Attrition of new graduate RN: why nurses are leaving the profession.
There are over 3 million Registered Nurses (RNs) in the U.S., making it the largest workforce in healthcare (U.S. Department of Health and Human Services [USDHHS], 2010). Data from the Health Resources and Services Administration (HRSA) suggest that although approximately 71,000 nurses graduate from associate's degree, diploma, or baccalaureate degree nursing programs annually (2004), an estimated 35% - 60% turnover rate exists among new graduates (Halfer & Graf, 2006; Regan, 2003). This article serves as a review of the literature around the attrition of new graduate nurses from the workforce and the implications attrition has on healthcare. Suggestions for improvements to professional preparation and workforce retention are made.
IMPACT OF ATTRITION
Candela and Bowles (2005) report 30% of new graduates leave the profession of nursing within the first year of licensure, as opposed to an average nurse turnover rate of 13.9% (Bernard Hodes Group, 2007, as cited by the American Association of Colleges of Nursing [AACN], 2010). The high level of attrition among new graduate nurses significantly contributes to the shortage of practicing RNs and creates an extensive financial burden to the hiring institution (Halfer & Graf, 2006). The loss of a graduate nurse in the first year of practice costs employers approximately $40,000 in hiring and orientation expenses (Halfer & Graf, 2006). In addition, hospitals may experience loss of productivity because the physical absence of the nurse, in addition to loss of productivity from other staff nurses due to increased workloads (Lafer, Moss, Kirtner, & Rees, 2003).
The impact of attrition of nurses is additionally revealed in patient safety statistics. The Joint Commission (TJC) reports that staffing levels have affected 24% of the 1609 sentinel patient events in the last 5 years (TJC, 2002). Kane and associates (2007) suggest that patient mortality decreases as RN staffing levels increase. Occurrence of pulmonary failure, cardiac arrest, and failure to rescue decreases with increased RN staffing (Kane, et al) Increased staffing levels have also been associated with fewer patient falls, fewer medication errors, shorter hospital stays, lower rates of patient death, and higher levels of patient satisfaction (Cho&Yun, 2009).
Attrition from the profession of nursing has the power to impact any new nurse on a personal and professional level, as well as interrupting or interfering with building relationships with patients and families (Halfer & Graf, 2006). The loss of practicing RNs contributes to the nursing shortage. According to the National Sample Survey of Registered Nurses (USDHHS, 2010) the average age of the practicing RN is 46 years old. With high attrition of younger RNs, there is no replacement available as the current members of the profession retire. Fewer nurses will be available to provide care to the aging or ill population (Beurhaus, Staiger, & Auerbach, 2000). Thus, it is imperative that we retain the nurses we educate.
FACTORS CONTRIBUTING TO ATTRITION
Myriad research studies have been conducted in an attempt to identify factors contributing to the mass exodus of new graduate nurses from the profession (Candela & Bowles, 2005; Casey, Fink, Krugman, & Propst, 2004; Duchscher, 2009; Halfer & Graf, 2006; McKenna, Smith, Poole, & Coverdale, 2003). It has been summarily hypothesized that inadequate training directly affects the ability of a new graduate to remain in the profession (Halfer & Graf, 2006; Marcum & West, 2004; Winter-Collins & McDaniel, 2000).
Research results report new graduate nurses do not feel prepared to manage patients or other staff, function in independent leadership roles, communicate with physicians, or provide care in an organized manner (Candela & Bowles, 2008; Casey, Fink, Krugman, & Propst, 2004). Candela and Bowles (2008) identified that new graduate nurses felt that their nursing education programs better prepared them for taking the National Council Licensing Exam (NCLEX) than to perform patient care in clinical practice. This dissatisfaction with the clinical practice preparation is a solid indicator of the nurse's inability to adjust to the demanding and stressful healthcare environment.
