Overall RN turnover continues to reach historic highs, exceeding 27% in 2021. However, turnover isn't the only disturbing trend. The increasing challenge of RN intent to leave will further disrupt workforce stabilization unless deliberate steps are taken to detect and address RNs' reasons for considering departure. Monica Westhead sat down with Carol Boston-Fleischhauer, Advisory Board's Chief Nursing Officer, to examine this trend.  

Q: Carol, in your conversations with nurse executives, you've been raising the issue of "intent to leave."  What do you mean by that?

Simply put, "intent to leave," sometimes referred to as "flight risk," is when an employee is beyond the point of dissatisfaction with their current employer and is actively considering alternative options. For an RN, those options typically include moving to a non-direct care role with the same organization or leaving the organization altogether.

RN intent to leave their current direct caregiver roles has been increasing over the past few years. 32% of RNs surveyed by McKinsey in November 2021 said they were considering leaving their current, direct care role, up from 22% in February 2021. According to a survey from the AACN this past summer, 36% of RNs said they planned to leave within the next year, with similar findings from Advisory Board's 2022 Clinician Survey where 36.1% of RNs said they are either definitely leaving, very likely to leave, or somewhat likely to leave their roles in the next year.

You see the problem; substantial turnover coupled with increased numbers of RN intending to depart will further destabilize the inpatient nursing workforce.

Q: What is driving those high levels of intent to leave among RNs?

The primary drivers have been well-documented and shouldn't surprise anyone.  Reasons expressed by RNs include:

• Insufficient staffing
• Below-market compensation
• Not feeling listened to or supported by the organization
• Burnout and the emotional toll of the role
• Demanding nature of the job
• Poor work/life balance
• Workplace safety concerns

Many of these work environment concerns were prevalent before the pandemic, but Covid-19 significantly amplified them.

Q: How concerned are you about these rising intent-to-leave numbers?

I am very concerned. Continued destabilization of the nursing workforce will impact an organization's ability to maintain core service levels; in particular, the ability to deliver quality, safe, and effective patient care. Amidst margin shortfalls, chronic reliance on agency staff to substitute for permanent employees is financially unsustainable.

Q: What is the biggest mistake you see C-suites making when it comes to RN intent to leave?

I observe a limited understanding of this intent to leave trend.  The majority of C-suites have been investing heavily in recruitment to immediately shore up staffing, as well as significantly adjust compensation.

The impact of nurse turnover, in 2 charts

However, efforts to confront other work environment challenges are lagging. Failure to address all drivers of intent to leave will promulgate continued RN mobility away from direct caregiver roles and will mitigate any gains made from even the strongest of recruitment efforts.   

From a practical standpoint, reversing an RN's intent to leave should be easier than attempting to re-recruit them once they have already departed, let alone to hire a new RN into a vacancy. Failure to address upstream drivers of potential turnover, not just turnover that has already occurred, is a strategic error that will hinder workforce stability and organizational growth. 

Q: What should executives be doing to assess this trend within their systems?

First, leaders must assess current intent to leave within their RN population. "Stay interviews," conducted by either front-line managers or other leaders outside of the immediate employment area, are one good tool to surface challenges.

This tool should be used for all RNs at the operating unit level to gather individual information that could be acted upon to address specific RN concerns whenever feasible. Data collected from stay interviews should also be analyzed more broadly, to surface themes that may be common across units.

As an alternative, early adopter organizations are investing in predictive analytic tools to automate data collection and provide leaders with targeted options for follow-up conversations. The development of predictive tools requires close partnerships with data analytics and human resource leaders. Nurse manager/leader readiness and capacity for conducting thoughtful conversations with any RN that is identified through this automated process is essential.   

Q: What should leaders do to address the key drivers of intent to leave?

The majority of organizations are already doing all they can to recruit new staff, extend novice nurse onboarding, and adjust compensation to be as competitive as is financially feasible.  Equally important, however, is the work environment. Leaders must gather nurse input into environmental challenges of particular concern to them and be prepared to resource efforts that address those concerns.

Authentic, full transparency regarding organizational efforts to improve on the areas identified by staff is essential for both internal staff as well as potential employees. 

Q: What is the role of the nurse manager in reducing intent to leave among RNs?

Advisory Board has consistently emphasized the pivotal role of the frontline nurse manager in overall retention efforts. Frontline managers are gatekeepers of the health of the practice environment at the operating unit level.

There is a direct correlation between nurse manager ability to cultivate a healthy practice environment and lower RN absenteeism, higher engagement, and lower turnover. If a nurse manager has the time and the tools, the front-line nurse manager is uniquely positioned to detect and address RN intent to leave.

Resource library: The nurse manager portal

Supporting the nurse manager's role as the organization's "chief retention officer" is especially relevant in the post-pandemic environment, and yet, is harder now than ever before. Every effort must be made by organizations to address barriers to effective nurse manager practice as part of their RN workforce stabilization plan. 

Q: What one thing would you want executives to remember about RN intent to leave?

RN turnover is different than RN intent to leave. While C-suite leaders know that keeping requisite beds open is critical to ensure service access and system growth, I am concerned that RN intent to leave may be flying under leadership's radar in many systems.

Just because staff aren't leaving today doesn't mean you will have enough staff to keep beds open tomorrow. It is the responsibility of everyone on the leadership team to address the work environment, ensuring that RN intent to leave doesn't turn into increased RN turnover.