University of Southern California Dissertations and Theses

Don’t leave: a safety net hospital’s response to retain nurses during a nursing shortage

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Don’t leave: a safety net hospital’s response to retain nurses during a nursing shortage

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Content 1
Don’t Leave: A Safety Net Hospital’s Response to Retain Nurses During a Nursing Shortage
By
Katherine Hollman
A Dissertation Presented to the
FACULTY OF THE USC ROSSIER SCHOOL OF EDUCATION
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the
Requirements for the Degree
DOCTOR OF EDUCATION
May 2024
Copyright 2023 Katherine Hollman

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Acknowledgements
A special thank you to my dissertation committee – Dr. Cathy Krop, my chair, Dr.
Douglas Lynch, and Dr. Bessie Young for your time, expertise, and guidance at every stage of
the research study. To my study group, Dr. C, Dr. L, Dr. S, and Dr. T – WE DID IT!!!! I never
expected the support, love and friendship gained from this program. I look forward to many
adventures and more tea with the EdDs. To my colleagues, thank you for participating in this
study and supporting me throughout this journey. Last but not least, thank you to my people! To
my family, your unconditional love and support are always with me in whatever I pursue. I’m
forever grateful for every one of you. To my friends, near and far, without your tremendous
understanding and encouragement these past few years, it would’ve been impossible for me to
complete my study. Thank you!

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Table of Contents
List of Tables 4
List of Figures 5
Abstract 6
Chapter One: Introduction to the Study 7
Background of the Problem 9
Organization Context and Mission 13
Purpose of the Study and Research Questions 15
Importance of the Study 15
Overview of Theoretical Framework and Methodology 16
Definitions 17
Organization of the Dissertation 18
Chapter Two: Literature Review 19
Healthcare Workforce: Challenge and Opportunities 19
Global Healthcare Workforce Shortage 19
Great Resignation in Healthcare Workers 21
Impact to Staffing Shortages 22
Health Outcomes 23
Safety Net Hospitals and Health Equity 24
Financial Burden 26
Nurse Retention Factors and Strategies 28
Factors Contributing to Nurse Turnover 28
Factors Contributing to Nurse Retention 31
Conceptual Framework 33
Summary 41
Chapter Three: Methodology 42
Overview of the Methodology 42
Data Sources 44
Ethics 50
The Researcher 52
Chapter Four: Findings 53
Participants 54
Findings Organized by Theme 59
Summary of Findings 77
Chapter Five: Discussion and Recommendations 79
Discussion of Findings 80
Recommendations for Practice 87
Limitations and Delimitations 94
Recommendations for Future Research 95
Conclusions 97
References 99
Appendix A: Survey Protocol 118
Appendix B: Interview Protocol 124

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List of Tables (Double-Spaced)
Table 1: Factors Contributing to Nurse Turnover 30
Table 2: Factors Contributing to Nurse Retention 32
Table 3: Data Sources Linked to Research Question 42
Table 4: Survey Participants Demographics - Nursing Experience and Education 54
Table 5: Survey Participants Demographics 55
Table 6 Interview Participants 56
Table 7: Thematic Findings 59
Table 8: Importance and Presence of Factors Associated With Nurse Retention 66
Table 9: Participants Perception of Changes in the Healthcare Workforce 69
Table 10: Participant Feedback on Changes in the Healthcare Workforce 71
Table 11: Leadership Reflection on the Impact of Pay Adjustments 75
Table 12: Evidence Based Recommendations for Practice 88

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List of Figures (Double-Spaced)
Figure 1: National Institute of Minority Health Research Framework 6
Figure 2: Job Opening Rates in Healthcare 12
Figure 3: Burke Litwin Organizational Performance and Change Model (BIOPCM) 34
Figure 4: BIOPCM: Transformational Factors 35
Figure 5: BIOPCM: Transactional Factors 37
Figure 6: Conceptual Framework for this Study 39
Figure 7: Supervisory vs Nonsupervisory Responses 60
Figure 8: Importance of the Mission on Nurse Retention - 0-10 years of experience 63
Figure 9: Importance of the Mission on Nurse Retention - 10 plus years of experience 63

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Abstract
This study examined nurse retention in a safety net hospital and how the hospital
responded to a nursing shortage exacerbated by workforce changes related to the global
pandemic and the Great Resignation in order to fulfill their mission. This study utilized a mixed
methods design to examine how events in the external environment, including the coronavirus
pandemic and the Great Resignation, influenced nurses’ decisions to stay at a safety net hospital,
the hospital’s ability to fulfill its mission, and internal changes to the organizations’ systems,
processes, and policies to address nurse retention. This analysis identified four main themes. (1)
Mission of the organization is the most significant organizational factor influencing nurse
retention and the most significant organizational barrier. (2) Sufficient and competent staff are
the most significant work unit factors influencing nurse retention. (3) Influx of newer, younger,
and greener nurses have helped to stabilize the nursing workforce but have also led to
underserving the patient population in safety net hospitals. (4) Effective retention strategies were
aimed at the organizational culture and individual needs or wants of nurses. The study findings
suggest that safety-net hospitals have the opportunity to use their mission as a competitive
advantage for recruitment and retention. Safety net hospitals can use evidence-based
recommendations including alternative care models, nurse residency programs, and virtual care
nurses to increase nurse retention and fulfill the mission of the organization.

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Chapter One: Introduction to the Study
At a Chicago press conference in March of 1966, before the convention on the Medical
Committee of Human Rights, Dr. Martin Luther King Jr. stated, “Of all the forms of inequality,
injustice in health is the most shocking and most inhuman because it often results in physical
death” (Galarneau, 2016). Activists, scholars, historians, and practitioners have routinely referred
to Dr. Martin Luther King’s powerful statement to raise awareness of health disparities within
the United States (U.S) and drawn alignment to efforts within the civil rights movement
(Galarneau, 2016). Hence, health disparities have been described as the ‘civil rights issue of the
21st century’ (Exworthy & Washington, 2006). Despite the emphasis on health disparities and
advances in technology and medicine over the past half century, health disparities persist
resulting in inequality in health for underrepresented racial and ethnic minorities (UREM).
Health disparities is a term used to describe the difference in health or healthcare amongst
racial, ethnic, or social groups (LaVeist & Pierre, 2014). Studies have shown a need for a
multifaceted approach to eliminate health disparities and achieve health equity, and health
service researchers have proposed a plethora of solutions to reduce and eliminate health
disparities with the goal accomplishing health equity (Bailey et al., 2022; Dickman et al., 2017;
Exworthy & Washington, 2006; Jackson & Garcia, 2014; LaVeist & Pierre, 2014; Paredas et al.,
2020). In 2019, the National Institute of Minority Health introduced the National Institute of
Minority Health and Health Disparities Research Framework, a multilevel, multidomain model
that demonstrates the various health determinants that contribute to health disparities and
promotes health equity (Alvidrez et al., 2019). This framework reflects the complexity of
minority health and health disparities within different domains of influence (biological,
behavioral, physical/built environment, socio cultural environment, healthcare system) and

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different levels of influence (individual, interpersonal, community, and societal). While there are
many elements within the NIMHD Research Framework, as displayed in Figure 1, this study
focused on the intersection of the healthcare system and the community level of influence.
Figure 1
National Institute of Minority Health and Health Disparities Research Framework

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The purpose of this study was to examine the impact of nursing shortages in safety net
hospitals, which were exacerbated in the wake of the coronavirus pandemic and the Great
Resignation that followed, and strategies health care executives developed to increase nurse
retention in support of their mission with regard to health equity. While there is no official
designation for a safety net hospital, hospitals that are labeled as safety net hospitals share a
commitment and mission to care for all patients, regardless of their financial or insurance status
(Paredas et al., 2020; Sarkar et al., 2020). With poverty and uninsured rates highest amongst
minorities, especially African Americans and Hispanics, it is not surprising that hospitals with a
safety net designation serve a high proportion of racial and ethnic minorities (Crown et al.,
2022). Because of their mission and patient population, safety net hospitals play a pivotal role in
addressing health disparities. Threats like a nursing shortage and high turnover rates not only
impact the healthcare system’s ability to provide high-quality healthcare services, in safety net
hospitals these threats also lead to furthering health disparities for racial and ethnic minorities
(Crown et al., 2022; Darzi & Evans, 2016)
Background of the Problem
In the United States healthcare system, race, ethnicity, and primary language impact
health status, access to health services, and delivery of services (Li et al., 2017). For decades, the
U.S. healthcare system has been faced with the challenge of delivering affordable high-quality
health care to an increasingly diverse patient population (Dotson & Nuru-Jeter, 2012). According
to a benchmark survey by the American Hospital Association, in 2016, underrepresented racial
and ethnic minorities accounted for 31% of patients seen within a U.S. hospital (Henkel, 2016).
The patient population is predicted to continue to be more diverse as 50% of the population will
belong to at least one minority group by 2043 (Zambrano, 2019). Despite the growing number of

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UREM patients, the lack of access to high quality healthcare services and experiences across
racial groups has resulted in disparities in health outcomes (Paredas et al., 2020).
With disparities at the core of the U.S. healthcare system, safety net hospitals fill an
essential role of caring for all patients, regardless of their financial or insurance status (Paredas et
al., 2020). Safety net hospitals are facilities that deliver a significant level of health care to
patients with no insurance or those with Medicaid coverage (Sarkar et al., 2020). With poverty
and uninsured rates highest amongst minorities, especially African Americans and Hispanics, it
is not surprising that in 2019, 51% of patient discharges from safety net hospitals in America
were racial and ethnic minorities (Crown et al., 2022). As Crown et al. (2022) noted, hospitals
with a safety net designation serve a high proportion of UREM patents. Given the patient
population that relies on safety net hospitals for services, safety net hospitals play a pivotal role
in addressing health disparities; however, safety net hospitals, like all healthcare systems, cannot
provide high-quality healthcare services without an adequate healthcare workforce of trained
staff to deliver the services (Darzi & Evans, 2016).
Staffing in healthcare has been a growing concern due to the anticipation of an aging
population both globally and in the U.S. In a 2016 World Health Organization (WHO) report,
WHO researchers forecasted a global shortage of 18 million healthcare workers by 2030, a
significant increase from the initial report in 2013 estimating a shortage of seven million
healthcare workers (World Health Organization, 2016). Similarly, the American Association of
Medical Colleges predicted that by 2034 the U.S. healthcare system would have a shortage of
124,000 physicians, and the American Hospital Association predicted a shortage of 500,000
nurses by 2026 (Fry, 2022).

