NURSING RETENTION STRATEGIES IN THE ACUTE CARE SETTING by CLAIRE BOGER A Senior Honors Project Presented to the Honors College East Carolina University In Partial Fulfillment of the Requirements for Graduation with Honors by CLAIRE BOGER Greenville, NC 4/4/2025 Approved by: DR. SANDRA MORRIS East Carolina University College of Nursing ACUTE CARE NURSING RETENTION STRATEGIES 2 Abstract The ongoing nursing shortage presents a critical challenge to healthcare systems globally. The aim of this study was to identify the retention strategies discussed in literature that had the greatest impact on nursing retention. Increased patient loads, occupational stress, and burnout contribute to nurse retention, further exacerbating staffing shortages and financial costs. This integrative literature review examines the primary factors influencing nursing turnover and identifies effective retention strategies to mitigate this issue. Key determinants of turnover include lack of organizational support, compassion fatigue, and inadequate onboarding. The review identifies four key strategies for mitigating turnover intention among nurses: preceptorship and mentorship programs, adjustments in leadership styles, enhanced organizational support, and the promotion of professional networking and social support. Each of these approaches plays a vital role in improving nurse retention by fostering job satisfaction, reducing compassion fatigue, and cultivating a supportive work environment. Organizational healthcare leaders can use this information to combat the issue of nursing retention. Keywords: preceptorship, turnover intention, job satisfaction, transformational leadership, resilience, burnout, organizational culture, leadership styles, compassion fatigue ACUTE CARE NURSING RETENTION STRATEGIES 3 Background Undoubtedly, there is a significant nursing shortage in the present day, impacting not only at the national level but also locally within the state of North Carolina. Statistics note there is a 22.2% turnover rate in the state of North Carolina, with the national turnover rate being 20.7% as of 2023 (NSI Nursing Solutions, Inc, 2024). Nurses make up for nearly half of the global healthcare workforce and their shortages present a major challenge for healthcare systems. As of 2020 there were an estimated 5.9 million vacant nursing positions globally (Pressley & Garside, 2023). In the U.S. alone it is projected by the Bureau of Labor Statistics that there will be 193,100 openings for RNs each year through 2032 (Rosseter, 2024). These statistics give reason for a change in nurses attitudes towards their positions and their intent to stay. Unfortunately, aspects of the nursing shortage such as higher patient ratios, occupational stress, and burnout not only jeopardize patient safety and care quality but also contribute to higher turnover rates. Given the critical shortage of nurses, it is crucial for healthcare organizations to adopt effective retention strategies to enhance the stability of this already understaffed profession. When a nurse departs a position, it significantly affects the workload and job satisfaction of the remaining nurses, leading to increased pressures and workloads. Nursing turnover also implies substantial financial costs due to lost productivity from skilled workers and the expenses associated with hiring and training new members for the position. There is no exact cost for the replacement of one nurse, but it is thought to cost more than one annual salary, only increasing the longer the position remains vacant. Considering the number of nurses retiring as well as leaving the profession for other reasons, nursing turnover is a worrisome issue as there are inadequate reserves to replenish the departing nurses. Thus, the implementation of extensively researched and tested retention strategies is becoming increasingly detrimental for the nursing profession. ACUTE CARE NURSING RETENTION STRATEGIES 4 Research Questions RQ1: What were the implemented retention strategies found in literature that had the most impact on nursing retention? RQ2: What factors contribute to increased intent to leave among nurses? The aim of this study is to determine effective retention strategies as well as the factors that contribute to a nurse’s intent to leave. Through examining these factors and strategies, this research should be able to help healthcare organizations combat the nursing shortage and increase retention of nurses. The population of focus for this study are registered nurses working in the acute care setting, Nursing turnover is notably higher in acute care settings due to nurse burnout and stress, patient-to-nurse ratios, more new nurses on staff and since COVID-19 causing an increase in patient loads. Pinpointing the variables that contribute to high turnover rates in the acute care setting is crucial for developing effective retention strategies. By identifying these variables, organizations can target the sources of dissatisfaction and implement tailored interventions to improve retention. Methodology The method of this research is an integrative literature review. An integrative review provides a broad summary of literature and includes findings from a range of research designs. It gathers and synthesizes both empirical and theoretical evidence relevant to a clearly defined problem. Integrative reviews have been found to be important for evidence-based practice initiatives in nursing. Through