The landmark Institute of Medicine Future of Nursing report predicted a significant nursing shortage by 2020,1 but no one predicted the effect of a coincidental global pandemic, COVID-19. When factoring in the increased need for nurses with the retirement of the baby boomer generation and nurses leaving the profession for other careers, the estimated openings of registered nurses (RNs) each year through 2029 is 175,900.2

Nationally, the RN turnover rate increased from 18.7% in 2020 to 27.1% in 2021, with a vacancy rate that has increased in 1 year from 9.9% in 2020 to 17.0% in 2021. In the past 5 years, the average hospital has turned over 95.7% of its RN workforce.3 When coupled with the availability of lucrative travel contracts, the stability of nurse staffing was devastated. Currently, 22% of nurses providing direct patient care indicate an intention to leave their job within the next year, with insufficient staffing levels and intensity of workload cited as the top reasons nurses are leaving their positions.4

In 2021, a quaternary inner-city academic medical center in southwestern Pennsylvania experienced nursing turnover rates of 36.1% and an overall vacancy rate of 34.5%, potentially costing the organization $9,167,340 per year. Nursing turnover significantly impacted patient flow, nurse workload, nurse satisfaction, and hospital finances. To address rising turnover, nursing leadership elected to implement a stay interview process to provide an opportunity to prevent turnover with targeted interventions based on interview findings. Before this project, stay interviews were not utilized as a retention strategy at this hospital. To a large extent, nurse leaders are held accountable for nurse satisfaction and turnover. The Advisory Board, a company that identifies healthcare challenges and actionable strategies, went so far as to identify nurse managers as Chief Retention Officers.5 Even in the face of a tumultuous healthcare environment, nurse leaders must continue to be innovative and creative with RN retention strategies. One measure that has been cited as a retention strategy is the stay interview, although only 30% of all nonprofits routinely use them.6

Literature Review

Stay interviews, also called retention interviews, are specific, planned, and structured conversations between the leader and the staff member and can be used both inside and outside healthcare.7 An effective stay interview includes a manager asking standardized questions in a casual and conversational way.8 Finnegan7 recommends using 5 questions or less focused on what the employee enjoys in their daily duties and tasks, what they value most about their job, if they have thought about leaving and why, and what can be done to make it better for the employee. The interview should be completed in a nonargumentative, nondefensive, and safe space so the RNs feel comfortable answering the questions.9

The interview should take no longer than 20 minutes and should not be associated with performance appraisals.7,9 Robeano9 suggested avoiding yes or no questions in the interview, practicing active listening, being honest, and working with the team member on solutions. The discussion should be collaborative and solution driven.10 Although 3 articles noted that the focus of stay interviews should be top performers,6,9,11 Finnegan7 encouraged the participation of all employees to prevent those not included from feeling left out and undervalued, resulting in a greater risk of turnover.

Stay interviews provide leaders with actionable feedback that can be used to improve satisfaction and engagement.6 One misconception is that the human resources department controls most of the things that are dissatisfiers for staff, for example, unit culture, but many aspects are within the leader's control.11 Poor leadership is a reported cause of 60% of employee turnover; thus, leaders play a critical role in engagement.7 Stay interviews can strengthen engagement and convey to team members that they are highly valued.6 After the stay interview, leaders can create individualized or team-based retention plans and forge new relationships with employees on an individual basis. Follow-up can be done, based on what matters most to the nurses both individually and in aggregate.8

Most of the literature on stay interviews comes from sectors outside of healthcare. Lancaster10 implemented stay interviews in a food service business, resulting in retaining 3 of 5 employees considering leaving. Three articles noted the use of stay interviews in healthcare8,9,12 and 2 provided reports of implementation and metrics.10,12 Duru and Hammoud13 completed a qualitative study of 6 senior healthcare leaders to explore strategies to retain frontline nurses. One leader reported conducting stay interviews to maintain a direct relationship with the frontline staff and anticipate issues that might lead to disengagement.

