Nurse retention: A review of strategies to create and enhance positive practice environments in clinical settings

Abstract

Objectives

This paper summarises and critically reviews strategies identified in the literature which support retention of nurses by the creation and enhancement of positive practice environments in the clinical setting.

Design

Literature review.

Data sources

A literature search was undertaken in February 2012 of major healthcare-related databases, Cinahlplus, Medline, and Proquest.

Review methods

The keywords “nurs* AND practice AND environment” were used in the first instance. Additional keywords “retention strategies” were also searched. Abstracts were reviewed and articles which potentially outlined strategies were identified. Reference lists were scanned for other potential articles. Articles in languages other than English were excluded. Lake's Practice Environment Scale of the Nursing Work Index provided a framework from which to assess the strategies.

Results

Thirty-nine papers reported strategies for creating a positive practice environment. Only two articles reported on a pre-test post-test evaluation of the proposed strategy. Strategies included: empowering work environment, shared governance structure, autonomy, professional development, leadership support, adequate numbers and skill mix and collegial relationships within the healthcare team.

Conclusions

Creating positive practice environments enhances nurse retention and facilitates quality patient care. Managers and administrators should assess and manage their practice environments using a validated tool to guide and evaluate interventions.

Introduction

The global nursing shortage is a challenge for healthcare systems around the world and solutions are critical to prevent escalating adverse health outcomes (International Council of Nurses, 2006). While the exact extent of the shortage is unknown, several reports provide estimates of the size of the problem. The World Health Organisation (2006) estimated a shortage of almost 4.3 million doctors, midwives, nurses and support workers globally. Buerhaus (2008) predicted a deficit in Registered Nurses (RNs) in the United States, relative to projected demand, will begin in 2015 and continue to worsen with projected shortages of 285,000 RNs by 2020 and 500,000 RNs by 2025. More recently a Health Workforce Australia report (2012) identified projected shortages of 20,079 nurses in 2016 increasing to 109,490 in 2025. If Australia aimed for medium self-sufficiency of the nursing workforce with a 50% reduction in migration (self-sufficiency is defined as meeting health workforce requirements from domestic training), the shortage in 2025 would increase to 129,818 nurses.

The shortage of healthcare workers has forced governments and employers to address not only training and recruitment issues but staff retention strategies as cost effective and beneficial to health outcomes (Gaynor et al., 2007, Hayes et al., 2006). For example, Australian data suggest if retention was improved by sustaining exit rates at 2% of the total workforce, the shortage would fall to 25,000 in 2025, a reduction in the nurse shortage of over 100,000 nurses (Health Workforce Australia, 2012).

In the last decade, the relationship between staff retention and positive practice environments has been well established (Aiken et al., 2008a, Kramer and Schmalenberg, 2004, Laschinger et al., 2003, Upenieks, 2003). The nursing practice environment can be examined from many perspectives, however for the purposes of this discussion it will be defined as: ‘the organisational characteristics of a work setting that facilitate or constrain professional nursing practice’ (Lake and Friese, 2006, p. 2). Health service managers may need guidance as to the development and implementation of a positive practice environment. This paper summarises and critically reviews strategies identified in the literature which support retention of nurses by the creation of positive practice environments.