How can the healthcare providers improve retention of nurses and their job satisfaction?

How can the healthcare providers improve retention of nurses and their job satisfaction?

“By 2030 India will need 6 million nurses and the global demand of healthcare workers will rise up to 80 million

-World Bank

It has been quoted a zillion times that healthcare cannot survive without nurses yet we fight to hold on to the nurses in most organizations. We would need millions of nurses by the end of the decade but are we taking steps to resolve the issue?

It puts in immense pressure on healthcare management as well as it topples the healthcare team which struggles to train and fit members in their team with much effort.

Top Reasons why Nurses Leave

Staffing and Workload

Balancing the nursing matrix can give nightmares to not only the nurse leaders but the top leaders of an organization. But, the solution isn’t that easy. Staffing issues and high workload are reported to be the topmost reason why nurses chose to leave the job. It is a kind of a vicious cycle!

Workload is not easy to define. It can be multifaceted how we can classify workload for nurses.

Classification of work load

It could be workload at the unit level where the nurse-patient ratio is not right. Or it could be workload in terms of what type of job role a nurse has. For example, researches indicate that nurses who work in an ICU setting or emergency areas are prone to feel stressed due to the high workload and urgency of the situation.

Other patient level workloads may include ineffective communication which might result in a bad day for the nurse or lack of adequate stock supplies which might bother her/him as the work gets hindered. Situational workload might arrive unannounced many times even when a nurse is serving in so called ‘easy’ areas like wards (which are absolutely NOT). In fact, ward nurses might suffer from lack of supplies more frequently than ICUs and emergency areas counterparts which are rather luxurious in terms of supply. Every area where a nurse can possibly work has its own pros and cons.

You decide who is better off??

An ICU nurse who might not have to attend to patient attendants that frequently since communication protocols are well defined about how and when to pass the information, they are sorted. The nurse is assigned one or two patient at a time depending on the patient’s condition. But they deal with sicker patients, patient needs frequent monitoring and nurses hardly get a break to eat, hydrate or pee.

A ward nurse who has stable patients, who need no constant monitoring or need to be checked frequently and given medications only at routine intervals. The nurse is assigned four to six patients (sometimes even more) in one shift. She has additional responsibilities like attending rounds moving from room to room, attending to problems of patients and attendants, responding to call bells and list goes on…but something in common among ward and ICU nurses that is nurses hardly gets a break to eat, hydrate or pee.

So, here I have just put up two common scenarios but the challenges in other units where nurses work whether it is an OPD, diagnostics department or daycare, the problems are similar due to staffing issues which leads to increased workload.

Any comments yet about who is better the ICU ‘star’ or the ward ‘runner’?

Eventually in the hope of a better work environment, staffing or lesser workload nurses ‘Move’.

Job satisfaction

Simple it may sound, the word has multidimensional aspects to it. Job satisfaction has different definitions at different phases of work service. For example, a new nurse might not be satisfied with her/his job as she/he is unable to settle in, maybe she/he is not given much support or so-called ‘orientation’ or is overwhelmed as she/he is never seen such a setting before. I have personally interacted with many nurses who shared their concerns much later after the orientation phase. Some of them had never seen a ventilator machine before. Blame game won’t work, such people do enter the system.

Contrarily, if you talk to a senior nurse, who is in the middle management, the problems may emerge such as too much workload, carrier stagnation, issues with team members or work-life balance. So, ‘one size fit all’ approach might not work to sort the problems of nurses in general.

A study done in Coimbatore, India on nurses revealed that factors like age, nativity, support from family members, monthly income, place of stay, marital status, experience and tenure of job impacted the job satisfaction.

Pay and Benefits

As per May et al, increasing the wages to solve institutional workforce recruitment and retention problems is an easy-to-implement intervention in the short run. It can also not conclude about nurses’ outcomes such as nurse burnout, job dissatisfaction and intent to leave. Nurses in India still fight for wage difference between private and public sector.

Work-life imbalance

Missing in most of the professions of the world, nurses and health professionals were probably the first few, who were always pushed to boundaries to finish work or rather keep serving the patients without giving much thought about their personal lives. It is hard to maintain a work-life balance in healthcare as the demand-supply graph is skewed.