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In 2019, the year before the coronavirus pandemic, there were 22 million workers in the
healthcare industry (Laughlin et al., 2021). According to the Census Bureau’s 2019 American
Community Survey (ACS), the healthcare workforce accounted for 14% of all U.S. workers
(Laughlin et al., 2021). Healthcare was one of the largest and fastest-growing sectors in the
United States (U.S. Bureau of Labor Statistics, 2020). Despite the expected growth in the
industry, staffing was still a national and global concern due to the anticipation of an aging
population. The healthcare industry was working diligently to plan for and mitigate the looming
healthcare workforce shortage, but in 2020 everything changed.
On January 30, 2020, the World Health Organization declared the global coronavirus
outbreak a public health emergency of international concern (World Health Organization, 2020),
an event that exacerbated an already existing nursing shortage. While many Americans found
themselves out of work or sent home and forced into a new world of remote work, essential
workers like healthcare workers and emergency services served on the front-line treating patients
with coronavirus and doing their best to maintain a healthcare infrastructure. After a year of
lockdowns and with the growth of remote work, a large shift in the American workforce
emerged. As the pandemic continued, the toll of being on the front line began to take shape. By
the end of 2021, two years after the declaration of the global pandemic, 48 million Americans
had quit their job with 13% of these resignations coming from the healthcare workforce.
According to the U.S. Bureau of Labor Statistics, the healthcare workforce had decreased by
600,000 positions leaving a significant shortage of workers and thousands of job openings
(2022). According to a 2022 survey by the NSI Nursing Solutions, Inc., hospital turnover among
the participating hospitals increased by 6.4% in 2021. The survey collected data from 272
hospitals across 32 states and concluded that nurses’ turnover rate was 27.1%, representing an

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increase of 8.4% from the previous year and resulting in a nurse vacancy rate of 17%, an
increase of 7.1 percentage points from the previous year (NSI, 2022). As shown in Figure 2, the
rate of job openings in the health care and social assistance industry nearly doubled from the end
of 2019 to September 2022.
Figure 2
Job Opening Rates in Healthcare

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With healthcare as one of the top three industries impacted by the Great Resignation, a
term used to describe the unprecedented levels of turnover and turnover intention seen in the
U.S. workforce beginning in early 2021 in the wake of the coronavirus pandemic, safety net
hospitals have been hit particularly hard (Jacobs & Doyle, 2022). The healthcare impact of
staffing shortages includes, but is not limited to, patient safety issues, increased health
disparities, and worse patient outcomes (Brooks Carthon et al., 2021; Lasater et al, 2016).
This study examined the ability of safety net hospitals to retain nurses, navigate
workforce trends exacerbated by the pandemic, and provide needed care for the most vulnerable
patients within the healthcare system.
Organization Context and Mission
Pacific Hospital, a pseudonym, is an academic medical center in the Pacific Northwest
region of the United States. As an academic medical center, Pacific Hospital plays a critical role
in the U.S. healthcare system. Academic medical centers differentiate themselves from the 6,093
community hospitals in the United States due to their three-part mission – clinical care,
education, and research (Fleishon et al., 2017). Academic medical centers not only train and
educate the next generation of providers, but they also provide valuable research and innovation
to the healthcare community (Niedzwiecki, 2020).
While Pacific Hospital plays an important role in training future healthcare workers, its
primary mission is to improve the health of the public. Pacific Hospital provides high quality
healthcare services, with a specific focus on care for patients who are uninsured or underinsured
and/or have barriers to access, including limited English proficiency. Pacific Hospital’s explicit
commitment to serving vulnerable populations, patients who are underinsured or uninsured and
patients who are at risk or have barriers in receiving care in other institutions, aligns with the

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Institute of Medicine’s definition of a safety net hospital (Wakeam et al., 2014). While there is
no official designation for safety-net hospitals, safety net hospitals are characterized as having a
stated or mandated mission to provide services to all patients regardless of their insurance
coverage, ability to pay, or immigration status (Moura, 2021).
Pacific Hospital is one of many safety net hospitals within the United States who
experienced nursing shortages exacerbated by the Great Resignation and were tasked with
implementing changes to maintain their workforce and, in return, meet the needs of their patients
and fulfill their mission. Pacific Hospital has roughly 500 inpatient beds, 40 inpatient mental
health beds, and provides outpatient services through a network of primary care and specialty
care clinics. The 6,000 employees of Pacific Hospital provide care for over 300,000 lives each
year.
Prior to the pandemic, the hospital was able to maintain staffing levels at 84%, meaning
84% of positions at the hospital were filled at any given time. The employee turnover rate was
13% with the average length of employment being 10-15 years. Like many hospitals, clinical
care is delivered through a multidisciplinary team of physicians, nurses, technicians,
administrative staff, and other professional staff. However, the backbone of the hospital is the
nursing staff, who make up over 40% of the workforce and account for 65% of personnel costs at
Pacific Hospital.
In healthcare, the largest expense for any hospital is expenses associated with staffing.
The revenue, however, is influenced by the patient population it serves, market conditions and
payment rates (Wakeam et al., 2014). Sixty percent of the care provided at Pacific Hospital is
provided to Medicaid or underinsured patients. Reimbursement for these services is minimal in
comparison to commercial insurance and is a major contributor to the less than 1% operating

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margin for Pacific Hospital. While this operating margin is standard for most safety net hospitals,
the events of the pandemic further threatened the financial health of the organization.
Additionally, Pacific Hospital is in a major U.S. city with multiple not-for-profit and forprofit hospitals within a 30-mile radius. Pacific Hospital is the only teaching and safety net
hospital in the area. In this competitive healthcare market, the teaching mission of Pacific
Hospital used to be a competitive advantage for attracting and retaining staff, but in recent years,
especially following the pandemic, the increased salaries and benefits of competing hospitals has
made the area hospitals major competitors for the resource of healthcare workers.
Purpose of the Study and Research Questions
This study examined nurse retention in a safety net hospital and how the hospital
responded to a nursing shortage exacerbated by workforce changes related to the global
pandemic and the Great Resignation in order to fulfill their mission. This study used a mixed
methods approach to answer the following research questions.
1. What key factors influence an inpatient nurses’ decision to stay at Pacific Hospital?
2. How do inpatient nurses perceive changes in the healthcare workforce have impacted
Pacific Hospital’s ability to fulfill their mission with regard to health equity?
3. What systems, processes, or practices have nurse leaders at Pacific Hospital developed to
address nurse retention?
Importance of the Study
While the U.S. healthcare system is plagued by many issues, including rising costs,
smaller operating margins, and health disparities, there is no healthcare without a healthcare
workforce. Failure to address workforce shortages presents a serious threat to protecting the
health of individuals, families, and communities, especially racial/ethnic minority populations

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who have poorer outcomes from preventable and treatable diseases such as cancer, asthma, and
cardiovascular disease in comparison to the general population (Jackson & Garcia, 2014). When
considering the patient population that relies on safety net hospitals, the nursing shortage,
exacerbated by the unprecedented impact of the Great Resignation, further impacts the health
disparities experienced by racial and ethnic minorities. Without a robust nursing staff, patients
who rely on safety net hospitals will be left without any other option. The ability to navigate and
respond to the current nursing challenges is essential to promoting health equity and to the health
of future generations.
Overview of Theoretical Framework and Methodology
The theoretical framework utilized for this study was the Burke-Litwin Organizational
Performance and Change Model (Burke & Litwin, 1992), a framework that examines how the
external environment influences the outcomes or performance of an organization by using a
cause-effect paradigm. In this model, organizational conditions serve as the cause, while results
or outcomes serve as the effect (Spangenberg & Theron, 2013). The Burke-Litwin Model builds
off prior open-systems frameworks that recognize the dynamic external environment in which
organizations exist (Coruzzi, 2020). As Coruzzi (2020) identified, what separates the BurkeLitwin model from previous open systems theories is the distinctions between transformational
and transactional dimensions. In the Burke-Litwin Model, the external environment serves as the
input, the transformational and transitional factors drive the throughput, and the performance or
motivational factors are the output (Stone, 2015). Transformational factors include the external
environment, leadership, mission and strategy, and the organizational culture; transactional
factors are identified as the management practices, organizational structure, systems to include
policies and processes, and work/unit climate (Lee et al., 2013).

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This study utilized a mixed methods design to examine how events in the external
environment, including the coronavirus pandemic and the Great Resignation, influenced nurses’
decisions to stay at a safety net hospital, the hospital’s ability to fulfill its mission, and internal
changes to the organizations’ systems, processes, and policies to address nurse retention. Mixed
methods research involves the collection of quantitative data and qualitative data; then using the
separate data forms to either integrate the data, merge the data, further explain the data, build off
each other or embed within a larger framework (Creswell & Creswell, 2018). This strategy
aligned with the study’s framing by identifying the factors that nurses feel are the biggest driver
in their decision to stay with the safety net hospital and comparing those with the systems,
processes, and policies that healthcare executives have developed and implemented in response
to nursing shortages exacerbated by the Great Resignation.
Definitions
Academic Medical Centers – Also known as teaching hospitals, are tertiary care hospitals that
are organizationally and administratively integrated with a medical school (Joint Commission)
Great Resignation - A term coined by Anthony Klotz of Texas A&M University to describe the
massive turnover of employees (Kuzior et al., 2022)
Healthcare Executives - Clinical and administrative healthcare workers responsible for the
oversight and leadership of healthcare workers and healthcare systems.
Healthcare Workers - Employees involved in primary healthcare (Nkomazana et al., 2015).
This includes clinical and administrative staff who support the delivery of healthcare services
such as Doctors, nurses, therapists, pharmacists, community health workers, etc.
Safety Net Hospitals - Hospitals designed to provide healthcare services regardless of a
patient’s insurance status or ability to pay (Paredas et al., 2020).

