Predicting Nursing Turnover


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By Matthew Hamilton, for, June 5, 2002

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The nursing shortage problem has continued to devastate labor budgets all around the world. While there are many theories as to why hospitals and other medical providers cannot maintain an appropriate level of staff nurses, the overall demand for nurses will continue to grow. Yet the supply of competent nurses will not ascend to the predicted levels needed to replace the accelerated attrition within the field.

The demographics of turnover

In our effort to dramatically decrease our use of contract labor, we discovered that the population age 65 years and older will double during the period between 2000 and 2030. Conversely, the number of women between 25 and 54 years of age who form the core of the nursing workforce will remain relatively constant. Thus, the majority of providers who require registered nurses to make up of the bulk of their staffing are likely to continue incurring exorbitant agency fees. For that reason, all providers must find organic solutions to this labor problem, and quickly.

In an effort to step out of the paradigm, we sought recent studies that identified the exact relationship between job dissatisfaction and connecting staff attrition. Specifically, we analyzed individual specific vectors such as work-values, absolute wage, job characteristics, employer characteristics, number of hours worked and shift times.

Of course, we discovered numerous articles that have suggested that the problems of retention and recruitment are complex and labor-behavior contingent. Given that spending hundreds of thousands of dollars on marketing, sign-on bonuses and international recruiting is proving to be cost-prohibitive and ultimately counterproductive, perhaps it would be prudent for a hospital to develop a statistical model of why nurses quit. Such a model would identify those nurses already on staff that are strong candidates for resigning.

Many cross-sectional studies have clearly identified job satisfaction as one of the most reliable predictors of resignation probablity, especially as it relates to the correlation between absenteeism and subsequent resignations. Specifically, job satisfaction and subsequent behavior, (retention or resignation) provides a greater tool to explain labor market behavior. The relationship between the two appear to be mutually inclusive. A thorough examination should focus on personal characteristics such as marital status, age, education, gender, race and children. Also, keep in mind that these employees have already been hired. Thus, greater emphases should be placed on age and gender. The relative significance is that each group will have very different life issues, and these disparate individualities may or may not cross over from one group to the next. This is very important, as nearly two thirds of all nurses were more than 40 years old in 2000 (Fitch, Ibca, Duff and Phelps, 2001).

Another consideration should be a "settlement factor." This factor is the calculation of all employees still on payroll for over a one-year period minus all of the new hires. Furthermore, the demographic data from the employees that terminated can also be compared and contrasted with any available exit interview data. In addition, this factor can be used to quickly compute all of the dollars that have been allocated to bringing in new people, which subsequently allows for the use of "pattern hunting." By drilling down into the scattered variables, which make up an individual's reason, or reasons for termination, these indicators can then be used as the drivers for your model. This information can now be compared with the employees that have remained with the company for particular blocks of time, such as one year, five years and so forth.

Why do this? Historically, even with the myriad of employer-sponsored hiring selection processes, new training techniques, motivational speakers and the like, it still appears that there will always be a core of employees that will leave no matter what interventions are engaged. And, conversely, there is a core of employees that will remain loyal to the firm regardless of the retention mechanism employed. Hence, as many nurse managers and administrators already know, the shortage has dramatically increased workloads and has adversely affected the attitudes of the nurses that have been with the facility for more than one year.

Again, it is extremely important to be able to monitor these "settled" nurses for signs of termination contingencies and behavior. And, as for the new hires, various statistics indicate that many of these nurses are at their critical point during the first three months of employment and will generally resign within 90 days of their start date. And so, depending on the institution's new hire retention rate, this number can exceed more than 65% of a new orientation group within the first year of employment.

Unfortunately, the reason for termination is usually discovered after the employee has decided to resign. Therefore, in an effort to be really proactive, we found that management must have provisions in place to begin an immediate "rescue" of an employee that may be at risk of terminating his or her employment.

Where to begin

You should observe many key job-related characteristics. For example, consider non-preferred shift pattern choice, undertaking tasks that are below their grade, mentor of student or beginning nurses. Many nurses believe that their current grade is not a fair reflection of their present undertakings. A comprehensive study undertaken by the British National Health Service reported that just more than 96% of nurses reported entering the nursing profession in search of 'rewarding work', 87.5% for 'job security' reasons, 84.4% in order to 'help others in the community,' 76.3% for 'promotion prospects,' 65.5% for 'pay' and 47.7% for 'flexibility of working hours' (Shields and Ward, 2000).

Thus, an employee who reports a high level of job satisfaction has successfully integrated his or her lifestyle within the company's operating environment, including its support structure. It would be evident that this employee has "settled" and is replete in his or her job. This employee may have had socioeconomic, geographic, and perhaps emotional difficulties sometime during their career, and that for whatever reasons, these issues have been satisfactorily resolved with or without the employers' direct intervention. Accordingly, it would be advantageous to pursue these elements of job satisfaction quite robustly. We must also assume that the reasons for quitting are pre-determined and exogenous to these values. A nurses' reflection of work therefore will be either pecuniary or non-pecuniary.