Zallman et al12 used stay interviews as an intervention to improve communication, build relationships, deepen relational trust, and improve engagement. Two physician leaders completed stay interviews with 33 physicians from 1 department.12 Evaluations from 18 (55%) participants reported that the experience made them feel valued and better understood, resulting in a decrease in voluntary turnover by 4%. Participants thought the stay interviews were worth their time and would recommend that others participate. In addition, the 2 leaders who conducted the interviews found the process motivating and insightful.12

Robeano9 described stay interviews as a nurse retention strategy. Nurse satisfaction and retention are directly linked to the relationships that nurses build with their direct leaders, and the leader's ability to identify and address their needs as well as the perceived level of communication from the leader to employees.9 Recommendations from the literature are that the interview is performed at least annually during a 1-on-1 meeting with well-defined questions guiding the discussion.9 The ultimate goal of the interview is to identify what motivates and frustrates the nurse and identify creative solutions for issues.

Specific Aims

The purpose of this quality improvement (QI) project was to develop, implement, and evaluate a process of stay interviews for nurse leaders to provide information to engage and retain nurses.

Methods

The project was implemented in a 524-bed quaternary academic medical center, the flagship hospital for a network of 14 hospitals. This hospital is a level 1 trauma center that specializes in the care of critically ill patients. The hospital employs more than 1,100 RNs and utilizes a shared governance model of professional practice; thus, the process of stay interviews supported information from direct care providers to leadership. Despite numerous efforts to engage and retain nurses, including senior leader rounding, quarterly check-ins, professional development plans, and breakfast and lunch with leadership, RN turnover continued to increase at an alarming rate and was a significant concern for leaders.

The 1st step in implementing the project was the formation of a stay interview team. The stakeholders included the chief nursing officer, directors of nursing, nurse managers, assistant nurse managers (ANMs), frontline RNs, finance leaders, senior leaders, professional practice and education leaders, and the network turnover and retention committee. From the group of stakeholders, the project leader formed a project team consisting of the 3 directors of nursing, the nurse manager of the floor, the 2 ANMs of the units, a frontline nurse, and the director of professional practice and education. The team was responsible for developing, implementing, and evaluating the project. The team met regularly during the project.

The project leader conducted a gap analysis between evidence-based best practices and current practices and reviewed the results with the stay interview team for consensus and feedback. Preimplementation information that could be gathered during a stay interview, such as the number of nurses who had or were considering leaving, was not collected or collated. The hospital had a strategy for quarterly check-in meetings with frontline staff, a stoplight communication tool, and a functional operational excellence (OE) communication board that was consistently utilized. The OE board was utilized to communicate quality, safety, and patient experience information and initiatives or interventions that were in process. The units used the stoplight tool for communicating about changes or initiatives underway based on staff feedback (SDC 1, STOPLIGHT Tool Template, https://links.lww.com/JONA/A989). The tools maintain a connection and interaction between leaders and RNs facilitating a better work environment.13

Based on the high turnover, the team selected 2 units of the hospital, a 24-bed cardiothoracic (CT) telemetry unit and a 24-bed CT surgical intensive care unit (CTSICU), for the project. The leadership team of 1 manager and 2 assistants were engaged to participate. At the start of the project, the turnover rate in the CT telemetry unit was 28.7% and the CTSICU was 32.4%. Of note, in the CTSICU, 47 nurses left for lucrative travel contracts during the pandemic and 4 nurses decreased to casual status, working minimally while accepting a travel assignment.

Interventions

Within the team, rigorous discussion about what evidenced-based questions should be utilized to get the most accurate and beneficial response from the RNs resulted in the identification of 5 stay interview questions (Table 1). The questions were structured to be consistent, and all RNs were asked the same questions. The team developed an electronic tool to anonymously record the interview results, which could be done during or after the interview. The tool included 5 interview questions and 3 demographic questions. To ensure sustainability, the team targeted the stay interviews to be no longer than a 20- to 30-minute quarterly check-in. The team attempted to anticipate possible answers to the questions and provide a drop-down menu in the tool, but each question also had a free-text option. The last question in the tool was for the interviewer to supply the length of time taken to complete the survey.