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Organization of the Dissertation
This study is divided into five chapters. Chapter One provided an overview of the study,
a brief history of the problem, the purpose of the study, and the theoretical framework that
supports the objective of the study. Chapter Two provides a detailed analysis of the scholarly
literature related to the healthcare workforce prior to and during the coronavirus pandemic, the
impact of staffing shortages, and the factors contributing to nurse turnover in healthcare. Chapter
Three introduces the methodology, approach, and design of the research study. Chapter Four
presents the thematic findings of this study and their linkage to the research questions that guided
this study. Lastly, Chapter Five discusses the findings, provides recommendations for practice,
and presents limitations to the current study and opportunities for future research.

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Chapter Two: Literature Review
This study examined nurse retention in a safety net hospital and how the hospital
responded to a nursing shortage exacerbated by workforce changes related to the global
pandemic and the Great Resignation in order to fulfill their mission. The chapter begins with
research on trends within the healthcare workforce prior to and during the coronavirus pandemic.
Next, the review examines the impact of staffing shortages, including the impact to patient
outcomes and health equity and the financial impact. The review concludes with existing
literature on the factors contributing to employee turnover in healthcare, specifically the nursing
workforce.
The second part of this chapter discusses the Burke-Litwin Organizational Performance
and Change Model (Burke & Litwin, 1992) and the conceptual framework guiding the study.
Health Care Workforce: Challenges and Opportunities
The health care workforce is the core of the health system (Liu & Eggleston, 2022).
Research has demonstrated the relationship between the healthcare workforce and health
outcomes (Amiri & Solankallio, 2019; Liu & Eggleston, 2022). Furthermore, research has
demonstrated the importance of a health care workforce to meet the needs of a growing and
diverse patient population (WHO, 2013). At the same time, there is a growing consensus that the
global healthcare workforce will not be sufficient to meet the demands of the population (Fry,
2022).
Global Healthcare Workforce Shortage
A 2013 World Health Organization (WHO) report, The Global Strategy on Human
Resources for Health: Workforce 2030, projected a healthcare workforce shortage of 18 million
healthcare workers by 2030 (WHO, 2013). At the time, 2013, the WHO identified 43 million

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healthcare workers in the world, including 20.7 million nurses/midwives, 9.8 million physicians,
and approximately 13 million other healthcare workers. The WHO report predicted a 2030
workforce of 67.3 million healthcare workers encompassing 13.8 million physicians, 32.3
nurses/midwives, and 21.2 other healthcare workers. Despite the significant growth expected
within the healthcare workforce, the WHO predicted that the workforce would not be adequate to
meet the needs of the global population. Unfortunately, the 2013 report was based on WHO’s
Global Health Observatory data that had known concerns of quality and completeness (Boniol et
al., 2022). In 2016, as part of the recommendations from the 2013 WHO report, the World
Health Assembly adopted new strategies for capturing global workforce data and improving the
quality and availability of the data (Boniol et al., 2022; WHO, 2013). As a result, the WHO
implemented the National Health Workforce Accounts, the State of the World’s Nursing 2020
and a new annual report (Boniol et al., 2022).
Five years after the implementation of the National Health Workforce Accounts, Boniol
et al. (2022) used the newly available resource to recalculate the global health workforce
shortage for 2020 and revise estimates for 2030. Boniol et al. estimated a reduction of the 18
million healthcare workforce shortage to 15 million in 2020 and a further decrease to 10 million
by 2030. While the improvements in data allowed for a more accurate prediction, the global
healthcare workforce shortage remained. The supply of healthcare workers was not expected to
keep up with the growing demand. It was also noted that turnover and low retention rates were
known risks that could directly impact the supply of healthcare workers and exacerbate the
healthcare worker shortage (Neves et al., 2022).
The largest healthcare professional group impacted by the healthcare shortage were
nursing professionals. The 20.7 million nurses and midwives identified in the 2013 WHO report

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made up 50% of the global healthcare workforce. Nurses are the largest professional group
within the healthcare workforce and are essential to the delivery of healthcare services (Tamata
& Mohammadnezhad, 2022; U.S. Department of Health and Human Services, 2017). In the U.S.
the relationship between nurse supply and demand has been cyclical, with periods of shortages of
nurses, followed by periods of surpluses (U.S. Department of Health and Human Services,
2017). In 2017, the U.S. projected growth in registered nurse supply (39% growth) and expected
to exceed growth in demand (28% growth) resulting in a projected excess of about 293,800
registered nurses in 2030 (U.S. Department of Health and Human Services, 2017). When these
projections were made, researchers did not take into consideration a global pandemic and mass
exodus of healthcare workers.
Great Resignation in Healthcare Workers
In a 2019 opinion piece with NBC News, Dr. Anthony Klotz, associate professor of
management in the Mays Business School at Texas A&M University, forecasted a wave of
resignations as employees across the United States began transitioning into a post-pandemic life
(2021). He coined this workforce trend the Great Resignation and summarized his findings as,
“The pandemic has made many realize their job does not contribute enough (or at all) to their
happiness and meaning, and they have decided to invest their energy elsewhere – in new jobs,
new careers or in other aspects of their lives.” (Faulds & Raju, 2023; Klotz, 2021)
In the healthcare industry, the pandemic impacted the population seeking care, the
workforce providing care, and the data available for both (US Department of Health and Human
Services, 2022). All healthcare workers experienced a high risk of being infected by the virus,
but nurses had the highest risk due to their frequent encounters with infected patients (Shah et al.,
2022). The risk and additional stress led to increasing turnover amongst nurses. According to the

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2022 Nursing Solutions, Inc. (NSI) report, National Health Care Retention and RN Staffing
Report, in 2021 hospital turnover increased by 6.4% to 25.9%, and nursing turnover increased to
27.1%, representing an increase of 8.4% from the previous year (NSI, 2022). Historically, nurse
turnover trended below hospital turnover but the rising patient ratios, high acuity of patients,
emotional and physical exhaustion, and burnout resulted in bedside nurses leaving at an alarming
rate (NSI, 2022). To complicate the matter, recruitment efforts were unsuccessful in mitigating
the jump in turnover, resulting in a 2.47% reduction in the hospital nurse workforce and a 17%
vacancy rate amongst participating hospitals (NSI, 2022). The reduction in nursing workforce
and increased vacancy rates resulted in a reversal of previous workforce trends. In 2017, the U.S.
projected a nurse surplus of almost 300,000 nurses by 2030. In 2022, the American Hospital
Association predicted a shortage of 500,000 nurses by 2026 (Fry, 2022). Future supply of and
demand for nurses are affected by a host of factors, including population growth, the aging of the
nation’s population, overall economic conditions, expanded health insurance coverage, changes
in health care reimbursement, geographic location, and health workforce availability. While
many of these factors are outside of the control of many healthcare systems, nurse retention has
been shown to be the result of various aspects of the healthcare system and the organization
where the nurses work.
Impact of Staffing Shortage
This section presents research on the impact staffing shortages have on patients’ health
outcomes and the disproportionate impact on racial and ethnic minorities. This section concludes
with the financial impact of staffing turnover and shortages.

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Health Outcomes
Health systems can only function with a health workforce. The foundation for improving
health service coverage and realizing the right to the enjoyment of the highest attainable standard
is undoubtedly the availability, accessibility, and quality of a health workforce (World Health
Organization, 2016). Studies have shown that a strong health workforce contributes to better
health outcomes (Amiri & Solankallio, 2019; Liu & Eggleston, 2022; Robinson & Wharrad,
2001). Liu and Eggleston (2022) conducted a cross country study to analyze the relationship
between the health workforce and health outcomes and found a significant association between a
high density of health workforce and reduced maternal mortality ratio, under five mortality rate,
infant mortality rate and neonatal mortality rate. This study’s findings were consistent with
previous studies including Amiri and Solankallio (2019) who found that the life expectancy at
birth and at 65 years old is positively associated with a higher proportion of nursing staff and
Robinson and Wharrad (2001) who found higher ratios of physicians and nurses were linked to
lower infant mortality rates and under-five mortality rates.
While research has shown the linkage between staffing and patient outcomes generally,
studies have also shown disparities in care linked to the staffing levels. Brooks Carthon and
colleagues (2021) found that when patients were seen at a better staffed hospital, patients had
increased likelihood of survival. This study also found that greater staffing had a larger effect on
Black patients in comparison to White patients. Similarly, Lasater and McHugh (2016) found
that Black patients had a lower likelihood of readmission following joint replacement when seen
at a hospital with fewer nursing staff. Growing evidence suggests that racial disparities can also
be attributed to the staffing levels of the hospital in which they receive care, for underrepresented