So, in other words, money is important. However, helping others or a rewarding work environment can be equally important. In view of that fact, should your facility's statistics identify that non-pecuniary reasons for quitting are the major factor in turnover, then more money will not retain nurses in your facility. More importantly, it appears that nurses who report overall dissatisfaction with their jobs have a 65% higher probability of intending to quit than those reporting to be satisfied. Yet dissatisfaction with promotion and training opportunities have a stronger impact than workload or pay.

In addition, the BNHS study suggests that policies that focus heavily on improving the pay of all BNHS nurses will only have limited success unless they are accompanied by improved promotion and training opportunities (Shields and Ward, et al., 2000). This is the reason that each provider must identify the specific underlying issues for their turnover and begin to actively identify those employees who may not "settle."


Fitch, Ibca, Duff & Phelps, June 27, 2001, pg.2.

Shields, M & Ward, M., 2000. Improving Nurse Retention in the British National Health Services: The Impact of Job Satisfaction on Intentions to Quit. pg. 8.


Matthew Hamilton, MBA is a Finance Manager with Kindred Healthcare Inc., ( a national provider of healthcare services. He can be reached at 201-392-3543 or by e-mail at


1 Article; 5,758 Posts

I like this one. It places the responsibility for retention right on managments doorstep. Traditionally nursing managment has had this "disposable nurse" attitude towards their staff. Even with the shortage it has been very slow to change.

nightingale, RN

2,404 Posts

Yes it does put the responsibility on managers shoulder. Retention, as this article states has very little to do with money and everything to do with job satisfaction. It is rare to find a nurse who will look for another facility based on salary or bonus.

Great article Karen.

That is a cool avatar my dear.



1,244 Posts

I'm starting to wonder how the heck the suits ever got where they did, and how they're able to stay on and on and on. They remind me of the "Rainmaker" mentality, telling admins they can cut costs...and cut costs...and cut costs--til it's raining money for the industry.

Outlandish promises and wishful thinking and the illogical notion that hospitals can do without experienced nurses--but pay incredible amounts of money out for lawsuits and agency nurses--got them their BMW's. (Reminds me of a dysfunctional relationship I once had.... :chuckle: )

We did a little exercise at our orientation that exemplified this denial....we all had to get around in a group and each touch a ball as fast as we could. First time...38 seconds. Second time....15 seconds. Third time....4 seconds.

While the game's stated goal showed that teamwork increases efficiency, it also struck me that no one realized that it also showed that practice improves effectiveness--ergo, the longer you worked there, the more effective and thus efficient you became. So that, indirectly, retention and experience became the pivotal issues.

(Were we taught to think critically or were we just born that way? Seems so second nature to me now :lol2: or am I just raving cause I'm stuck home sick??? )

nightingale, RN

2,404 Posts

I hear ya SleepeyEyes! And you are not just a raving sicko!

My thought is that we are all so busy making it work that we do not have time/make the time to think of solutions. This board and awesome posters has "enlightened me".

When the suits are made to be responsible for long terms fiscal results AND quality of care then "maybe" we will see a change.

It is not revolution but evolution that will mandate change. We must make the public aware.



1,244 Posts

Originally posted by nightngale1998

I hear ya SleepeyEyes! And you are not just a raving sicko!

:roll :rotfl:

HAHAHAHAHAHAHA!!! but seriously, some of my family might beg to differ with ya.

Geez, do that a couple more times and I won't need that guainefesin syrup after all!!!! Heeehawww!! :rotfl: :roll


1 Post

I must say that I do agree with your argument. However, the "suits" will never divert their attention away from their calculators to see the REAL problem until they are placed upon the battlefield of healthcare.

They will continue to tear through nurses like a lion does to a zebra until there are none of us left.

They will not pay us what we are worth or reimburse us appropriately until they realize who their #1 customer really is...NURSES! We are their bread and butter. Unfortunately, they are blinded by greed and expansion!

Nurse managers run behind the same invisible electric fence that the rest of the nursing world is enclosed. For just a few dollars more an hour, they get the priviledge of coming in to fill holes on top of their 60 hour work week, have staff berate them, and upper management degrade them.

There is no solace at present.

We need STRONG political representation that will present the bleak and dire future of healthcare to the world.

Whew! I really took flight with that one.

Jenny P

1,164 Posts

Specializes in CV-ICU.

Eros, you said a mouthful!

The idea that NURSES are the #1 customer is a totally new train of thought for me! That means we have PATIENTS again, right?

This is an interesting article. I will have to read it again when I'm not so out of it. I think I may copy this and post it at work.


1,244 Posts

Are you thinking, nursing is more like subcontracting than waitressing?

(translating from Suit-Speak, of course... :rolleyes: )

Personally I think a lot of this problem got started with Business majors trying to change the conceptual model of nursing to fit a retail framework (the only thing their tiny minds could comprehend...)

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