Table 1 - Stay Interview Questions Demographic questions  1. Unit  2. Years of service at Hospital <1 yr 1-3 yrs 4-7 yrs 8-10 yrs 11-20 yrs 21-30 yrs 31-40 yrs >40 yrs  3. Level of education Diploma Associate Bachelor's Master's Doctorate Other: Stay interview questions  4. What do you typically look forward to each day in your current nursing practice?  5. Why do you stay in your current position?  6. How likely is it that you would recommend our hospital as a place to work to a friend or colleague? 1 being would definitely not recommend and 10 being would definitely recommend. 1 2 3 4 5 6 7 8 9 10  7. If you ever considered leaving us, what prompted it?  8. Based on the previous question and your answers do you have any suggestions for improvement?  9. How long did it take you to complete the interview?   a. <10 minutes   b. 11-20 minutes   c. 21-30 minutes   d. >30 minutes

Assisting leaders in achieving the goals of completing the interview in a nonargumentative and nondefensive way, the team created a toolkit that included a stay interview question guide (SDC 2, Stay Interview Question-Answer Guide, https://links.lww.com/JONA/A990), body language tip sheet, avoiding interview pitfalls tip sheet, stoplight tool template, and a QR code and web link to the electronic data collection tool. Once the tools were developed, team members educated the nurse leaders on the importance of stay interviews, the implementation process, the electronic tool, and the toolkit components. It was reinforced with nurse leaders to add any group interventions identified as part of the stay interviews to the stoplight tool, with green representing that the work was complete, yellow indicating work in progress, and red meaning that the work was not started or could not be accomplished because of organizational constraints. The stoplight was added to the unit OE board (SDC 3, OE Board Template, https://links.lww.com/JONA/A991), which was housed in a prominent place on the unit and available to all staff, and items can be escalated to senior leaders as needed.

After the education, the nurse manager and the assistant managers of the selected units conducted 1-on-1 stay interviews over a 4-week period from April to May 2022, with the inpatient staff nurses during a normally scheduled quarterly check-in meeting. The only nurse excluded were 2 nurses on leave of absence.

Measures

The outcome measures utilized for this project were RN turnover, calculated as an annualized percentage, and RN satisfaction as measured by the National Database of Nurse Quality Indicators survey results from April 2021 compared with May 2022. The project goal was to decrease nursing turnover by 2% and increase the mean practice environment score by 0.2. Process measures were survey completion, survey efficiency, and RN engagement measured by the Gallup Core Behaviors in March 2021 compared with April 2022. The scores were derived from the 5 pulse questions on the Gallup survey. The interview completion was the percentage of stay interviews completed and the efficiency was the number of interviews completed within 20 minutes. The goal for both metrics was 80%. Data analysis incorporated descriptive statistics for all metrics with the use of percentages and means. The project was reviewed by the hospital's research council and network internal review board; it was deemed as a QI project.

Results

Demographic findings revealed that 32.0% (n = 24) of the RNs had less than a year of service on these units and 34.7% (n = 26) had 11 years or more of service. Most (69.3%, n = 52) had a bachelor's degree or higher education. During a 4-week period, the nursing leaders performed stay interviews with 97.4% (75/77) of their bedside RNs with 88.0% (n = 66) within 20 minutes or less. The managers were able to capture 100% (75/75) available RNs and complete stay interviews with them, exceeding the project goal of 80% completion. The RN engagement on the Gallup Core Behaviors Pulse Survey showed a slight improvement in 3 of the 5 questions.

RN turnover increased year over year from prepandemic to current year-to-date 2022 in the hospital and on both units. Hospital RN turnover increased from 24.0% in 2021 to 36.1% in 2022. The CT telemetry unit increased from 28.7% in 2021 to 41.9% in 2022, and CTSICU increased from 32.4% in 2021 to 60.8% in 2022. These increases did not meet the project goal of decreasing turnover by 2%, but causation for turnover could not be identified based on the influence of market factors and the ongoing pandemic. For RN satisfaction, the mean practice score on both units increased. The CT telemetry unit increased from 2.37 in 2021 to 2.87 in 2022; the CTSICU increased from 2.85 to 3.36, exceeding the project goal of a 0.2 mean score increase.

