Do generational differences impact turnover?

Millennial Nurses
A survey of nurses’ intention to
leave reaffirms the value of manager
relationships and personalization over
the differences in nurse generations

Advanced Practice Strategies © 2017

 Abstract

RN turnover rates continue to rise upwards of 17%

(NSI, 2016), costing US hospitals over $17 billion
annually (APS). With the average cost of replacing
a single RN estimated at $50K, APS set out to
understand what drivers cause a nurse to leave.
Do the reported generational differences among
nurses, particularly millennial nurses (born 1980
and later), create different resignation risk drivers
than the rest of the nursing workforce?

An APS survey of 1,270 nurses found that

generation had no impact on 17 out of 20
meaningful turnover risk factors identified.

The message to health system

leaders is clear: Regardless
of generation, nurses need
to have strong relationships
with their managers, work
in an environment that
empowers them at an
individual level, and
have opportunities for
advancement in a
clinical specialty for
which they are
well-suited.

Table of Contents

Why We Did It...... 2-6

What We Did........ 7-10
What We Found... 11-15
What It Means...... 16-20
Conclusion............ 21
References............ 22

1
Why We Did It
How Do We Keep
Our Skilled Nurses?
Nurses are the heart and hands of
the hospital care-delivery system. Of
all healthcare providers, nurses are
the most numerous, spend the most
time with patients, and have great
influence on patient outcomes.1-5
As a result, skilled nurses and are in
high demand and short supply.6 In
other words, front-line nurses are
essential – and difficult to replace.
Unfortunately, as all hospital
leaders know, nurse turnover is a
constant challenge. Estimates of
nurse turnover in the U.S. typically
approach 20%; yet higher rates are
reported in specific groups, such as
younger nurses.7-10 Understanding
why nurses leave their jobs – and
which nurses are at risk to leave – can
empower managers to intervene
before a nurse heads for the door.
APS, a national leader in holistic
nursing assessments, is dedicated to
understanding what characteristics
of nurses and the nurse work
environment make a great and
durable match. In this article, we
report the results of an evidence-
based survey of front-line nurses,
which identified meaningful risk
factors for turnover. Analysis by
nurse generation (Millennial versus
non-Millennial) produced some
unexpected findings, with important
implications for nurse managers and
health system leaders.
2
 Why We Did It
The Human and Financial Costs
of Nurse Turnover
Hospital leaders are all-too familiar
with the burden of nurse turnover.
In a 2016 National Healthcare
Retention Report, the estimated rate
of nurse turnover was 17.2%, up
from 16.4% in 2014 (Figure 1).7 The
average cost of nurse turnover in
this study was $37,000 to $58,400
per RN. In other studies, estimates of
total costs reach nearly $90,000 per
nurse.11 Based on these figures, APS
estimates that nurse turnover costs
U.S. hospitals over $16B annually.
The impacts of turnover extend
beyond financial costs. The loss
of an experienced nurse burdens
remaining nurses with the need
to train new hires, while attending
to the higher acuity patients, as
new nurses orient to the unit. This
increased work burden and stress
3
can lead to secondary turnover
among remaining nurses, further
straining the work environment.12
Patients also may suffer. Nurse
turnover has been associated with
meaningful impacts on the quality of
nursing care, job satisfaction among
remaining nurses – and possibly
adverse patient outcomes.1-3,13,14
The imperative to address nurse
turnover is clear, but fixing the
problem remains a challenge. In
the National Healthcare Retention
study, 85% of surveyed organizations
identified nurse retention as a key
strategic imperative, but even these
groups did not incorporate methods
to improve retention into their
strategic planning.7
Why We Did It

What Drives Nurses

to Leave Their Jobs?