A new nurse is ‘utilized well’ by the supervisor in double shift many a time. And with monetary incentives, it is often compensated. But, these practices tend to take a toll on the patient and nurse herself/himself physically, mentally and socially. I came across nurses who would attend continuing nursing education programmes after night duties and I used to wonder what exactly are they going to learn from such sessions? So by doing so we are also shattering the individual need of a nurse to ‘learn or grow professionally’.

An experienced nurse, on the other hand, is caught up in a different direction. Though she/he may not be doing double shifts but she/he is made to stay longer sometimes to finish her/his assignments or to attend those management meetings which does not fit in her/his work timings and disturbs her/his family life.

Result in both case is frustration. It builds up and eventually leads to burnout where nurses no more care or they leave their jobs in the hope of a better work environment and culture. In this case, the role of nurse leaders and administrators is immense. Encouraging, appreciating the efforts as well as simple actions such as relieving the staff on time counts. So, think next time before you are keeping someone beyond their work time, everyone wants to go home!

Work environment

Initially, once a person settles in the job, it might appear to be a cakewalk but once you start interacting with the team, not only the nursing team but the others who contribute directly or indirectly in patient care like physicians, physiotherapist, nutritionist, ward assistants, they all start to matter. And these are significant factors that can make a nurse stay on the job.

A study by Duffield reported that a nursing manager who was perceived to be a good leader, was visible, and consulted staff, provided praise and recognition and offered flexible work schedules was a great factor found to distinguish the positive and negative working units. 

A survey by People element shows reasons, why people leave the job. Interestingly, ‘Staffing and workload’ tops the reason in each phase of tenure when the nurses leave the job.

Reason for leaving by tenure

Other reasons cited why nurses leave the job
  • Lack of role/job clarity
  • Not valued
  • No recognition or rewards
  • Lack of career opportunities

An Indian study highlighted the difference in job stressors that might impact the retention of nurses in the public and private sectors.

Private hospitals
  • Over duty and excessive timings
  • Feeling of exploitation
  • Low salary and slow increments
  • Heavy work pressures
  • Physical exertions with less or no breaks
Public hospitals
  • No recognition
  • Monotonous nature of job
  • Peer issues
  • Danger and legal exploitation by patients
  • Less technical knowledge leading to job dissatisfaction
The Big Question- How to retain Nurses?

The scenario in India is changing for better (at least in the government sector). The demand is everywhere. Nurses are better paid now and are also encouraged to progress professionally through in-service initiatives and sponsorship for career progression. But we need to catch up in private sector. The work wages are still shameful to even disclose and other factors like workload and overload remain prevalent in private sector.

So What can administrators do?

The problems are different so the solution will have to be set based on the need. Some steps can be taken by the management to make a stronger bond with the nursing task force.

Support Nurses

Support Nurses

Support to the nurses can come in many forms.

Welcome the new members- New nurses are often vulnerable due to lack of experience, newness to the settings in addition to the apprehension of what and how she is going to shine. Many hospitals follow a ‘mentor or buddy program’ that might help the new bees to settle in and orient them to the atmosphere. ‘Transition to Nursing Practice’ is what is being followed for safer practice and better adaptation of nursing students to transform into confident nurses. Below is a useful link to such practice.

Here is an excellent link that takes a nurse stepwise through a defined area where she/he might practice as a nurse.

Show that you ‘care’- This may reflect in the appraisal process and acknowledging the immediate efforts put in by the nurses.

Listen to them- Often nurses as a community feel that they are not heard. Here, the role of top leaders is to ensure that the nurse representatives and genuine, communicative and good problem solvers rather than the one who creates more hurdles for the group. Leaders can also encourage open sessions.

Positive work culture

Positive work culture

Work culture tremendously impacts whether a nurse stays or goes out of the system. The study by Cowden T, reflects that there is a positive relationship between transformational leadership, supportive work environments and staff nurses’ intentions to stay in their current positions.

Incentive to Stay

An organization can set examples with a different approach through monetary and non-monetary incentives they might offer to nurses.