using diverse data sources, integrative reviews synthesize research data from various research designs to reach comprehensive and reliable conclusions. Integrative reviews are popular in nursing research because they define complex concepts. ACUTE CARE NURSING RETENTION STRATEGIES 5 There are 5 steps involved when conducting an integrative review. The first step is to identify the problem which needs further research. During this step it is also essential to define a focused research question that will guide the review process. Identifying a research question should help you in finding relevant literature to your topic of interest. The next step is to perform a literature search, this involves conducting a systematic search of literature from different types of studies using multiple databases and sources. Through obtaining a wide range of studies, it allows for lots of information to be found about various aspects of the research question. Thirdly, an integrative review requires a data evaluation, this allows for an assessment of the quality of the literature obtained during the search step. Evaluating the literature involves determining its methodological rigor, relevance to the research question and limitations or biases. The studies that meet these qualifications should be selected for further analysis and synthesis. That leads to the fourth step, data analysis, this is used to extract relevant data and findings from the selected studies. During this step the data should be categorized based on common themes, patterns, or relationships. Through grouping common themes and patterns, it is easier to compare and contrast findings across studies to identify prevalent concepts or conclusions that address the research question. The final step of an integrative review is the presentation of findings, this step involves presenting the findings but also conclusions (Oermann & Knafl, 2021). The integrative review should present a comprehensive overview of the current state of knowledge on the topic, highlighting key themes, gaps in literature, implications for practice and suggestions for further research. In this step of the review, it is important that the review process is presented clearly as it enhances the credibility and usefulness of the findings. Utilizing these steps ensure that an integrative review ensures a robust synthesis of existing research that offers insights that contribute to a deeper understanding of the topic under investigation. ACUTE CARE NURSING RETENTION STRATEGIES 6 Considering this research was conducted using an integrative literature review there was no need for approval from the IRB. The data collection for this review was focused on gathering and analyzing existing research literature. In this project, research articles were meticulously reviewed and analyzed to explore the factors contributing to turnover among registered nurses, as well as to identify optimal retention strategies aimed at mitigating this prevalent issue. Employing an integrative review methodology involved synthesizing findings from multiple studies, thus negating the need for a specific sample. However, the review did specify inclusion criteria related to studies conducted within the acute care setting. The articles selected for this review are scholarly works published within the last five years and underwent systematic analysis. Conducting this integrative review has facilitated a thorough exploration of the factors contributing to nursing turnover and effective retention strategies. The aim of this research is to provide actionable insights for healthcare organizations grappling with the nursing shortage crisis. Effective retention strategies are pivotal in addressing today's healthcare workforce challenges and should be viewed as transformative in mitigating these issues. Themes It has been found that lack of organizational support, compassion fatigue and lack of an effective onboarding process has caused dissatisfaction and led to a decrease in retention of nurses. Research has been done to improve nurses’ perception of their positions which has found that preceptorship, resilience training, organizational support and networking, effective leadership styles and recruitment strategies, along with other strategies can lead to an increase in nurse retention. ACUTE CARE NURSING RETENTION STRATEGIES 7 Though there are many reasons nurses leave their jobs, a few have been shown in research to have the biggest impact on nurses’ intent to leave, one is the effect of compassion fatigue. One study observed that compassion fatigue rose in instances where nurses experienced elevated emotional demands and lacked substantial social support (Wang et al., 2023). Furthermore, it was found that social support can mitigate compassion fatigue among nurses, with acknowledgement and support from leaders and colleagues identified as primary forms of support that significantly enhance nurses’ compassion satisfaction (Wang et al., 2023). Another source based their research off a concept analysis model of turnover intention in nurses, it then proposed that work engagement and compassion fatigue, which represents employees positive and negative responses to the workplace, significantly influence the likelihood of leaving. Hence it is essential that there are strategies aimed towards mitigating compassion fatigue and work engagement to reduce turnover intention among nurses, and more specifically in this article, dialysis