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racial and ethnic minorities that care is often being received in a safety net hospital (Lasater et
al., 2023).
Safety Net Hospitals and Health Equity
Healthcare equity can be construed along three axes: equitable access, equitable use, and
equitable quality (Exworthy & Washington, 2006). Health disparities, and the resulting health
inequities, have been studied and identified as a key initiative of the US healthcare system for
over fifty years, yet disparities persist. In the 1970s, the Institute of Medicine (IOM) began
publishing reports highlighting the disparities in the health of Black people and other minority
groups as compared with White people in the United States (Lavizzo-Mourey et al., 2021). In
response to the findings of the IOM reports, Margaret Heckler, the U.S. Secretary of the
Department of Health in Human Services, in 1985 released the Black and Minority Health report.
This report was the first U.S. government report to focus exclusively on the health of racial and
ethnic minorities. This report documented the differences in Black and minority populations in
terms of higher burden of disease and lower life expectancy, in comparison to white patients.
This report launched a new era of reporting and sparked the creation of the Office of Minority
Health, a new office within the federal government, established with the goal of implementing
new health policies and programs that would improve the health of racial and ethnic populations.
For the first 30 years following the creation of the Office of Minority Health, much of the
research on health disparities identified differences in outcomes for racial and ethnic minorities.
Since the 2000s, the conversation has shifted from the health outcomes to the contributing
factors of health disparities. In 2003, the Institute of Medicine (IOM) released a report that
shifted the conversation to causes and contributing factors to health disparities in the U.S.
healthcare system. The report, A Shared Destiny: Community Effects of Uninsurance, was a six-

25
volume report documenting the effects of lack of insurance on access to care. The report
highlighted the disproportionately low rates of health insurance among minority populations and
the limited availability of community-health care services, resulting in health disparities (IOM,
2003).
Studies have continued to show that the high rates of uninsurance and inadequate health
insurance among low-income Americans contribute to health disparities. The uninsured are far
more likely than the insured to forgo needed medical visits, tests, treatments, and medications
because of cost (IOM, 2003). Minorities are disproportionately more likely than the general
population to be uninsured and are overrepresented among those in the public funded health
systems like Medicaid (IOM, 2003). The institutions and financing patterns of the U.S.
healthcare system do not align to support the goal of quality healthcare for all (Dickman et al.,
2017). Fortunately, safety net hospitals play a crucial role in filling this gap in the U.S.
healthcare system (Mouch et al., 2014).
As defined by the Institute of Medicine, health care safety-net hospitals refer to facilities
that deliver a significant level of health care to patients with no insurance or those with Medicaid
coverage (Sarkar et al., 2020). Safety-net hospitals provide care for a large percentage of
uninsured and Medicaid-insured patients, and overall provide a valuable service for underserved
individuals across the United States (Sarker et al., 2020). Due to their mission of providing
services regardless of ability to pay, patients who receive services from safety-net hospitals are
likely to be of racial and ethnic minority and often have fewer resources, including lower
socioeconomic status and social support, leading to barriers to receiving high-quality, timely
health care and (Hoehn et al., 2016; Sarkar et al., 2020)

26
Similar to the patients who receive services at a safety net hospital, safety net hospitals
themselves have disparities in resources in comparison to non-safety net hospitals (Scales, 2020).
Safety-net hospitals care for vulnerable patients and receive decreased reimbursement compared
with hospitals with a lower safety-net burden; consequently, they are more financially limited
(Hoehn et al., 2016; Mouch et al., 2013; Scales, 2020). Despite their limited resources, Safety net
hospitals play a pivotal role in addressing health disparities. However, a healthcare system
cannot provide high-quality healthcare services without an adequate healthcare workforce of
trained staff to deliver the services (Darzi & Evans, 2016) Without a robust staff at the safety net
hospital, the services cannot be provided and the patients who rely on them will be left without
any other option; therefore, leading to an inequity in access to healthcare services.
Financial Burden
Employee turnover is costly in any industry. In addition to the tangible expenses like
recruiting, onboarding, and training a new employee, there is also the intangible expenses like
decreased productivity, loss of efficiencies, and increased workload on the remaining team
members (SHRM, 2021). Experts estimate that the total cost of nurse turnover is $46,100 per
nurse with hospitals averaging losses of $7.1 million from nurse turnover in 2021 (NSI, 2022).
With increasing vacancy rates and increasing demands for services, during and following the
coronavirus pandemic, many hospitals turned to contract or travel nurses to provide coverage
while the organization worked to recruit additional nurses (Bernstein, 2021). While this solution
maintained key operations for patients, it resulted in additional expenses to the cost of employee
turnover as contract and travel nurses were compensated at a higher rate than employees and
positions remained vacant for longer periods of time. (Hansen & Tuttas, 2022).

27
In response to the pandemic, the demand for travel staff increased significantly. Travel
nurses lured many bedside nurses into lucrative contracts and convinced nurses to delay
retirement for contracts that reached a maximum of $12,000 a week during the peak of the
pandemic (NSI, 2022). While nurse travelers filled an important gap to support patient care, the
use of travelers contributed an average of $4 million increase to hospital expenses (NSI, 2022).
For safety net hospitals, who often serve large numbers of uninsured and underinsured patients,
the high turnover rate, and the added expenses of agency staff, specifically travel nurses, had a
significant burden on the financial status of the organization (Pope & Yehia, 2023; Rhodes et al.,
2023).
Healthcare finances are largely driven by the patients who are treated within the
organization. Safety net hospitals face several financial disadvantages due to their mission of
delivering care to patients regardless of their ability to pay (La et al., 2019). Safety net hospitals
typically receive a smaller percentage of reimbursement because they serve a higher proportion
of patients who are covered by Medicaid or Medicare, or to patients who are underinsured. This
is known as the safety-net burden (La et al, 2019). The high proportion of Medicaid or uninsured
patients results in lower reimbursements for the services provided, leaving safety net hospitals
limited flexibility in addressing financial challenges (La et al., 2019) In contrast, hospitals more
generally, or healthcare systems without missions to serve vulnerable populations, may require
patients to carry commercial health insurance or pay out of pocket for services. As a result, these
institutions receive a higher reimbursement rate for the services provided and have greater
flexibility to adjust to a changing environment.

28
Nurse Retention Factors and Strategies
The shortage of healthcare workers, specifically nurses, is a global concern with major
implications on the global healthcare system and the health of the global community. To address
this problem, a variety of solutions have been suggested, initiated, and implemented specifically
focused on retention. Retention is a complex concept. Retaining a skilled workforce and
decreasing employee turnover is a necessity for organizations (Belbin et al., 2012). A literature
review by Hayes et al. (2012) showed that a nurses’ intention to leave is a strong indicator of
nurse turnover. Intention to leave describes an individual’s desire to leave or quit a position in
the near future and pursue opportunities in another unit, department, organization or to leave the
profession (Neves et al, 2022). Higher levels of intention to leave lead to nurse turnover;
conversely, lower levels of intention to leave result in nurse retention. Numerous studies have
been published on the factors that contribute to higher and lower levels of nurses’ intentions to
leave that ultimately result in nurse turnover or nurse retention. (Boston-Fleischhauer, 2022;
Juraschek, 2012; Koehler & Olds, 2022; Nei et al., 2015; Pitt-Catsouphes & Matz-Costa, 2008;
Shah et al., 2022; Sweet & Swayze, 2017; Twigg & McCullough, 2014).
Factors Contributing to Nurse Turnover
High levels of intention to leave have been identified as predictors of nurse turnover
(Neves et al., 2022). Furthermore, studies have shown that key influences like work
environment, job satisfaction, and exhaustion/burnout have been linked to nurses’ intention to
leave and eventually nurse turnover (Leone et al., 2015). These broad categories - work
environment, job satisfaction and burnout -are a combination of many contributing elements at
the organizational and individual level.

29
Studies suggest nurses who are dissatisfied with the work environment have a higher
level of intention to leave (Lee et al., 2015; Lengerich et al., 2017; Sasso et al., 2019; Tamara &
Mohammadnezhad, 2022). In a qualitative study of the impact of the nursing shortage, Tamara
and Mohammadnezhad (2022) identified factors such as poor salaries or no changes to salaries
and unmet career opportunities as potential factors to increase intention to leave. At the work
unit level, researchers have identified unsafe working conditions and inadequate staffing, which
often leads to increased workload and inadequate patient-to-nurse ratios, further facilitating nurse
dissatisfaction with the work environment (Tamara & Mohammadnezhad, 2022). In a crosssectional study of predictive factors to nurse retention, Sasso et al. (2019) revealed
organizational factors such as staffing ratios, heavy administrative burdens, and the inability to
practice standards of care contributed to a higher level of intention to leave (Sasso et al., 2019).
These findings were consistent with previous studies on nurses’ intention to leave (Lee et al.,
2015; Schwazkopf et al., 2017). In addition, poor relationships between nurses and physicians as
well as amongst nurses have been shown to contribute to high levels of intention to leave caused
by the work environment (Lee et al., 2015).
Another commonly identified factor associated with intentions to leave is burnout and
emotional exhaustion. Numerous studies have concluded burnout and emotional exhaustion are
prevalent within many disciplines of the healthcare workforce (Heinen et al., 2013; Jiang et al.,
2017; Nantsupawat et al., 2017; Sasso et al., 2019; Schwazkopf et al., 2017). In a 2019 crosssectional study, Sasso et al. suggested that nurses’ perception of patient safety issues within the
workplace and/or perceptions of poor patient outcomes contribute to poor job satisfaction which
overtime leads to burnout and emotional exhaustion. These findings were consistent with
previous studies that show how at the individual level, high levels of burnout and diminishing

30
sense of accomplishment are associated with nurse turnover (Nantsupawat et al., 2017;
Schwarzkopf et al., 2017).
Table 1 summarizes the literature on factors within the work environment that contribute
to nurse turnover.
Table 1
Factors Contributing to Nurse Turnover
Categories Factor Studies
Factors associated
with the work
environment
High burden from administrative
tasks
Sasso et al., 2019
Unmet career opportunities Williams, 1992
Leone et al., 2015
Poor staff relationships Lee et al., 2015
Work overload or increased
workload
Tamara & Mohammadnezhad, 2022
Poor salaries or no changes to
salaries
Tamara & Mohammadnezhad, 2022
Unattractive or Poor working
conditions
Tamara & Mohammadnezhad, 2022
Unable to practice standards of
care
Sasso et al., 2019
Schwazkopf et al., 2017
Factors associated
with the
individual’s
values or needs
Burnout – emotional exhaustion
and depersonalization
Heinen et al., 2013
Jiang et al., 2017
Nantsupawat et al., 2017
Sasso et al., 2019
Schwazkopf et al., 2017
Low level of job satisfaction Tamara & Mohammadnezhad, 2022
Nurses’ perception of patient
safety issues
Sasso et al., 2019