The psychological demands of clinical practice can be attributed to a variety of factors, including heavy workloads, time constraints, and increasingly complex patient care requirements (Lavoie-Tremblay, et al. 2008). In a study of 309 RNs aged 24 or younger, Lavoie-Tremblay and associates (2008) identified 43.4% of the respondents experienced high levels of psychological distress as measured by the Psychiatric Symptom Index (PSI). When compared with previous measures of psychological distress among healthcare providers of all ages (Bourbonnais et al., 2007), new graduate nurses had a significantly higher reports of distress (22% of healthcare providers of all ages identified high levels of psychological distress). Bellerose et al (1995) identify that the PSI measures psychological symptoms such as anxiety, irritability, depression and cognitive difficulties experienced during the previous week of work (as cited by Lavoie-Tremblay, et al, 2008).
Communication between peers and with physicians is a common challenge for new graduate RNs (Casey, et al, 2004; Halfer & Graf, 2006). McKenna, Smith, Poole, and Coverdale (2003) surveyed 551 new graduate nurses about their experiences with horizontal violence (bullying) in the workplace. Findings from this study indicate that 58% of the respondents felt undervalued by other nurses and 34% experienced some form of direct verbal assault. After these incidences of horizontal violence, 34% of the new graduate nurse respondents considered leaving the profession of nursing. In addition, 43% of these respondents reported that they had received training in management of interpersonal conflict. Casey and associates (2004) further hypothesize that new graduate nurses experience stress over peer relationships. Graduate nurses report a lack of acceptance from more experienced nurses, as well as a lack of positive support and feedback from preceptors and peers. New graduates express difficulty being assertive enough to advocate for themselves during the initial periods of hire. In addition, Casey, et al (2004) identified new graduate nurses as having lower levels of confidence when speaking with interns, residents and attending physicians. These skills significantly increased (P=0.001, P=0.003) between six months and one year of employment. This study also determined that 37% of the respondents were uncomfortable communicating with dying patients and that study participants showed no improvement communicating with dying patients over time.
Lack of confidence was frequently cited as a stressor among new graduate nurses. This lack of confidence extends to multiple areas, including: skills performance, patient assessment, clinical decision making and independent autonomous functioning (Casey, et al., 2004; Halfer & Graf, 2006). Halfer and Graf (2006) report that self-confidence among new graduates declines over the first 12 months of hire, then slowly increases by 18 months after initial hire. These results indicate that the risk for attrition is greatest during the first year of employment, and subsequently, that new graduates are not remaining in the profession long enough to gain the confidence required for autonomous practice.
The exodus of new graduate nurses is a grave problem for healthcare. With potential impact to patients, hospitals, and the nursing profession, nurses and nurse educators are implored to find solutions. There is a critical need for more research to investigate methods of retention for this population of RNs. The issues cited in this article indicate opportunities for all aspects of the nursing experience. Challenges such as poor skill attainment can be addressed in education settings, whereas issues such as bullying can be attended to in the workplace setting. Collaboration between schools of nursing and nursing workplaces needs to occur to identify measures to better prepare the new graduate for a career in nursing. Longer new graduate orientations, one-to-one mentorships, simulation based orientations and remediation, skills training, communication, and stress management courses offer single solutions to the contributing problems with new graduate attrition. Providing simulation or scenario based experiences to new graduate nurses gives new graduates crucial experience with conflict resolution and stress management in a safe environment without risk to clinical patients. The use of simulation or scenario based strategies allows nurse mentors or hospital based educators to provide opportunities for new graduates to practice and improve skills associated with direct patient care and interpersonal and interprofessional skills. By offering a more comprehensive approach to new graduate preparation, novice RNs will experience more confidence and a more realistic anticipation of the workplace. Retention of this population of nurses is tantamount to the continued growth and success of the nursing profession.
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Christine M. Zimmerman, RN, PhD(c) and Peggy Ward-Smith, RN, PhD
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|Title Annotation:||THE MISSOURI NURSE; registered nurse|
|Author:||Zimmerman, Christine M; Ward-Smith, Peggy.|
|Date:||Mar 22, 2012|
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