1. Flexible timings-  As per Becker et al, nursing professionals are putting a demand of flexible timing due to varied reasons like aging nursing force, staff shortage and work-life balance. In such a case, chances of retention and staying back of experienced professionals are quite good.

A study with Flexibility!

  • The nursing staff expressed the desire for more flexible rostering and the opportunity to work 12-hour shifts.
  • After an agreement was reached between the hospital, the union and the Industrial Relations Board, guidelines were put in place and a Flexible Rostering System was proposed and trialed.
  • Initially, the trial was conducted for three months and extended to six months.
  • The shifts trialed were between 4- 12 hours in length with varied starting and finishing times.
  • The Flexible Rostering System was evaluated using feedback from staff surveys and the results of a staff vote.


  • Positive with over 80% of staff voting to implement the Flexible Rostering System permanently.
  • Reduction in sick leave by 41%.
  • Improved retention of skilled registered nursing staff.
  • Both patients and nurses commented on the improved continuity of care.
  • Salaries and wages were within budget.
  • Staff surveys showed positive feedback such as increased morale, increased flexibility with rosters, decreased fatigue levels, improved patient assessment on night duty and an increase in the number of days off.

2. Rules to protect nurses- with the massive number of cases coming to light every day about abuse against health professionals, administrators must work on stricter policies and rules to protect nurses. Several incidents have come to light and must be taken seriously. Usually, grievance policies are defined clearly but are the nurses aware? Make sure such policies are put to light clearly.

3. Clear job responsibilities- It might sound trivial but conflict might arise if the job roles are not defined properly. For example in many private set up ‘non-nursing tasks’ are defined and are taken over by the nursing assistants. But in India, we are yet to define them for the whole nursing community. It saves the precious time of a nurse and she/he can provide better quality patient care. As an administrator, poke your nose and know your nursing department inside out, to perform better as an organization. If you have a positive team of top and middle-level nursing managers who listen to their nursing team and communicate well with you, there is nothing better you can ask for.

4. Career opportunities- Often in government hospitals in India, a nurse can pursue her career further without losing her/his job but we hardly see such opportunities in the private sector. The same step might not be possible or practical but as an organization, encouragement to participate professionally or involve in conducting professional events like conferences, workshops might encourage nurses and allow them to showcase the work they do differently every day.

Fair Staffing

Fair staffing

The most difficult step and a daily headache for the middle-level nurse leaders is staffing. Listening to the demands and not giving into the pressure by a specific unit (just because the head of department is bossy) is the key ?. A strong headed nurse leader can only do that and that is why it becomes all the more important for the administrator to pick leaders wisely.

Continuing Education on Current Updates

A well informed and skilled nurse is motivated and happy to work. Allow innovative ways to come into the learning system. Often, we see nurses are pushed to attend classes due to many reasons like requirement of quality initiative, policy of the hospital to name a few but you might also find some units where nurses happily attend the sessions. So, plan the session as per the interest, area where they work and introduce something that is challenging to keep their interest from fading away. Try online learning methods which will allow them to learn at their own pace.

Other interesting ways of learning like role-playing, case analysis and skill review sessions for newer technologies can also be helpful. See the link to know more.

Click on the link below to see some inspiring ways to retain your nurses.


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2. Homburg V, Van der Heijden B, Valkenburg L. Why do nurses change jobs? An empirical study on determinants of specific nurses’ post-exit destinations. J Nurs Manag. 2013 Sep;21(6):817-26. doi: 10.1111/jonm.12142. Epub 2013 Aug 16.

3. Carayon P, Gurses AP. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville (MD): Agency for Healthcare Research and Quality (US); 2008 Apr.

4.  May JH, Bazzoli GJ, Gerland AM. Hospitals’ responses to nurse staffing shortages. Health Affairs. 2006;25(4):W316–W323.

5. Duffield, C., Roche, M. A., Blay, N., & Stasa, H. (2011). Nursing unit managers, staff retention and the work environment. Journal of Clinical Nursing, 20 (1-2), 23-33. doi: 10.1111/j.1365-2702.2010.03478.x

6. Kumar S. Nursing Turnover – A Vibrant Problem in Healthcare Management: Costs, Causes, & Solutions. International Journal of Information Technology & Systems. 2012 June 7. 1 (1).