31
Nurses’ perception of negative
patient outcomes
Sasso et al., 2019
Lack of social support Tamara & Mohammadnezhad, 2022

32
Factors Contributing to Nurse Retention
Addressing the factors that contribute to nurse turnover can support efforts to reduce
nurses’ intention to leave and subsequently retain nurses. Sasso et al. (2017) found that nurse
intention to leave did reduce significantly when nurses were satisfied with all dimensions of their
work environment including adequate staffing and interprofessional relationships. These findings
were consistent with previous studies related to nurse retention. In 2015, Lee et al. found a
correlation between balanced workloads due to adequate nurse staffing and nurse retention. And
Jonsson et al. (2021) found nurse retention increased as organizations addressed wages and
flexible scheduling.
At the same time, at the organizational level, Sasso et al. (2017) identified a strong
correlation between nurse retention and a nurses’ trust in the institution and its leadership,
participation in hospital affairs, and personal accomplishment. These findings were consistent
with previous studies showing nurses who were actively involved in decision making within an
organization and were given the opportunity to participate in hospital affairs had a lower level of
intention to leave and a stronger commitment to the organization (Aiken et al., 2014; Gkantaras
et al., 2016; Sasso et al., 2017; Van Bogeart et al., 2012). Similarly, Bobbio and Manganello
(2015) found nurse intention to leave was notably lower in nurses who had trust in the institution
and its leadership. Lengerich (2017) noted nurses reported a lower level of intention to leave
when they viewed management as supportive and engaged on the unit and supportive of a
nurses’ autonomy to practice effectively. And in 2015, Leone et al. concluded that career
advancement and professional development within the organization were linked with
organizational commitment and lower intentions to leave.

33
Table 2 summarizes the studies mentioned above that identified factors contributing to
nurse retention.
Table 2
Factors Contributing to Nurse Retention
Categories Factors Literature
Factors associated
with a strong work
environment.
Adequate Staffing. Appropriate patient to
nurse ratio
Aiken et al., 2012
Sasso et al., 2019
Active involvement in decision making.
Participation in hospital affairs
Aiken et al., 2014
Gkantaras et al., 2016
Van Bogeart et al., 2012
Interprofessional Teamwork - nurse –
physician relationships
Aiken et al., 2014
Gkantaras et al., 2016
Van Bogeart et al., 2012
Trust in the institution and its leadership Bobbio & Manganello,
2015
Leadership style of the nurse manager Morsiani et al., 2017
Career advancement and professional
development
Leone et al., 2015
Nurse staffing and balanced workloads Lee et al., 2015
Higher wages, flexible hours Jonsson et al., 2021
Lengerich et al, 2017
Preceptorship for new nurses Jonsson et al. 2021
Management that supports staff, manager
engaged on the unit
Lengerich et al, 2017
Support for autonomy to practice
effectively
Lengerich et al, 2017
Low levels or burnout and emotional
exhaustion
Nantsupawat et al., 2017

34
Factors associated
with the individual’s
values or needs.
Recognition of staff Lengerich et al, 2017
Positive patient outcomes Sasso et al., 2019
Positive patient experiences Sasso et al., 2019
As shown in the research discussed in this section, nurse retention is a complex concept.
There are many factors that contribute to nurse turnover and nurse retention. And nurse retention
impacts different aspects of the healthcare system, including patient outcomes. The multifaceted
nature of nurse retention required a robust framework that accounted for the interrelationship of
multiple layers of the organization and accounted for the external environments influence on the
organization.
Conceptual Framework
The conceptual framework for this study was modeled after the Burke-Litwin
Organizational Performance and Change Model (Burke-Litwin OPCM) (Burke & Litwin, 1992).
The Burke-Litwin OPCM uses a cause-effect paradigm to predict behaviors and performance
outcomes (Spangenberg & Theron, 2013). The model emphasizes the importance of the external
environment on the organization (Spangenberg & Theron, 2013). The external environment
serves as the input while the individual and organizational performance serve as the output. The
twelve boxes that contribute to the feedback loop represent organizational variables that
influence organizational performance.
The organizational variables are categorized into total system level variables
(Transformational) and individual variables (Transactional) (Burke & Litwin, 1992). The
transformational variables are levers at the organization level that are responsive to the external
environment and guide the actions of leaders and managers. The transactional variables

35
encompass levers at the management level that are responsive to the changes initiated at the
management level as well as changes initiated at the individual level. Figure 1 illustrates the
factors associated with the Burke-Litwin Organizational Performance and Change model.

36
Figure 3
Burke Litwin Organizational Performance and Change Model
External Environment
External environment is defined as any outside influence, condition, or situation that
influences the performance of an organization (Burke & Litwin, 1992). Changes to the external
environment may include changes in industry practices, a global pandemic, or a drastic change in
the workforce. The Burke-Litwin OPCM reflects previous research demonstrating leaders’
response to the environment to influence strategy as well as leaders’ perception of the external
environment that is directly linked to decisions that impact variables identified in the
transformational factors (Burke & Litwin, 1992).

37
Transformational Variables
Transformational factors within the Burke-Litwin OPCM include mission and strategy,
leadership, and organizational culture. Mission and strategy not only describe the mission and
strategy by the executive leaders of the organization, but it also describes the employees’
perception of the purpose of the organization (Burke-Litwin, 1992). Leadership is described as
the organizational direction and behaviors modeled by the executives within the organization.
And lastly, the organizational culture describes the rules, values, customs, and principles that
guide organizational behavior. Transformational factors account for key variables at a total
system level. Figure 4 illustrates the transformational variables within the Burke-Litwin OPCM
and the reciprocal relationship between the variables.
Figure 4
A Model of Organizational Performance and Change: The Transformational Factors

38
Transactional Variables
Transactional variables encompass the factors that contribute to the everyday interactions
and exchanges at the work unit level and individual level (Martins & Coetzee, 2009). Factors at
the work unit level consist of structure, management practices, systems, and work unit climate.
Structure describes the organization of people and functions within the organization. The
structure of an organization leads to decision making authority, levels of responsibility,
communication, and relationships that support the organization’s ability to deliver on the
organization’s mission and strategy. Management practices describe the typical activities or
actions of a manager based on the resources available to them and their role in serving the
organization’s mission and strategy. Systems describe the standardized policies and practices that
facilitate work within the work unit. Burke-Litwin intended this to be a broad category as it
encompasses the human resources, fiscal, and management information systems that allow the
organization to fulfill the organizational strategy. And lastly, climate describes the attitudes,
opinions, and feelings that members have about their work unit, their manager, and other units
within the hospital. Figure 3 illustrates the transactional variables within the Burke-Litwin model
OPCM. Similar to the transformational variables, the model illustrates the influence or feedback
look amongst the variables.

39
Figure 5
A Model of Organizational Performance and Change: The Transactional Factors
At the individual level, transactional variables include task requirements, individual values and
needs, and motivation. Task requirements describe the individual skills and abilities to complete
the task. This variable is commonly referred to as the job-person match. Individual needs and
values describe the psychological variables that provide meaning and value for individuals. And
motivation describes the enhanced behavior to work towards or achieve a goal.

40
The final variable of the Burke-Litwin OPCM represents the outcome or results at the
individual or organizational level.
Conceptual Framework as a Lens to This Study
This study used the Burke-Litwin OPCM to examine nurse retention in safety net
hospitals and the strategies that healthcare leaders developed to increase nurse retention in order
to fulfill their mission. In the context of the Burke-Litwin model, the global pandemic, and
resulting Great Resignation, exacerbated the nursing shortage which represents a change in the
external environment of the organization. According to the model, the Great Resignation impacts
multiple variables within the organization and multiple levels of the organization from the top
system level to the individual level. The model implies that the changes in the external
environment would prompt changes in the organization’s performance and changes within the
transformational variables. These changes could then influence changes in the transactional
variables at the unit and individual level.
This study examined the changes to the organization in responding to the nursing
shortage, focusing on select variables that research has demonstrated influence a nurse’s
intention to leave, which serves as an indicator of nurse retention. The approach to this study
focused on transactional variables of work environment and individual values and needs. At the
transformational level, this study focused on the mission and strategy variable. Figure 4
illustrates the conceptual framework guiding this study.

41
Figure 6
Conceptual Framework of This Study

42
Summary
The literature review examined the global healthcare shortage workforce prior to and to
in response to the pandemic. The review also discussed the importance of addressing nurse
retention demonstrating the impact to patient outcomes and consequently health equity as well as
the impact on safety net hospitals finances. Lastly, the literature review demonstrated the
complexity of nurse retention and the variables within the organization, the work environment,
and the individual that led to turnover or, conversely, retention of nurses. Utilizing the research
presented in chapter two, chapter three outlines the methodology of the study.