nurses (Cao & Chen, 2021). Stress is frequently identified as a significant factor leading to nurse burnout. Research suggests that early implementation of interventions aimed at managing stress and enhancing resilience is crucial. These strategies may encompass stress management techniques, mindfulness practices, and resilience training. In regards to nurses' turnover intention, it is crucial to implement empirically tested interventions that address stress and burnout. This approach not only prevents the psychological and physiological effects of occupational stress in individual nurses but also diminishes their desire to leave. Effective management of stress and burnout involves assessing nurses' coping abilities and implementing measures to enhance these skills and their overall resilience to stressors (Labrague et al., 2020). ACUTE CARE NURSING RETENTION STRATEGIES 8 Some sources emphasize organizational culture as a determinant of nursing turnover and retention. This encompasses workplace conditions, job satisfaction, and commitment to the organization. Many studies on nursing retention support the notion that nurse managers significantly influence how nurses perceive their roles within the organization, one says to enhance organizational culture and reduce turnover, fostering leadership practices such as transformational and servant leadership styles is crucial (Penconek et al., 2024). Conversely, a negative organizational climate has been shown to decrease nurses' intention to remain at their jobs. According to one study, there was a significant positive relationship between intention to stay among nurses and hospitals with a positive organizational climate, highlighting the detrimental impact of a poor organizational climate on retention (Hossny et al., 2023). In the context of organizational commitment, when nurses experience job satisfaction and feel a strong sense of obligation towards their work, organizational commitment serves as a stabilizing force. This reinforces their intention to stay within the organization and promotes positive behavioral outcomes (Pressley & Garside, 2023). The work environment of nurses frequently emerges in research as a significant factor influencing their intention to remain in their positions. Encouraging nurses to participate in events such as conferences enables them to engage with a broader professional social network. Networking has been consistently associated with improved retention rates, one study said “a core influence on retention from within the talent management initiative was the presence of networks and networking. The networking can be viewed as a form of social capital, which stood out in these findings as being a facilitating factor between retention and career development” (Fisher et al., 2022, pg. 4478). Another study emphasized nurse identity and its connection to social networks as a retention strategy, they discovered a positive association between nurse ACUTE CARE NURSING RETENTION STRATEGIES 9 identity and retention, therefore, efforts should be made to improve nurses' sense of belonging to the profession. Hospital administrators could support nurses financially to attend international nursing congresses or conferences, thereby integrating them into a broader professional social network (Huang et al., 2024). The idea of integrating preceptorship and mentorship in the recruitment and retention of nurses is another strategy some studies suggested that nursing managers should develop into their organizational practices. According to one source, “preceptorship can make a positive contribution to both the work environment and future recruitment” (Jönsson et al., 2021, pg. 1846). Another study examining nurse residency and mentorship programs suggests that these initiatives, whether individually or in combination, effectively reduce the turnover rate among newly graduated registered nurses (Vázquez-Calatayud & Eseverri-Azcoiti, 2023). The exchange relationship between the preceptor was studied and it noted by (Kim & Yang, 2023, pg. 10) that “the study indicates that the exchange relationship with the preceptor acts as a mediator in the relationship between burnout and job retention intention.” In researching effective retention strategies, resilience emerged as a consistent and pivotal factor. This trait not only influences job satisfaction but also plays a crucial role in fostering long-term commitment among healthcare professionals. One study explored the impact of resilience on compassion satisfaction, suggesting that resilience training shows promising preliminary evidence for increasing compassion satisfaction among healthcare professionals. Building resilience not only enhances job satisfaction but also strengthens emotional well-being, contributing to overall retention and performance in the healthcare field (Greinacher et al., 2022). Another study focuses on strategies tailored for dialysis nurses, advocating for the implementation of nursing policies aimed at promoting resilience training and education within ACUTE CARE NURSING RETENTION STRATEGIES 10 clinical settings. These initiatives are designed to enhance work engagement, mitigate compassion fatigue, and ultimately reduce turnover among dialysis nurses. The study further recommends mindfulness meditation training programs for nursing managers as a proactive approach to fostering resilience among dialysis nursing teams. These efforts are crucial for sustaining