7. Cowden T, Cummings G, Profetto-McGrath J. Leadership practices and staff nurses’ intent to stay: a systematic review. J Nurs Manag. 2011 May;19(4):461-77. doi: 10.1111/j.1365-2834.2011.01209.x.

8. Becker S, McCutcheon H and Hegney D (2010). Casualisation in the nursing workforce-the need to make it work. Australian Journal of Advanced Nursing, 28(1): 45-51.

9. Sullivan C, Reading S. Nursing shortages: let’s be flexible. Collegian. 2002 Oct;   9(4):24-8.

10. Lundberg K. Promoting self-confidence in clinical nursing students. Nurse Educ. 2008 Mar-Apr;33(2):86-9. doi: 10.1097/01.NNE.0000299512.78270.d0.

11. Rawal CN, Pardeshi S. Job Stress Causes Attrition among Nurses in Public and Private Hospitals. Journal of Nursing and Health Science. 2014 Mar0 Apr: 3 (2); 42-47.

Burnout among Nurses

Burnout among Nurses- Is it for Real?



“This is a disaster!” Mike said.

“May be you shouldn’t take your laughs so seriously” said Sully (Mike’s best friend)

“But – I- I mean, work has been-” Mike tried to explain that he took his jokes very seriously..

A story about the best laugh collector (Mike) inspired from the movie “Monsters, Inc.” The best laugh collector forgets how to laugh himself, taking his job too seriously, spending lesser time with family and friends. But thankfully he was confronted on time by his friends about what he was doing to himself.

Burnout is a term used very commonly to describe simply the amount of stress someone is undergoing these days. But is this phenomenon that simple? Is it same as stress? Read on to understand how burnout might spread across an organization if left untreated as any contagious disease. There are studies that indicate that if someone around you suffers from burnout, it is likely that you might get affected. In fact, a study indicated that nurses who reported highest prevalence of burnout among their colleagues were more likely to experience high level of burnout themselves.


Story of a highly competent Nurse

Ms. N graduated from a premier institution of the country where she got exposure to the best of the facilities, mentors and clinical exposure. She had learnt from the best and seen the most challenging cases. She graduated and joined a private hospital as an ICU nurse. Within months of her service she was assigned mostly the difficult cases and was often called on off days as she was one of the most competent nurses. Her unit was busy, working hours mostly exceeded and she sometime even skipped her break time to manage the patients. Over time, she developed back pain and suffered problems of GI track. At home, she would often eat unhealthy as she would feel exhausted all the time and was unable to cook. She would hardly go out or talk to anyone. As time passed she started to fall sick more frequently. One day she did a major medication error but patient was thankfully saved with timely intervention. She applied for a leave and did not return to work for a week. Later, it was found that she had locked herself in the house and did not interact with anyone including friends and family. She took quite a long time to join back.

Nursing Burnout not only impacts the nurses but also the patients and the organization for which they work. In fact, nurses who suffer from burnout are more likely to leave their jobs creating yet another reason for staff shortage which might create a vicious cycle of more nurses falling prey to burnout.

Is Stress same as Burnout?

Stress and Burnout are not the same. However, stress in combination with other factors might lead to burnout.

Stress is the response of body to any internal or external stimuli. Peculiar it might sound I am sure if you are health professional and reading this, you might have heard of ‘good stress’ or ‘Eustress’. As a student I was quite fascinated by this term and it is ingrained in my memory forever. Eustress is a positive response to perceived threat or stressor which is known to enhance once performance. The figure below explains simply how stress might affect an individual.


Stress level

As it is rightly pointed, burnout occurs as a result of too much stress and happens over a period of time. An individual if exposed to constant stress will eventually suffer from burnout.

What is Burnout syndrome?

Burnout syndrome is a prolonged response to chronic emotional and interpersonal stressors on the job. It affects an individual on physical, mental and emotional level. The term ‘syndrome’ is frequently attached rather than calling it simply burnout as the individual suffers from group of symptoms and burnout affects more than one system of the body.

The three dimensions of burnout

Maslach Burnout Inventory is often used to assess the level of burnout an individual is undergoing. As per this there are three important scales that can define burnout.