43
Chapter Three: Methodology
The purpose of this study was to examine the impact of nursing shortages in safety net
hospitals, which were exacerbated in the wake of the coronavirus pandemic and the Great
Resignation that followed, and strategies health care executives developed to increase nurse
retention in support of their mission with regard to health equity. This chapter provides an
overview of the methodology, including data sources, data collection procedures and
instruments, participants, data analysis, and ethical considerations. The following research
questions guided the design of this study and are supported by the methodology discussed in this
chapter:
1. What key factors influence an inpatient nurses’ decision to stay at Pacific Hospital?
2. How do inpatient nurses perceive changes in the healthcare workforce have impacted
Pacific Hospital’s ability to fulfill their mission with regard to health equity?
3. What system, processes, or practices have nurse leaders at Pacific Hospital developed to
address nurse retention?
Overview of the Methodology
This study utilized a mixed methods design to examine the key factors behind a nurse’s
decision to stay at a safety net hospital, Pacific Hospital (a pseudonym), as well as how the
nursing shortage has influenced the ability of the hospital to fulfill its mission and changes to the
systems, processes, and policies related to nurse retention. Mixed methods research involves the
collection of quantitative data and qualitative data and then using the separate data forms to
integrate the data, merge the data, further explain the data, build off each other or embed within a
larger framework (Creswell & Creswell, 2018). The benefit of a mixed methods strategy is the
opportunity to benefit from the positives of qualitative and quantitative data, and the opportunity

44
to gain additional insights by utilizing the two methodologies. The exploratory sequential mixed
methods design is a strategy where the researcher collects quantitative data, analyzes the results,
and uses the results to design the qualitative data collection phase (Creswell & Creswell, 2018).
This strategy aligned with the study’s framing by identifying the factors that nurses feel are the
biggest driver in their decision to stay or leave the safety net hospital through a quantitative data
collection and comparing this information with the systems, processes, and policies that
healthcare executives implemented in response to the nursing shortage to identify alignment,
misalignment, and opportunities through a qualitative data collection process.
The sample population for the quantitative portion of the study was inpatient nurses at
Pacific Hospital, a safety net hospital in the Pacific Northwest part of the United States. The
sample population for the qualitative interviews were identified from criteria questions built
within the survey. Table 3 outlines the data sources for each research question in this study.
Table 3
Data Sources Linked to Research Questions
Research questions Survey Interview
What key factors influence an inpatient nurses’ decision to stay at
Pacific Hospital?
X
How do inpatient nurses perceive changes in the healthcare
workforce have impacted Pacific Hospital’s ability to fulfill their
mission with regard to health equity?
X X
What system, processes, or practices have healthcare executives at
Pacific Hospital developed to address employee retention?
X

45
Data Sources
Data for this mixed method study were collected through an online survey and participant
interviews. The online survey was administered through Qualtrics and provided by email to
nursing staff within the inpatient nursing division at Pacific Hospital. Nursing staff in the
division includes front line nurses as well as nurses who serve in a supervisory or leadership
position. Participants for the interview were identified through the survey by self-identifying as a
nurse in a supervisory or leadership role. Participants who self-identified were directed to a
separate link outside of the survey and invited to participate in an interview to discuss retention
strategies at Pacific Hospital.
Method 1: Survey
Data were collected using a survey administered through Qualtrics. The survey
instrument consisted of four sections, 22 closed ended questions and two open ended questions.
The first section consists of 6 close ended questions. The second section consists of two closedended questions with 12 sub questions under each and one open ended question. The first set of
close-ended sub questions in the retention section were scored using a 5-point Likert Scale (1 =
not important; 5 = extremely important). The second set of close-ended sub questions used a 3-
point Likert Scale (1= Rarely; 2 = Some; 3 = Most). The third set of questions consisted of seven
closed-ended questions and one open-ended question. The fourth, and final section included
seven closed-ended demographic questions.
Participating Stakeholders
The population for the study was defined as nurses who worked in an inpatient setting at
Pacific Hospital. Participants were selected using criterion-based selection or purposeful
sampling. Purposive sampling consists of determining the criteria that is essential to the purpose

46
of the study (Merriam & Tisdell, 2020). In this study, the criterion for the study was nurses who
worked in the inpatient nursing division at Pacific Hospital. Pacific Hospital’s inpatient nursing
division consists of roughly 750 nurses, with roughly 50 nurses serving in a supervisory or
leadership position.
Instrumentation
The survey utilized in this study was built off an existing survey known as the Baptist
Health Nurse Retention Questionnaire (BHNRQ). The BHNRQ was developed in 2017 to assess
the key factors in retaining nurses given the recent changes in the healthcare workforce
(Lengerich et al., 2017). The original BHNRQ consisted of an assessment of 12 items and asked
participants to assess the importance of each item using a Likert scale and to assess their
presence within their work environment (Lengerich et al., 2017). Items listed within the survey
were based on a comprehensive literature review on nurse retention and satisfaction (Lengerich
et al., 2017). For this research study, factors included in the survey were focused on the
individual needs and values of the nurses as well as the work environment. Additional questions
were added to measure the importance of the mission on nurse retention as well as nurses’
perceptions of the changing workforce and its impact on Pacific Hospital’s ability to fulfill its
mission. Additional demographics questions were added to the survey, and participants were
asked two open-ended questions. The open-ended questions asked them to identify or share any
additional factors, not previously listed, that influenced their decision to stay or leave and
provided an opportunity to elaborate on the impact the changing workforce had on Pacific
Hospital’s ability to fulfill the mission. Appendix A presents the survey instrument for this study.
Data Collection Procedures

47
The survey was reviewed and approved by USC’s Institutional Review Board (IRB) prior
to its administration. In May 2023, IRB approved the study design and instrument, and the
survey was sent electronically to inpatient nurses of Pacific Hospital through the nursing
education department. Communication to the inpatient nurses included the purpose of the study,
the voluntary and anonymous nature of the survey, the estimated time for completion, and
contact information for the researcher.
Data Analysis
The survey responses were collected through the Qualtrics platform and analyzed using
descriptive analysis. Data collected from the survey were analyzed to identify the frequency of
responses as well as the mean. Data collected from the open-ended questions were coded,
categorized and analyzed using a content analysis process. Qualitative content analysis is
commonly used in nursing research and describes the process of open coding, creating
categories, and abstraction (Elo & Kyngas, 2008; Lindgren et al., 2020) Open coding describes
the process of analyzing data to identify concepts, themes or categories. Codes are generated to
capture the main theme or concept (Elliott & Timulak, 2021) These codes were then organized
into groupings to reduce the number of categories into broader categories (Elo & Kyngas, 2008).
Lastly, abstraction describes the process of transforming categorical data into a higher logical
level, thereby allowing a deeper understanding of the area of interest (Graneheim et al., 2017)
Validity and Reliability
Internal validity, or credibility, measures whether the findings match reality (Merriam &
Tisdell, 2020). A 2017 study on the BHNRQ used a content validity index and test-retest
approach to test the validity and reliability of the survey once it was developed. The study found

48
each element of the BHNRQ had a content validity index value of excellent (0.8 - 1.0),
confirming the validity of the tool.
Reliability refers to the repeatability and consistency of the survey instrument (Creswell
& Creswell, 2018). Due to the newness of the instrument, limited research is available to show
reliability of the BHNRQ using the Cronbach’s alpha value, however the newly developed
instrument has acceptable subscale test-retest coefficients (Lengerich et al., 2017). To test
reliability of the tool, the developers recruited additional nurses outside of the original study to
utilize the survey. The results were analyzed to determine consistency over time utilizing the
Pearson approach. The results showed consistency for two of three subparts and moderate
consistency of the remaining subpart (Lengerich et al., 2017).
Method 2: Interviews
Data were collected by conducting semi-structured interviews of nurse managers and
senior leaders of the organization. Each interview was conducted via Zoom and participants were
asked for consent to be recorded. At the conclusion of the interview, interviewees were offered a
summary of the notes and transcripts to ensure their comments and responses were captured
correctly.
Participating Stakeholders
This portion of the study included interviews with six nurse leaders, including front line
managers and senior leaders within the inpatient nursing organizational structure that are directly
involved with the recruitment or supervision of inpatient nurses. Nurse leaders self-identified
within the survey and were provided a separate link to volunteer for the interview. Participants
were asked to provide their name, title, and contact information. Six nurse leaders agreed to be
interviewed, all three nurse leaders were invited and agreed to participate while only three of the

49
four front line managers agreed to participate. One nurse leader failed to respond and efforts to
schedule were discontinued after two weeks of multiple attempts.
Instrumentation
The interview protocol consists of 10 open ended questions. The interview questions
explored elements within the conceptual framework based on the Burke Litwin Organizational
Performance and Change model. As shown in Table 3, the interview protocol was developed to
answer the second and third research questions guiding this story. Interview questions explored
how changes in the external environment influenced the systems, processes, and procedures at
Pacific Hospital as well as the performance of Pacific Hospital in terms of patient outcomes. The
interview protocol utilized a semi-structured approach to allow flexibility to explore answers and
responses from the participants. The flexibility to adjust questions allowed the researcher the
ability to meet the goal of capturing complete data for the research questions. Data from the
surveys helped to guide follow up questions based on participants' responses. Appendix B
includes the interview protocol utilized in this study.
Data Collection Procedures
Once a survey participant identified as a nurse leader, they were directed to a separate
questionnaire to volunteer for an interview. Interviewees were contacted by the researcher for
scheduling within a week of completing the questionnaire. At that time, they were also provided
a copy of the information sheet and given the opportunity to ask any questions. Interviewees
were scheduled ahead of time and conducted over Zoom video. All interviewees were asked for
consent to record the interview and were given the opportunity to review the summary and
transcript to ensure accurate capture of the data.
Data Analysis