Each interview question was analyzed both as a total and by unit, giving the ability to look for trends and themes. The analysis revealed some common themes from the interviews. The top 3 reasons RNs look forward to each day in their current practice are their team/peers, learning something new, and patient acuity/skills (Figure 1). The top 3 reasons RNs stay in their current position are unit culture, team/peers, and schedule (Figure 2). When asked about the likelihood of recommending the hospital to a friend or colleague, 81.6% reported they were extremely likely or somewhat likely to recommend it. Unfortunately, approximately 85.3% of the RNs had considered leaving, and the top 3 reasons why were salary, professional growth/development, and travel (Figure 3).

Figure 1:

What RNs look forward to in current practice.

Figure 2:

Why RNs stay in current position.

Figure 3:

Percentage of RNs who considered leaving and what prompted it.

Discussion Summary

In this project, stay interviews were a promising retention strategy that provided information about what keeps nurses at the hospital. As recommended by others in the literature,7,9 most interviews lasted less than 20 minutes. Nurse managers reported that the nurses were willing and engaged in the process, excited that the leaders were capturing information regarding what was important to them, and using the information for retention strategy development.

Improvement in engagement scores was mixed with 3 questions improving and 2 decreasing slightly. In the current staffing climate, this was not surprising as the daily struggles present challenges for bedside providers. The goal of decreasing the RN turnover by 2% was not met, perhaps because of the unexpectedly high travel rates available in the local market. This metric will be tracked over time as stay interviews are implemented throughout the hospital. Nurse satisfaction increased above the 0.2 project goal in the mean practice environment score on both units. This finding is encouraging. Since staffing had reached crisis levels, many initiatives were running simultaneously, and it was difficult to ascertain the impact that any single intervention, such as a stay interview or the data obtained within, had overall. However, the initial findings are promising, and the intent is to expand this intervention at this hospital.

The importance of the local unit culture was evident in examining the responses. The telemetry nurses enjoyed coming to work each day to help people, make a difference, and patient care. The CTSICU was focused on team/peers, learning something new, and acuity/skills. No one on either unit stayed because of senior leadership, shared governance, benefits, or recognition/appreciation. When comparing the reasons why nurses considered leaving, they mirrored the reasons of nurses who terminated employment: salary, professional growth and development, and travel. This finding emphasizes the importance of understanding what motivates nurses to stay in their positions.

Although stay interviews were not historically used in healthcare, the recent staffing crisis since the pandemic began has resulted in interest in borrowing from successes in other professions. Interest in stay interviews is increasing. As an example, for the literature review before this project, only 3 articles about stay interviews in healthcare were identified.8,9,12 In the first 6 months of 2022, 3 articles about stay interviews in healthcare were published.14-16 In most publications, long-term results were not measured or available, but the immediate benefits of stay interviews are reported as positive. As the project is expanded to other units, the team plans to refine the dropdown menus based on the answers received in this project. The team is preparing a scripted introduction to the interview and examples of answers to difficult questions from staff. The team plans to include videos of stay interviews and role-playing in the nurse leader education. To capture the results of the interviews and subsequent interventions and follow-up, the team has created a stay forecasting sheet for managers to complete postinterview. If these work additional items are implemented, it will be unclear if these interventions are more or less effective than the original toolkit and education.

Limitations

A limitation of the project was that it was completed on 2 units in 1 hospital, the sample is small, and the findings are not generalizable. Also, there was an inability to discern if nurses were forthright in their discussions with their managers. To maximize the chances for honest communication, managers were educated regarding how to conduct a non-judgmental stay interview; however, in the future addressing interrater reliability and bias is advised.

Conclusions

Frontline RN turnover affects patient flow and RN satisfaction, and the cost to hospitals is unknown and, in most cases, underestimated. Stay interviews are a feasible and effective strategy to open conversations and engage with staff about why they stay or why they may leave and create individualized and group strategies based on the results to support retention. The information gleaned from these interviews can be utilized to improve the current practice environment and entice RNs completing travel contracts to become permanent employees. With staffing at unprecedented crisis levels in this and many organizations, leaders must engage staff and listen to their opinions, concerns, and what matters most to them. Stay interviews are a positive, informative, and effective venue to enhance engagement, retain nurses, and address practice environment concerns.