Studies of nurse turnover and
retention reveal a complex story–
and certain common themes.
Salient findings highlight the
importance of relationships with
managers, organizational
support, workload, and control
over practice – all aspects of the nurse
work environment.15,16 Identifying and
modifying key features of the nurse
work environment has the potential
to improve nurse retention, as well as
the quality, safety, and efficiency of
patient care.1,2,17

Figure 1.
National RN Turnover Rate
National nurse
turnover rate has
17.2% been increasing
16.4% over the past five
years.
16.4%
14.2%
13.1%

2011 2012 2013 2014 2015

Source: NSI 2016 Turnover Survey

4
 Why We Did It

‘‘
If people are neutral on
their supervisor, they are
prone to look for other jobs.
When they feel adverse
about their supervisor, they
have one foot out the door.”

former Chief HR Officer

at an eight-hospital system
interviewed by APS

5
Why We Did It

Shifting Generations
of Nurses

A new wrinkle in the story of nurse As experienced Baby-Boomers retire,

turnover is the expanding presence the presence of Millennial nurses
of the Millennial generation of in the workforce will continue to
nurses in the hospital workforce. expand. Understanding what drives
Initial evidence suggests that this generation of nurses – and what
the younger nurses are more will encourage skilled Millennials to
willing to leave their jobs, and stay in front-line nursing jobs – is of
may be more vulnerable to poor timely and growing importance.
work environments, early career
burnout, and intention to leave the
profession.8-10 The factors underlying
these tendencies are not yet
understood.

6
 What We Did
What We Did:
The APS Survey Tool
To better understand why nurses
leave front-line jobs, APS created
an evidence-based survey tool
consisting of 26 different factors
potentially related to turnover. These
factors were identified through
interviews with hospital leaders
and a thorough review of the
literature. The survey items probed
multiple aspects of the nurse work
environment, including nurse-
manager relationships, unit culture,
leadership engagement, nurse
workload, teamwork, compensation,
7
and career development
opportunities.
Between December 2015 and July
2016, the survey was sent to nurses
who had previously completed APS’
Prophecy® Pre-Hire assessments.
Nurses were asked whether they
had started a new job after taking
the assessment, and if so, whether or
not they were still at that job. Nurses
scored their responses to survey
items on a 5-point Likert scale (from
disagree strongly to agree strongly).
 What We Did
Ensuring
Statistical Rigor
To optimize the reliability of the
analysis, statistical methods such as
bootstrapping were applied, with
the goal of identifying significant
predictors of nurse turnover.
Bootstrapping involves drawing
a random sample of the data,
performing a correlation analysis,
and repeating the process hundreds
of times. This systematic resampling
of the data provides an estimate of
the accuracy of the original sample
and avoids a potential weakness
of “one-shot” correlational studies.
To make comparisons between
Millennial and non-Millennial
participants, bootstrap studies were
completed separately for each group.
8
 What We Did

Survey
Sample

In all, we surveyed 1,519 nurses, balanced representation of years

of which 1,270 had sufficient
information to include in our
generational analysis. This sample
included a broad range of
nursing specialties (Table 1) and a
of experience, degrees held, and
generational status (see Figures 2-4).
Most nurses (84%) reported full-
time employment at the time of the
survey.

Table 1. Primary specialty of nurses surveyed by Prophecy Health

NURSE SPECIALTY N %
Adult Medical/Surgical 292 23%
Adult ICU 203 16%
Emergency Department 169 13%
Maternal Nursing (L&D, Post-partum) 102 8%
Operating Room/PACU 96 8%
NICU or PICU 60 5%
Cardiac/Stepdown/Telemetry 68 5%
Pediatrics 38 3%
Cardiac 33 2%
Oncology 30 2%
Behavioral/Psych/Mental Health 28 2%
Ambulatory Care 30 2%
Other 154 12%
TOTAL 1,270 100%

9
What We Did

Figure 2. Years in nursing practice

among surveyed nurses*
*Question asked of a subsample of
21% all surveyed nurses (N=1,005, 79%)
29%

<2

27% 3-5

23% 6-10

>11

2% Figure 3. Degrees held

by surveyed nurses
7%
(respondents could select >1 degree)*
*Question asked of a subsample of
34%
all surveyed nurses (N=411, 32%)

Associate Degree

62% BSN

MSN

Other Master’s or PhD

3% Figure 4. Generations
Proportion of Millennial and
non-Millennial nurses surveyed
(N=1,270, 100%)

51% 46%
Millennial

Non-Millennial

Age Unknown

10
 What We Did

Significant predictors of turnover

included manager relationships,
nurse autonomy, opportunities
for career advancement, role
clarity, workload, and adequate
nurse staffing.

