A Lean Guy Reads “Health Leaders” on Nursing Retention and Leadership


Here's the latest in an occasional ongoing series I call “A Lean Guy Reads ________”.

Today, I'm reading the latest issue of Health Leaders magazine (March/April 2019) whose cover features a number of stories about nursing retention.

The lead article shares some data about recruitment and retention. The article says that 17% of “newly licensed RNs” leave their first nursing job “within the first year.” 33% leave within two years.

Instead of blaming nurses for leaving, better organizations are looking in the mirror to see what they can do to improve the work environment. That's always been one of my primary motivations for Lean in any workplace — providing a better, more fulfilling work setting.

The article cites a number that says “the average cost of turnover for a bedside nurse” is $38,000 to $61,000. The average turnover rate for hospital nurses was 16.8% in 2017.

High nurse turnover causes problems with patient safety, quality of care, and patient satisfaction. But, it's important to note we're not blaming the nurses (or we shouldn't be). You can't fault a nurse who is leaving for what they hope is a better working environment. Leaders need to improve the system in a way that helps nurses choose to stay.

I've sometimes heard leaders complain about nurses who will leave for a competing hospital for “50 cents an hour more.” Is it really all about the hourly wage? Would the nurses want to leave if they were happy, engaged, and fulfilled in their current workplace?

As the HealthLeaders editor's letter says, we need less talk, more action.

The magazine has some stories about leaders taking action and getting better results from it. It's helpful to understand the problem and some of the causes, rather than just jumping to solutions.


I'm not sure this analysis goes quite deep enough:

Dissatisfaction with the work environment was the most commonly cited reason for leaving,” Dempsey says.”

OK, so WHY are they dissatisfied with the work environment?

What helps them want to stay? For nurses with less experience, it's:

“…praise, recognition, nurse manager support, certification, and joy in work,”

And for nurses with 20+ years of experience, it's:

“…leadership, influence over their schedule, and quality of care.”

I agree there's no magic answer, any more than there is a single root cause:

“According to the 2018 Press Ganey Nursing Special Report: Optimizing the Nursing Workforce: Key Drivers of Intent to Stay for Newly Licensed and Experienced Nurses, there's not one magic answer to that question.”

The study again calls for better leadership:

“We need to make sure there is strong managerial support for those units, efficient processes, and that we keep those nurses at the bedside.”

It's probably not a matter of efficient for efficiency's sake… when we reduce waste and make work easier for nurses (reducing overburden), then they are able to provide better care and service to patients. I'm sure that's a bigger satisfier than efficiency alone.

How can leaders create a better environment?

“…top-performing managers spend a large proportion of their time creating foundations for quality of care. That meant that they were visible through rounding. They trained nurses to lead clinical rounds. They developed shared governance structures led by direct care nurses. They use data to support decisions and drive practice. They involve direct care nurses in decisions involving the unit and staffing, and they promoted autonomy.

And those are some of the ways that high-performing nurse managers create a positive work environment.”

That all sounds like Lean leadership to me.


The article first features Rush Oak Park Hospital, located in Oak Park, Illinois. Their nurse turnover rate was 22% to 24% in various departments (which is higher than the national average of about 17%).

The Chief Nursing Officer realized she needed to change the culture. The current state sounded like the old, traditional General Motors culture of 1995 when I started working there.

“When you have bad outcomes, and leadership is beating you up and telling you how bad you are, as a staff nurse–even if you are a great nurse–you feel hopeless because nobody wants to work in an environment where they feel like they're providing bad care,” Mayer says. “There were excellent, excellent nurses working here, yet the punitive environment resulted in a lack of respect [toward nurses] by physicians [and] administrators, and from nurse to nurse.” 

Blaming individuals for the bad outcomes that result from systemic problems is NOT a pathway to employee engagement, low turnover, and great quality. In extreme situations, nurses are sadly being prosecuted for being involved in what's clearly systemic errors. I agree with what the ISMP writes about the Rodona Vaught case.

Now, back to Rush Oak Park, their turnover rates are about 8%, or half the national average.

As I saw during my time at General Motors, a new leader (in my case, a new plant manager who had been trained by Toyota) made all the difference in the world. The old leadership blamed workers for systemic problems. The new leader told everybody that the days of blame were over — we were going to work together to improve.

One of the things the CNO had to do was coach up other leaders:

“…coaching managers who weren't familiar with a collaborative leadership style.”

This was a real challenge at GM. The new plant manager still had managers under him who had decades of experience in the old system. People don't change overnight.

I hope that we'll see more hospitals shift away from the old culture of “naming, blaming, and shaming.” Nurses need better and patients deserve better…

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Mark Graban
Mark Graban is an internationally-recognized consultant, author, and professional speaker, and podcaster with experience in healthcare, manufacturing, and startups. Mark's new book is The Mistakes That Make Us: Cultivating a Culture of Learning and Innovation. He is also the author of Measures of Success: React Less, Lead Better, Improve More, the Shingo Award-winning books Lean Hospitals and Healthcare Kaizen, and the anthology Practicing Lean. Mark is also a Senior Advisor to the technology company KaiNexus.


  1. Mark, thanks for hitting an important topic, and timely given the news this morning about NY hospitals and their Nurses union reaching agreement on staffing. Can you provide any more details about the Rush Oak Park case, what they did and over what time, to achieve such a dramatic reduction in attrition? We are similarly challenged here as well at Franciscan Children’s, and would love to know what is working. The story if I’ve read it correctly is a new CNO leader joined, and started changing the culture from blame to collaboration and engagement. How long did this take?


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