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Turnover in Nursing Staff at the Unit Level: The Single Best Indicator of Manager Performance?

Recently I had lunch with a former student who was passing through town. Lisa graduated a little over two years ago and was one of the lucky ones who found a job fairly quickly.

What was most interesting about our conversation was the turnover rate on her unit. In 15 months, 15 nurses have left. The most recent was a group of five experienced night shift nurses, the kind any manager is loathe to lose. They left, according to the student, because they were tired of how they were treated.  Lisa is now the most experienced person on night shift at two years out of school. The loss of 15 nurses on one unit has also cost the organization nearly a million dollars. In an era of cost tightening, that is a steep price.

Acknowledging that this is only a report from one person, there is still something that rings true in her story: Well managed patient care units do not have high turnover rates of staff. So let's think about what constitutes turnover in nursing staff and it's causes.

Gilmartin provides an excellent review of the literature on nurse turnover in a 2012 study published in Medical Care Research and Review. If we consider turnover as a measure of manager performance, however, it needs categorization. Positive turnover might be staff who leave because they completed a higher degree and are moving into a new job that reflects their new level of education. It could also be termination of poor performing personnel who are likely toxic for unit culture and whose firing would likely improve retention overall. Internal transfers are a gray area because they could reflect poor management and a nurse "voting with her feet" to get away from it. Negative turnover, of course, is a situation like what Lisa described with the night staff.
Research by Kovner and Brewer on new graduate nurses adds another later of complexity to the performance equation because early career nurses may be more likely to leave due to life changes like marriage and child bearing. Rural locations may have high retention rates because there are fewer job options, but a proxy measure there could be staff burnout levels. Unhappy nurses make for unhappy patients as recent research out of the University of Pennsylvania shows.

If we move beyond borders to low and middle income countries, turnover grows still more complex. Poorly managed systems, for example, where staff do not get paid on time or as much as promised certainly drive people away and frontline managers do not always have control over those circumstances.

The take away message here is that turnover is complex, but it may be time to quantify it as a measure of manager performance. Turnover costs organizations too much to ignore any more. A million dollars in single unit turnover costs could be spent in much better ways.

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