50
Qualitative content analysis was utilized to analyze the data collected from the
interviews. Qualitative content analysis is one of several qualitative methods for analyzing data
and deciphering meaning. Qualitative content analysis describes the process of taking
unstructured and raw data and categorizing the information to create meaning (Merriam &
Tisdell, 2020). There are three main phases to the process: preparation, organization, and
reporting. The preparation phase includes collecting appropriate data and coding the data. The
organization phase was an open process where categories and codes were created based on the
information collected and organized into themes (Elliott & Timulak, 2021). Lastly, the reporting
phase describes the process of describing the results based on the content of the categories
(Elliott & Timulak, 2021).
Credibility and Trustworthiness
All research is designed to produce valid and reliable knowledge in an ethical manner
(Merriam & Tisdell, 2020). Concerns regarding credibility and trustworthiness can be addressed
during the collection, analysis, and interpretation phase of the study (Merriam & Tisdell, 2020).
There are many strategies available to researchers to increase the credibility and trustworthiness
of findings. One of the most common strategies is the use of triangulation, which was utilized in
this study. Triangulation describes the process of using multiple sources to data, multiple
investigators, or multiple theories to compare and cross-check the collected data (Merriam &
Tisdell, 2020). A second strategy that was utilized to promote credibility is member checks, or
respondent validation. Respondent validation describes the process of providing the researcher's
analysis to the respondent to see if they agree the summary is accurate, acceptable, and
convincing (Gibbs, 2018). Participants in the interviews were provided an opportunity to review
a summary of the interview and validate it to make sure comments and responses were captured

51
accurately, only two of the interview participants responded after being given the opportunity to
review their statements. A third and final strategy that was utilized to support credibility and
trustworthiness of the data was reflexivity, or researcher’s position. Researcher’s position is
included to explain the researcher’s biases, assumptions, or dispositions (Merriam & Tisdell,
2020). As Merriam and Tisdell noted, trustworthiness of the data is linked to the trustworthiness
of the researcher who collects and analyzes the data (2020).
Ethics
The research conducted for this study was approved by the USC Institutional Review
Board (IRB). The IRB reviews research studies to ensure they comply with regulations, follow
ethical and institutional standards, and adequately protect research participants. Once approved,
the research study was conducted as outlined to the IRB. Data collected from the surveys and
interviews were performed in a manner that protected confidentiality of all participants. Survey
participation was anonymous. Participants who volunteered to participate in the interview were
directed to a separate site so they could not be linked to their survey responses. Participants of
the survey and interviews received information regarding the purpose of the study and reminding
participants of their voluntary participation when they received the link to the survey. The
informational sheet was attached to the recruitment email and embedded in the survey during the
introduction to the survey. The information sheet was also included in the calendar invite to
interview participants. During the interview, limited personal identifying information was
collected to protect participant privacy. Interviewees were asked their name, pronouns, and title.
The interviews were conducted over zoom. Each participant was asked for consent to record the
interview. The recording was password protected in an electronic folder and deleted once the
study was concluded.

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While this study followed all the guidelines approved by the IRB, it is important to note
that I am an employee of the organization in this study. My position did not put me in a
supervisory position to any of the participants of the study. I did, however, hold a position of
authority within the organization and my position could have been perceived as a position of
power and result in response biases. Response bias, or social desirability bias, occurs when
survey participants are hesitant to tell the truth when it could be perceived negative or
unfavorable (Robinson & Leonard, 2019). Response biases can also occur when participants
overvalue positive attributes and undervalue negative attributes (Robinson & Leonard, 2019). To
mitigate potential bias in the study, the survey was disseminated via email from the researcher’s
USC email account through established communication channels within the organization,
limiting direct interaction with study participants who did not volunteer to be interviewed.
Overall, participants had limited questions regarding the study. Instead, participants expressed
excitement and eagerness to see the results and findings as this problem of practice is a key
initiative and priority for many of the participants.
The Researcher
I am a healthcare administrator employed by the healthcare organization in this study.
While my area of focus is not the inpatient units, my departments have also witnessed a change
in the healthcare workforce. I am also a Black woman who has witnessed and experienced
disparities in care. While my education, resources, and social support afford me opportunities to
seek high quality care and provide me options in how, where, and when I receive my healthcare,
I recognize that opportunity has not always been available for Black people and still not an
option for many members of the community. It is one of the guiding principles behind why I
chose to work in a safety net organization and it is what inspired me to pursue this research topic.

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As a healthcare administrator, I am focused on the business side of healthcare making
sure that the organization has the resources, such as staff, equipment, processes, and systems, to
deliver services to our patients. I am also privy to the financial challenges healthcare systems
face. I have first-hand knowledge of the financial situation of my organization as well as a seat at
the table to decide where resources are directed. I chose this topic because I think Pacific
Hospital, and the US healthcare system, is in a position to reshape the way that we deliver
healthcare. We are already seeing the effects of the healthcare workforce shortage. As we face
these challenges, I believe it is important and our responsibility to find creative solutions to this
problem to ensure that the most vulnerable members of our communities continue to have access
to quality healthcare services.

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Chapter Four: Findings
The objective of this study was to examine nurse retention in a safety net hospital and
how the hospital responded to a nursing shortage exacerbated by workforce changes related to
the global pandemic and the Great Resignation in order to fulfill their mission. This study
focused on the challenges unique to safety net hospitals in responding to the existing and
accelerated workforce shortage. This study utilized a mixed methods data collection approach,
consisting of surveys and interviews. The data collected from the survey and interviews were
examined through the lens of the Burke-Litwin Organizational Performance and Change Model
(BL-OPCM) to understand the factors that contribute to nurse retention in a safety net hospital,
the perceived impact of changes in the healthcare workforce on health equity, and how nurse
leaders are responding. The survey protocol was designed to address the first two research
questions that guided this study and was completed by front line nurses and nurse leaders.
Collectively, they are referred to as inpatient nurses throughout this chapter. The survey was also
utilized to recruit nurse leaders to participate in the interview portion of this study. Nurse leaders
refers to front line nurse managers, participants who serve in a supervisory position of front-line
nurses, and senior leaders, participants who supervise nurse managers. The interview protocol
was utilized in interviews with nurse leaders and was designed to address the second and third
research question. The three research questions that guided this study are as followed:
1. What key factors influence a nurses’ decision to stay at Pacific Hospital?
2. How do nurses and nurse leaders perceive changes in the healthcare workforce have
impacted Pacific Hospital’s ability to fulfill their mission with regard to health equity?
3. What system, processes, or practices have nurse leaders at Pacific Hospital developed to
address nurse retention?

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This chapter discusses the findings of the study. The first section describes the
participants of the study. The following section outlines the major themes identified in the study
based on their prevalence in the research data, which includes the survey responses and
participants’ interview responses. This chapter concludes with a summary of the results and
findings of the study.
Participants
The data for this study were collected utilizing a mixed methods data collection process.
Participants in the quantitative portion of the study were nurses who work in an inpatient setting
at Pacific Hospital, this includes front line nurses and nurse leaders of the inpatient units.
Participants in the qualitative portion of this study were nurses who serve in a management or
leadership position at Pacific Hospital.
Survey Participants
Survey participants were recruited via email to obtain a census sample of current
inpatient nursing staff. The survey was administered, and data collected through Qualtrics.
Survey participants were not required to answer every question in order to proceed and they were
allowed to exit the survey at any point. Of the 750 inpatient nurses at Pacific Hospital, 30
participants completed the survey, representing 4% of inpatient nurses. The demographic data
collected through the survey allowed for a general understanding of the characteristics of the
respondents as well as an understanding of their nursing specialty and years with the
organization. Almost half of the participants (48%) had been at the organization for six years or
less. For those who had been employed less than three years at Pacific Hospital, 100% of those
nurses had spent their entire nursing career at Pacific Hospital. In addition to nursing experience,
the survey also asked about nursing education, and 81% of participants held a bachelor's degree

56
in nursing with the remaining participants holding either an Associates or responding other.
Lastly, the survey asked about their position within the organization, 50% of participants were in
a supervisory or leadership position, meaning the participants served as charge nurse, assistant
nurse manager, manager, or higher leadership position. Table 4 provides an overview of the
survey participants’ demographics as it relates to nursing experience and education.
Table 4
Survey Participant Demographics – Nursing Experience and Education
Characteristics N %
Years of Nursing Experience at Pacific Hospital 27
0-3 years 8 29.7
4-6 years 6 22.2
7-9 years 4 14.8
10-12 years 1 3.7
13-15 years 4 14.8
22-24 years 3 11.1
25+ years 1 3.7
Total Years of Nursing 28
0-3 years 8 28.6
4-6 years 3 10.7
7-9 years 6 21.4
10-12 years 3 10.7
13-15 years 3 10.7
22-24 years 2 7.1
25+ years 3 10.7
Nursing Degree 27
Associates Nursing Degree 4 14.8
Bachelors 22 81.5
Other 1 3.7
Supervisory 30
Yes 15 50
No 15 50

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In addition to nursing experience and education, the survey asked demographic questions
of participants. Table 5 outlines the demographics of participants in this study. Generation X and
Millennials represented 74% of participants. Seventy-five percent of survey participants
identified as white and female, which is consistent with demographics of Pacific Hospital’s nurse
population.
Table 5
Survey Participant Demographics
Characteristics n %
Age 26
Boomer: 1946 – 1964 1 3.8
Generation X: 1965 – 1976 5 19.2
Millennials: 1977 - 1995 15 57.7
Generation Z: 1996 – 2015 4 15.4
Prefer not to answer 1 3.8
Race 26
Asian 2 7.7
Black or African American 3 11.5
Hispanic, Latino, or Spanish Origin 2 7.7
White 18 69.2
Prefer Not to Answer 1 3.8
Gender 28
Female 24 85.7
Male 3 10.7
Prefer not to answer 1 3.57
Interview Participants
Interviews were conducted between June and September of 2023 with six nurse leaders at
Pacific Hospital. Most of the participants, five of the six, identify as white females. Similar to the
demographics of the nursing population, white females make up the majority of the nursing
population at Pacific Hospital. The only participant who identified as male was a white male,