11
 What we Found

What We Found:
Drivers of Nurse Retention

Figure 5.
Scatter plot showing the relationship between categories of nurse-related variables
and nurses’ likelihood of leaving employment. Nurses’ relationship with their managers
was an especially important and common contributor to turnover.

12
 What We Found
Factors Related
to Turnover
The statistical analysis identified 17
factors that correlated significantly
with turnover for the nurse sample
as a whole (see Figure 5 and Table
2). Overall, our results underscore
the importance of investing time
and resources into nurse/nurse
manager relationships.
Nurses described a need for
supportive management, regular
feedback and communication,
recognition by managers, and
engaged leadership. Other
significant predictors of turnover
included nurse autonomy,
opportunities for career
advancement, role clarity, workload,
and adequate nurse staffing.
13
Surprisingly, only three significant
factors differed between Millennials
and Non-Millennials (see Table
2). For Millennials, these factors
related to scheduling time off
and opportunities for continuing
education. For older nurses, the
chief concern was the presence of
nurse hostility.
Another insight was that
compensation did not significantly
predict risk for turnover. For
this sample of nurses, the nurse
work environment trumps
monetary compensation as a
key consideration.
What We Found

Surveyed nurses
described a need for
supportive management,
regular feedback and
communication, recognition
by managers, and
engaged leadership.

14
 What We Found

Table 2. Significant relationships between factors on the

Millennial Non-
APS survey tool and likelihood of nurse turnover.
Nurses Millennial
(Significance level P<0.1) Nurses

Inability to schedule time off when needed p

generations
between
Different

Inadequate continuing education opportunities p

Nurse hostility on unit compromises teamwork p

Don’t feel supported by manager p p

Don’t receive regular manager feedback p p

Don’t receive manager recognition for efforts p p

Don’t see and talk to manager often p p

Don’t trust manager p p

Lack of leadership communication p p

Lack of leadership engagement p p

Same for all nurses

High turnover within the team p p

Not empowered to make nursing care decisions p p

Lack of career advancement opportunity p p

Lack of role clarity p p

Poor fit with clinical specialty p p

Inadequate staffing levels p p

Unreasonable mandatory overtime p p

Shifts have inconsistent start/end times p p

Unable to complete duties within shift p p

Inability to work desired shifts p p

Compensation dissimilar from others in the area

Compensation dissimilar from others at hospital

Same for all nurses

Lack of incentives for OT / holidays / weekends / nights

Not hired into desired specialty

Inability to self-schedule shifts

Inexperience of team members on shift

p Correlated and significant P<0.1

Not significant

15
What It Means
What Do the Findings Mean
for Nurse Retention?
The core findings of this survey
align with factors identified in the
published literature, particularly
the influence of nurse managers
on turnover.15,16,18,19 Our results also
support the conclusion that the
nurse work environment matters
deeply to all nurses, and each nurse’s
relationship with management is a
core driver of retention, regardless
of nurse age.
16
 What It Means

Only a few differences were

found between generations.
For Millennials, scheduling
time off and opportunities for
continuing education were
important. For non-millennial
nurses, the chief concern was
the presence of nurse
hostility the unit.