  • Emotional exhaustion- It refers to the feeling of being emotionally overextended and exhausted by one’s work. You must have come across someone around who is emotionally exhausted. For example a previously enthusiastic colleagues appears really dull, anxious or is easily irritable.
  • Depersonalization- It is the impersonal response of the individual towards patients/others. The person has callous or cynical attitude. For example blaming a patient for the disease or dropping an insensitive comments on colleagues.
  • Personal accomplishment- It is the feeling of competence and successful achievement in one’ work. The individual with sense of reduced personal accomplishments feels insufficient in terms of work he/she performs and has poor professional self-esteem.

Burnout syndrome is characterized by increased emotional exhaustion, increased depersonalization and reduced personal accomplishment.

Learn more about Stress and Burnout here:


Assess your burnout level with this burnout self- test here:

Risk factors of Burnout

Though burnout is mostly associated with work related stressors but personal attributes also impacts how prone a person is to burnout. Following are some of the risk factors associated with burnout.

  • Age- Age has been indicated to be associated with burnout. Some studies say that the burnout increased with age where as some say otherwise. Meta-analysis of studies indicate that age is inversely associated with burnout that is younger nurses are more likely to undergo burnout as compared to their older counterparts. Read more here:
  • Gender- Female nurses are more at risk of burnout as compared to male counterparts.
  • Marital status- Single or divorced individuals are at higher risk of burnout
  • Number of children- Having no children is found to be associated with higher risk of burnout
  • Level of education- Studies indicate that higher the level of education, more are the chances of an individual to suffer from burnout.
  • Work hours- Nurses’ job is often a difficult one, in terms of working hours. Sometimes, it is not even a choice for nurses to take double shift with staff shortage being an issue in healthcare. Nurses working in busy areas not only miss their breaks (which is required physically as well mentally) but also go overboard to extend work hours without even being paid for the extra hours.
  • Work setting- Challenging settings such as those nurses who work in emergency or ICUs are at higher risk of developing burnout.
  • Perfectionism- A nurse who is idealistic and is a perfectionist is at higher risk of burnout as such individuals are stressed if the work is not done as per their satisfaction.
  • Over commitment- Someone who takes commitments very seriously and goes beyond role definition can undergo emotional exhaustion and develop burnout more easily.
  • Work life balance- It is important to have work life balance to keep anyone sane. Often nurses witness a lot of disturbing things at work place which they do not wish to discuss at home. This could create a lot of stress as piling up things and not able to discuss with anyone about it.
  • Unhealthy copying strategies like alcohol or drugs- Use of alcohol, drugs or unhealthy eating habits like refined products not only impacts the physical health but also mentally. Drugs or alcohol can affect the way mind thinks and can lead to serious mental disorders.
  • Lack of support system outside work- Lack of support system can worsen the prognosis of burnout as the victims may not themselves understand how different they might start behaving.

Symptoms of nursing burnout

Know that if you have the following symptoms, you should stop and be aware that you might be heading towards burnout.

  • Social isolation- If you have decreased social interaction and go out less to see friends and family, stop and understand that it is important to socialize. Additionally, if you are loner there is chance that you could be an easy prey to burnout. Studies indicate whether it is on purpose or due to exhaustion, loneliness impacts psychological and physical health.
  • Sense of constant exhaustion- Nurses sleep cycle is often disturbed due to odd working hours and getting good sleep can be a problem. But if you observe that you have disturbed sleep pattern and you feel tired rather exhausted all the time, you might be falling victim to burnout.
  • Change in habits- Eating unhealthy, eating less or more than your usual self, trying to relieve stress by unhealthy habits on a regular basis, stop doing something which you use to love doing may indicate burnout.
  • Frequent sickness- Suffering from flues, stomach infection, back aches, headaches or inability to concentrate frequently indicates exhaustion.
  • Emotional instability- Being resistant to change, anxiety related to new changes at work, crying, being indifferent to patients or colleagues might be some of the responses of a nurse suffering from burnout.
  • Hate your job- While at some point of time all of us feel that we do not want to work if suffer a difficult situation. It is quite common to face such situations in healthcare. A nurse has to take a lot of human interaction which could be not so pleasant at times like explaining an anxious relative why his patient is not recovering or breaking bad news that a patient might never be able to walk again. But if you don’t like going to work and have this constant feeling every day what you are doing at this place reveals that you are stressed. There is less satisfaction, sense of achievement at work and more errors in patient care.
  • Work phobia- If you constantly feel anxious about going to work or keep thinking about it even if you are not on the job or you feel that you are no more confident doing your routine job assignments, you need to stop and re-think why is it so? Were happy going to work earlier and now you don’t? There is possibility of burnout creeping in.