a supportive and resilient workforce in dialysis care settings (Cao & Chen, 2021). Several studies indicate that resilience significantly influences nurses' intention to remain in their positions. For instance, one study suggests that higher levels of resilience, social support, and a positive work environment contribute to lower turnover intention by minimizing transition shock. These findings underscore the importance for nurse managers to focus on enhancing resilience, fostering social support networks, and cultivating a supportive work environment. These efforts can effectively reduce turnover intention among newly graduated nurses (NGNs) and contribute to their long-term retention in healthcare settings (Cao et al., 2021). Another crucial aspect of retention strategies involves examining the impact of leadership styles on nurses' perceptions of their roles within the organization. Effective leadership not only influences job satisfaction but also plays a pivotal role in shaping organizational culture and fostering a supportive work environment conducive to retention. A study investigated the link between transformational leadership and staff nurse retention, finding the significance of transformational leadership in improving staff nurse retention, job satisfaction, and quality of care. The article further recommends that nurse directors promote transformational leadership behaviors among nurse managers through targeted leadership training programs to strengthen staff retention initiatives, this highlights the proactive role of leadership development in fostering a supportive and effective work environment (Conroy et al., 2023). In another study exploring the impact of transformational leadership on the nursing work environment, it is found that ACUTE CARE NURSING RETENTION STRATEGIES 11 nursing managers demonstrating effective transformational leadership attributes can significantly enhance nursing staff satisfaction and reduce burnout risk by fostering a supportive and inclusive work environment, either directly or indirectly (Ystaas et al., 2023). Other leadership styles have also been studied as well. According to one article healthcare management must cultivate effective leadership styles, as recent research identifies ineffective managerial approaches as one of the top three reasons for employee turnover. The study further reveals that transformational and authentic leadership, as well as perceived organizational support, play crucial roles in moderating nurses' turnover intentions. These findings underscore the pivotal role of leadership effectiveness in shaping workplace retention dynamics (Pattali et al., 2024). Below is a graph illustrating the four most common strategies identified in the review, along with their respective frequencies. These strategies have been shown to be the most effective in mitigating turnover intention. 0% 5% 10% 15% 20% 25% Preceptorship/mentorship Adjustments in leadership styles Organizational support Professional networking Strategies for Mitigating Turnover Intention ACUTE CARE NURSING RETENTION STRATEGIES 12 Discussion The findings of this integrative review highlight that while turnover in acute care nursing is a complex, multifaceted issue, there are consistent themes in the literature regarding strategies that mitigate it. Organizational support emerged as a foundational factor, reinforcing the idea that nurses who feel valued and supported by their institutions are more likely to remain in their roles. This aligns with Maslow’s hierarchy of needs, as nurses require safety, belonging, and esteem before they can fully self-actualize in their professional practice. Hospitals that prioritize mental health resources, provide flexible scheduling, and establish transparent communication channels foster a culture of trust and resilience. These interventions, while sometimes resource- intensive, ultimately reduce costs associated with turnover and create a healthier, more sustainable work environment. Leadership style, preceptorship/mentorship, and professional networking also play critical roles in promoting retention, particularly among early-career nurses. Transformational and relational leadership approaches—those that focus on empowerment, individualized support, and shared vision—encourage engagement and job satisfaction. Meanwhile, mentorship and structured preceptorship programs help new nurses transition into practice with confidence, reducing feelings of isolation and burnout. Professional networking opportunities further contribute to retention by fostering a sense of belonging within the broader nursing community and opening pathways for growth and development. Together, these strategies address both the interpersonal and institutional dimensions of turnover and offer practical, evidence-based interventions for nurse leaders and administrators. Conclusion ACUTE CARE NURSING RETENTION STRATEGIES 13 In conclusion, the issue of nursing turnover in the acute care setting is pressing, yet addressable through strategic, evidence-based interventions. This integrative review found that organizational support, effective leadership, mentorship/preceptorship, and professional networking are critical strategies for improving nurse retention. As healthcare systems continue to face workforce shortages and increasing patient demands, investing in these areas is not only beneficial but essential. 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