Mostly it was health or relocation.

[NotYourMamasRN]

I think nurses quit because at some point they realize their personal quality of life is more important. Nursing affects your whole life, your health, your well being, hell it even affects your family. At some point, you have to put yourself and those you love first.

[Nurse Beth, MSN]

MrNurse(x2) said:

The cost to develop a new nurse is no more than an experienced nurse today because there is no difference in orientation time. That leaves the new grad in a position to fake it until they make it, a very dangerous place for the nurse, patients and coworkers. It really is a scary time to be a new nurse.

It is a scary time to be a new nurse-and overwhelming. I'm curious about your observation that new grads have the same amount of orientation as an experienced nurse.

In my community, new grads receive significantly longer orientation than experienced nurses. Is this not the case elsewhere?

[chiromed0]

I think part of the reason "new" nurses quit isn't any different than any other occupation. They just simply have that option b/c they can find work. If the job market is tight-they will stay. Some are just young and don't know the value of patience. Some get scared and hate it so that justifies quitting until they find out they will "hate" every new job for a while then might like it--that's just called "work". Others do what we all do and take the anything until what we really want comes along. Either way there is a high turnover and it even extends to mid-levels and physicians in big cities. Health care saturated markets just see a lot of moving around. Hard to turn down the next employer giving you $10/20/30K or more a year just for quitting one job and starting another. I never understood why they just don't make tiered salary bands for nurses vs just hourly rate...get a contract, give them a high salary and make them stay.

[Daisy4RN]

Ruby Vee said:

I have been a nurse for nearly 40 years, and nurses have ALWAYS been held accountable for the lab not coming, meds not being delivered by pharmacy, PT or OT didn't come, the physician didn't round, the meal wasn't what was ordered, the physician made the patient NPO without explaining it to the patient, the blood isn't ready, the interventional lab is backed up, surgery was delayed, the TV doesn't have the channel I want to watch, my family isn't here . . . The difference is that people used to be more polite and understanding about it. Now they're not. If you think that there was some particular "golden age" of nursing when nurses weren't accountable for everyone else's job, please be advised that there wasn't.

I was talking about new nurses and experienced nurses. I am well experienced like you and have found the hospital environment to only get worse every year that passes. Part of it is society in general, but other factors like increased technology, (like others have stated) work phones that never stop ringing, increased paperwork, increased workload in general, patient (oops customer) satisfaction, family satisfaction, etc...many of these were nonexistent or very minimal years ago. So yes, new nurses are not properly trained as what to expect, and experienced nurses are tired of all the PC stuff that gets in the way of good patient care, thus new and old nurses alike are leaving...

[Nurse Beth, MSN]

MrNurse(x2) said:

The cost to develop a new nurse is no more than an experienced nurse today because there is no difference in orientation time. That leaves the new grad in a position to fake it until they make it, a very dangerous place for the nurse, patients and coworkers. It really is a scary time to be a new nurse.

It is scary although in some places new grads get a longer orientation than experienced nurses. Often not long enough.