How to prevent nursing burnout?

Nursing burnout is a serious problem of the nurse as well as the organization he/she works at, as burnout impacts the quality of care a nurse provides hence impacts patient outcome as well as the overall performance of an organization.


Nurse in stress

If you are a nurse, practice following simple techniques to prevent burnout.

1. Trust yourself- If you feel you need to stop and you are not feeling well, stop and re-think. Think about what you are doing and ask questions if you have started doing something differently lately. Call in for a mental break.

2. Listen to those who care- Friends and family are often the first ones to notice the change in you. Listen to them. Find a work buddy with whom you can talk about work.

3. Eat healthy and exercise- If you are exercising without the necessary nutrition in your body, it may lead to more weight gain and fatigue to the body. Include as many colors in your food from fruits, vegetable, legumes, grains and avoid refined products.

4. Take short breaks- At work stop when you are feeling overwhelmed. Go for short tea breaks and consider it a mental break. Think it as a break from work and enjoy the time. Make deliberate efforts to find some time for yourself especially if you are a workaholic. And instruct yourself not to think about work when you are on a break. It will help in two ways. One, you will not worry too much. And two, you will come back with a fresh mental frame and perform better.

5. Practice relaxation techniques- If you are not an avid yoga follower, try practicing simple breathing exercises when you are feeling stressed.

6. Pursue a hobby- Easy it may sound, a difficult one to do. Try pursuing what you like doing like reading a book, swimming, dancing or playing a sport. Physical activities are recommended as it freshens your mind by releasing happy hormones like endorphins.

7. Be assertive- If you think you are unable to work in a particular area as it is taking toll on your health and you feel you’re heading for a burnout, talk to your supervisor and request a change.

8. Job change- An extreme step but if your job is too demanding and with all the efforts you have put in if you are still uncomfortable in the environment you work, consider a job change. This is a drastic step but if you ignore it for too long it might cost you your health and career. I recently came across an article where a person who suffered from burnout decided to quit the job, she talked to others who left the organization before she did and they told her that it was brave of her to stay for so long. The employer had unrealistic expectation and caused a lot of stress to the employees. So, it may not be you, if the work load is too much to handle with interpersonal conflicts a grave problem, it isn’t a bad idea.

Responsibilities of employer to prevent nursing burnout

  • Set clear expectations from the nursing team.
  • Lack of reward, control, clarity of role and support in an organization cause emotional exhaustion and depersonalization in an employee. It is the responsibility of an employer to periodically interact with employees to understand the individual goals. In bigger organizations the supervisors must take care of those working under them. Supervisor must stand by the nurses working in the unit in terms or working conditions and resources available to them.
  • Acknowledge the contributions of the nurses periodically. It could be monetary or in terms of promotion, role change or an opportunity to grow such as through educational advancements.
  • Plan time outs for the team like picnics or arrange indoor games like table tennis or outside easy to play games like badminton.
  • Provide facilities that genuinely address the needs of the employees. For example majority of the nursing task force is still female. Arranging a crèche facility for the nurses’ children. It will keep them stress free as they can reach their children not so far away. Many multinational companies and certain hospitals have tied up with crèche facilities that are subsidized for the employees.


glass filled with water


I will end this topic with the famous expression about the glass filled with water. Oh no, not talking about how you look at the glass, half empty or half full that tells how optimistic you are.

If the glass is half full (which shouldn’t be that heavy) but you keep holding it for hours, what will happen?

Your hand will start to ache… And if you hold the glass for days?

The hand will be numb and you will feel paralyzed.

Stress is like holding a glass of water. If you keep holding it, the end result is burnout…

So don’t carry it around, remember to put the glass down!


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