17
What It Means
Millennials Are
Nurses First
The overwhelming similarities
between nurse generations in our
survey run counter to commonly-
held beliefs that Millennials are
categorically different from older
generations of nurses. Certain
generational differences have
been described in the literature.
For example, a 22-hospital study in
the U.S. found that younger nurses
(27-40 years old) preferred personal
attention from their manager
and input on hospital decisions;
conversely, older nurses were
more concerned with decreasing
long work hours and the physical
demands of nursing.20
Furthermore, several studies
have demonstrated an inverse
relationship between nurse age
and intention to leave. 21-24 In the
22-hospital study, for example, one
third of Millennial nurses planned to
leave their jobs within 2 years; over
two thirds planned to leave within 5
years.20
While these studies suggest
differences between generations
of nurses, they do not describe
the many similarities, which, based
on our findings, may outweigh
generational differences. Similarities
between generations have been
described by other groups as
well. A study by LeDuc and Kotzer
(2009) compared professional
nursing values between students,
new graduates, and seasoned
practitioners and found greater
similarities than differences between
the groups.25 When the researchers
assessed values related to the work
environment, all cohorts reported
that it was very important to
“establish and maintain conditions
of employment conducive to high
quality nursing care.”
18
 What It Means
Job Fit, Continuing Education,
Nurse Hostility
Specialty job fit was a significant
predictor of turnover in our study.
From our work with clients and our
Prophecy Behavioral Assessment,
we have found that personality fit is
a critical component of successful
hiring and retention. In fact, APS
clients who use our assessments as
part of their hiring and onboarding
practices have seen dramatic
improvements in first-year nurse
retention rates.
The importance of continuing
education to Millennial nurses is not
surprising. Clients who use Prophecy
products to personalize the
onboarding process and provide
staff with meaningful education have
seen decreases in staff turnover.
These investments are particularly
important for new graduates, who
face a steep learning curve and
need tools that will help them
improve quickly.
For non-Millennials, the only unique
19
turnover driver was nurse hostility.
Hostility on the nursing unit may
be defined as unwanted verbal or
physical behavior in the workplace.
It may manifest as gossip, excessive
criticism, passive-aggressive
behavior, harassment, isolation, or
intimidation.26-28 Not surprisingly,
previous research has also linked
hostility to nurse turnover.26,27
And among clinical leaders,
abusive behavior contributes to
worse quality of care and strong
intention to quit among nurses.29,30
Conversely, leadership practices
known as transformational (eg,
idealized influence, inspirational
motivation, intellectual stimulation,
individualized consideration) are
associated with high quality care and
reduced intention to quit.29
The significance of this factor for
older nurses, and lack of significance
for Millennials, is an intriguing
finding that requires further study.
What It Means
The Importance
of Nurse Managers
Front-line nurses are not the only
ones at risk for turnover. Features of
the work environment can also strain
nurse managers and lead them to
consider quitting.31 Even at Magnet
hospitals, sites known for excellence
in nursing care, nurse managers are
challenged by workload, work-life
imbalance, and difficulty sustaining
positive relationships.32
Despite the demonstrated
importance of nurse managers,
they often receive little preparation,
education, coaching, or mentoring
to foster successful leadership.33
Providing nurse managers with
simple, evidence-based tools
and strategies to promote nurse
satisfaction and retention is essential
to overcome the challenges of
leadership – and prevent the
burnout and turnover of managers
themselves. Supporting nurse
managers is a core goal of APS and
its industry-leading assessment tools.
20
 Conclusion
The decision to leave employment
is a complex, multistage process.34
A majority of nurses who quit their
jobs begin by considering leaving
in the year before quitting; the final
decision to leave is made within 6
months of quitting.34 This extended
process suggests an opportunity to
identify at-risk nurses and intervene
to improve job satisfaction and
prevent turnover.
The main results of our survey align
with the published literature.
Nurses across generations have
much in common with regard to
reasons for turnover. Universally,
nurses value:
• Good relationship with their
manager and clinical leaders
• Clear understanding of their
role and responsibilities
• Opportunities to improve
and advance
• Manageable workload
21
Despite the common perspective that
Millennials have a unique set of needs
and desires, we found few significant
differences between generations of
nurses. Support from the nurse manager
remains a highly significant predictor of
turnover, across generations.
Nurse managers should dedicate time
to understanding and addressing the
needs of individuals rather than trying
to overgeneralize based on a nurse’s
generation.
At APS, a sharp focus on adapting
to individuals is core to what we do.
We build solutions that help clinicians
reach their highest potential through
personalized experiences – starting
before they are hired, through
the onboarding experience, and
continuously as they learn and develop.
Our research into nurse turnover
provides fresh support of our approach
to engage with the healthcare workforce
in this unique and innovative way.
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Advanced Practice Strategies (APS) is a
technology company that works with
organizations to build the best patient
care teams through our two assessment-
driven solutions Prophecy and GNOSIS.

Our data-driven insights help the nation’s

leading health systems reduce risk, costs
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