The importance of strong leadership for retaining nurses
EONS President Elect Lena Sharp describes how poor leadership is a known ‘risk factor’ which can influence nurses’ decision to leave their role and examines how can this be addressed
As we know, nurses are the largest group within the healthcare workforce. They play a central role in the multidisciplinary team and are heavily relied upon to expand their expertise and extend their input at this time of increased cancer rates, more complex treatments and growing numbers of cancer survivors. At the same time, nurse turnover is a growing problem which impacts continuity, quality, safety and the economy, and a shortage of nurses is a core reason for closed units and beds and delayed treatments.1
Across Europe, the same crisis issues are being identified:
- A large number of open nursing positions in hospitals
- Difficulty hiring nurses to supervise clinical staff and to perform higher-level duties
- Not being able to offer higher salaries to attract qualified candidates
- High levels of migration and mobility2
It is clear that within this context the turnover issue within the nursing profession is a serious one, and the economic implications are clear: the cost of losing one bedside nurse is twice the nurse’s annual wages, and the average hospital is estimated to lose $300,000- $379,500- per year for each % increase in annual nurse turnover.3
Within this worrying landscape of nurse shortages, poor leadership is a known ‘risk factor’ which can influence nurses’ decision to leave. So how can this be addressed? A key to reducing turnover is to detect early signs of intention to leave, and here leadership plays its part. Although the correlation between intention to leave and leadership is not yet fully established, researchers Coomber and Barriball4 concluded that leadership issues do influence a nurse’s intention to leave more than individual factors.
A recent ‘Intention to leave’ study5 carried out in 80 hospitals across Sweden, involving 7,412 registered nurses (RNs) produced some telling, and troubling, results. It found that one third of RNs intended to leave their workplace within the next year. The most prevalent factors among RNs were:
- Unhappy with leadership
- Worked ≤ 2 years
- Didn’t have enough education
- Higher burnout scores
To drill down a little further, the results showed:
- RNs in specialised cancer care (SCC) tend to consider switching to other nursing jobs, while RNs in general cancer care (GCC) tend to consider leaving the profession.
- RNs with lower burnout scores and more experienced RNs were more likely to report an intention to leave if they were unhappy with the leadership.
- A stronger association between leadership and intention to leave was detected among those who perceived that they had adequate cancer care education.
In other words, poor leadership was more often the reason more experienced cancer nurses intended to leave. Further, both nurses working in SSGs and GCCs who disagreed with the statement ‘The supervisory staff is supportive of nurses’ were at an almost threefold higher risk of reporting an intention to leave.
So, we can now conclude that the perception of leadership is strongly associated with intention to leave among nurses in both specialised and general cancer care; and, that the most experienced and qualified cancer nurses may be difficult to retain at a workplace with poor leadership.
How then, do we improve leadership to reduce intention to leave and nursing turnover?
Following the findings of the Swedish study, some suggestions were made for improvements and possible solutions that could have an impact on retention of nurses:
- A supervisory staff that is supportive of nurses
- Recognise the difficult tasks cancer nurses have
- Leaders must focus on better working conditions for nurses since it has a direct positive impact on patient satisfaction, safety, turnover
- Nursing management from bedside to boardroom! Nurse leaders need to develop effective strategies and implement these to improve the working conditions for the nursing workforce. These could include:
- Introduction programmes
- Work flow and guidelines
- Enough supporting staff
- Career pathways
- Mentor programmes
- A nurse manager who is a good manager and leader
- Speak up for nurses all the time, even when not asked!
- Balance between individual staff preferences and the overarching responsibility for safe, high quality cancer care and development for the future
- Sometimes choose long-term solutions that may have negative short-term effects
- Push students and nurses to take responsibility for their personal and professional growth
- Continuing education
- Seeking opportunities to develop
- Continue to develop their professional identity
- Exercise their leadership skills
- Praise and recognition for a job well done
- Contructive feedback, positive and negative
- Nursing leaders need to meet (but not necessarily care for) patients
- Never abandon the patients’ perspective
- A nurse manager who backs up the nursing staff in decision making, even if the conflict is with a physician
- Create autonomy for nurses
- Promote and reward multi-professional initiatives
- Avoid the ‘Doctor-Nurse- game’ (Poor physician-nurse communication creates big problems in cancer care: poor quality of care, patient safety risks, staff turnover, sick leave, stress, costs6)
- Management that listens and responds to employee concerns
- Coffee table talk’
- Be seen
- Change opinion, if needed
- ‘Walkarounds’ can improve safety culture and reduce the risk of burnout7
So, we can finally begin to answer the all-important question – What can healthcare organisations do to reduce nursing turnover rates? The following approaches would make a real difference:
- Actively support nurses and nurse managers
- Recognise cancer nursing as a specialty
- Pay attention to the impact of cancer nursing
- Open the door to the executive boardrooms!
- Develop Magnet Hospitals
Encourage more nursing researchers and Masters-prepared nurses to take on leadership positions in healthcare; today many nursing researchers work exclusively at universities.
Cultural factors – stop talking about nurses as angels
There are wider cultural changes that will make a difference too. Nurses need to be respected and treated like professionals. We need to stop talking about nurses as angels and instead recognise the critical contribution they make to better patient outcomes; fewer complications, lower mortality rates, patient safety and satisfaction. A WHO report in 2016, Triple impact of nursing, noted the virtuous circle arising from the contribution of nurses – “Strengthening nursing will have the triple impact of improving health, promoting gender equality and supporting economic growth” – but it also acknowledged that, paradoxically, nurses are ‘too often undervalued and their contribution underestimated’.
The ongoing ‘Recognising the value of cancer nursing’ (RECaN) project, set up by ECCO and led by EONS, should have a major influence in helping to make this shift happen: RECAN’s goal is to encourage the recognition of cancer nursing across Europe. It will make policy makers aware of the impact of cancer nursing on patients’ experiences and outcomes across the whole spectrum of cancer. This will be a big step towards helping improve the status, and leadership, of cancer nursing and, subsequently, to addressing the problem of nurse turnover.
Lena Sharp is Head of Cancer Care Improvement, at the Regional Cancer Centre, Stockholm-Gotland, Sweden. She is also EONS President Elect.