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which means the study failed to capture the responses of male nurse leaders at Pacific Hospital
who identify as Asian, Black, Hispanic, or other.
Three of the interview participants were in senior leadership positions. For the purpose of
this study, senior leadership positions were identified as leaders who do not supervise front line
nurses, instead these managers supervise other nurse managers. The remaining three participants
were front line managers. Each participant was assigned a pseudonym. Table 6 lists the relevant
data for each applicant including their pseudonym, level of leadership, years in healthcare, and
years at Pacific Hospital. To protect the confidentiality of participants, the years in healthcare
and years at Pacific Hospital have been rounded.
Table 6
Interview Participant Demographics – Nursing Experience and Education
Pseudonym Leadership Level Years at Pacific Hospital Years in Healthcare
Alice Senior Leader <5 years 30 years
Bailey Senior Leader 25 years 25 years
Charlie Front Line Manager 10 years <15 years
Denise Senior Leader 10 years 20 years
Elizabeth Front Line Manager <5 years <15 years
Frankie Front Line Manager <5 years <15 years
Data Collection
The survey utilized in this study was based on the Baptist Health Nurse Retention
Questionnaire and was expanded to incorporate questions designed to identify how the
organization’s mission influences nurse retention. The tool consisted of four sections, 22 closed

59
ended questions and two open ended questions. The first section consisted of six closed-ended
questions related to the individual's role within the organization, their education background, and
their experience in healthcare. The second section utilizes the Baptist Health Retention
Questionnaire. There are two closed-ended questions with 12 sub questions under each. The first
set of sub-questions asked participants to rate the importance and presence of 12 retention factors
- eight factors related to the work environment and four factors related to individual needs and
wants. The second set of sub-questions asked participants to rate the presence of each retention
factor at Pacific Hospital. The first set of close-ended questions in the retention section were
scored using a 5-point Likert Scale (1 = not important; 5 = extremely important). The second set
of close-ended questions used a 3-point Likert Scale (1= Rarely; 2 = Some; 3 = Most) The third
section contained seven closed-ended questions and one open-ended question related to the
mission and culture of the organization. The fourth and final section included seven closed-ended
demographic questions. Significant findings for retention factors were determined by comparing
the participants’ rating of importance of an individual factor with participants’ rating of a lack of
presence of that factor within the organization.
To facilitate qualitative analysis of the interviews and responses to the open-ended
questions in the survey, data was first coded using an open coding approach. Each code
identified was defined and outlined in a codebook, a term used to describe a structured list of
codes and the rules associated with their application (Gibbs, 2018). As qualitative analysis is an
iterative process, the interview transcripts were coded and recoded multiple times. Codes were
then arranged into a coding hierarchy. The coding hierarchy ultimately provided the structure for
a case-by-case comparison. The case-by-case comparison supported the identification of patterns
within the data to identify the factors that influence nurse retention; the impact to the

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organization’s mission in regard to health equity and the systems, processes, and practices
leaders have implemented to address nurse retention.
Findings Organized by Theme
The themes detailed in this section are supported by the data collected through the survey
and participant interviews. This data helps answer the study research questions about the factors
influencing nurse retention, the impact to the organization’s mission, and the strategies
healthcare leaders have implemented to mitigate nurse retention. Each theme is organized with
broad findings and supported with a synthesis of data collected in the study.
The first research question sought to explore the perception from inpatient nurses of the
factors within the organization that mattered most to them when deciding whether to stay with
the organization. Participants were asked to use a 5-point Likert scale to identify the level of
importance each factor had in influencing nurse retention as well as assess the presence of each
of the factors in the organization. Participants were also given the opportunity to identify any
crucial factors that were not listed in the survey through open-ended questions.
The second question sought to explore the inpatient nurse’s perception of changes they
have seen in the nursing workforce and the impact those changes have had on the organization,
specifically in how the changes in the workforce have impacted Pacific Hospital’s ability to
deliver on their mission to address health equity. Questions such as “What changes have you
seen in the workforce over the last 2-3 years?” and “How have the workforce changes impacted
the organization’s ability to deliver on the mission, specifically its mission to address health
equity?” were utilized within the survey and in interviews to encourage thoughtful reflection and
insight from inpatient nurses.

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Lastly, the third research question sought to identify changes nurse leaders have
implemented at the organizational level or targeted at the work unit to mitigate nurse retention.
Responses from the survey and interview were analyzed through the lens of the Burke
Litwin Organizational Performance and Change Model, specifically looking at how
transformational and transactional factors influence each other and nurses’ decision to stay with
the organization. Four thematic findings related to the research questions emerged from the data.
Table 7 describes how each theme answered the research questions within the study.
Table 7
Thematic Research Findings
Thematic Findings Research
Question
Mission of the organization is both a significant organizational factor
influencing nurse retention and a significant organizational barrier
RQ1
A sufficient and competent staff is a significant work unit factor influencing
nurse retention.
RQ1
An influx of newer, younger, and greener nurses has helped to stabilize the
nursing workforce but has also led to underserving the patient population in
safety net hospitals.
RQ2
Effective retention strategies were aimed at the organizational culture and
individual needs or wants of nurses.
RQ3
Theme 1: Mission of the Organization is Both A Significant Organizational Factor
Influencing Nurse Retention and A Significant Organizational Barrier
All inpatient nurses who participated in this study, including front line nurses and nurse
leaders, were asked whether they felt the mission of the organization positively influenced nurse
retention at Pacific Hospital. Despite the limited sample size, eighty-one percent of inpatient
nurses agreed that the mission of the organization had a positive influence on nurse retention.
When breaking out the data by supervisory or non-supervisory, the majority of study

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participants, 92% and 72%% respectively, agreed that the mission of the organization positively
influenced nurse retention. Figure 7 displays participants’ responses broken out by supervisory
role.
Figure 7
Supervisory vs Non-Supervisory Responses

In addition to the closed-ended question regarding the relationship between Pacific
hospital’s mission and nurse retention, survey participants were asked in an open-ended question
to identify any additional factors not previously listed that influence retention. More than half of
the responses referenced the mission or impact of the mission as a factor influencing nurse
retention, despite the survey question asking to identify factors not previously listed. Inpatient
nurses provided the following comments: “Mission of hospital, non-judgmental care – public
service, hospital location, education, and career advancement opportunities”, “Like-minded
colleagues that advocate for equity, diversity, in line within mission of Pacific Hospital”,

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“Coworkers with similar interest in the mission and collaborative nursing education”; and
“Pacific Hospital’s mission, connections with coworkers, and meeting people from all part of my
community.”
Elizabeth responded, “I think it helps for the most part because I think we attract the kind
of people who want to work at a safety net hospital and who have a passion for, for the kinds of
patients that we serve.” Denise expanded on this thought by linking it to the individual values
and needs, “I think of the mission as sort of this core value that we bring as an organization that
is marketable and real and tangible. To me, it is a key selling point and a marketing point.”
Frankie echoed these sentiments adding, “The mission helps nurses feel more fulfilled as a nurse
knowing that they’re working somewhere that is really trying to help people, individuals, and
communities. I know that is what keeps me at Pacific Hospital.” Front line managers spoke of
the opportunities and provided little to no responses in regard to the barriers caused by the
mission of the organization, unlike their senior leader colleagues.
Managers in senior leader positions also identified opportunities of the mission in regard
to nurse retention however, in reflection, these managers felt like the mission had played a bigger
role in retention in the past. Two of the senior nurse leaders shared how retention was not an
issue prior to the pandemic which now requires the system to change the way they have operated
and learn to compete with other organizations. Bailey, a senior nurse leader, pointed out that not
only is this a new problem for the organization, but it is also a problem the organization has
struggled to address stating,
I did not have a retention problem, did not have a recruitment problem…There were
shared frames of reference, shared mental models, shared sense of purpose and sense of
duty for individuals that came to work here. So, retention is more important in a place

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like this because it has to be those that understand what they’re doing and are committed
to it, but it was never an issue until now. So frankly, we were not good at figuring it out.
We did not pivot as well as other organizations.
Another senior leader hypothesized that many of the recent recruits were attracted to the
organization because they gave them the schedule they wanted or the stability that is offered by
employment within the organization and that their employment was more tied to their individual
needs than an organizational commitment or commitment to the mission. Interestingly, the
perception of these senior nurse leaders does not align with the responses of inpatient nurses who
participated in the study. When evaluating the survey data by years of experience at Pacific
Hospital, 88% of nurses with less than 10 years of experience at Pacific Hospital strongly agreed
or somewhat agreed that mission was an important factor in their decision to stay at Pacific
Hospital, compared to only 67% of nurses with more than 10 years of experience at Pacific
Hospital. Interestingly, none of the nurses with less than 10 years of experience disagreed that
mission positively influenced retention, while 22% of nurses with over 10 years of experience
somewhat disagreed. Figures 8 and 9 displays survey participants' responses to the question
based on their years at Pacific Hospital. Figure 8 displays the distribution of responses for nurses
with less than 10 years of experience; Figure 9 displays responses of nurses with more than 10
years. Based on the data it is plausible to assume that senior leaders have made incorrect
assumptions regarding the impact of the mission of Pacific Hospital.

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Figure 8
Importance of the Mission on Nurse Retention - 0-10 years of experience at Pacific Hospital
Figure 9
Importance of the Mission on Nurse Retention - 10 plus years of experience at Pacific Hospital

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In addition to questions measuring the impact of the organization’s mission on nurse
retention, nurse leaders were asked if the mission of Pacific Hospital presents an opportunity or
barrier to nurse retention. Five of the six nurse leaders agreed that in the current environment the
mission of the organization creates an organizational barrier to improving the factors that are
important to nurses and lead to nurse retention. Denise commented on the realities of being a
safety net hospital, “We are not going to be the organization that is always going to pay top
dollar relative to some other organizations. There are a lot of benefits to it (referring to the
mission) but I think we aren’t able to be as competitive… sometimes we have less flexibility
about how creative we can be about what we do.”
Bailey expanded on concerns of being competitive stating, “I worry that our inability to
be an employer that can be financially competitive will make us less and less attractive…That
which made us attractive in the past may not make us as attractive as it is now.” Alice provided
examples of strategies that other organizations used that were not open to the organization
because of the mission, “It is a common strategy outside of the safety net world to just shut down
beds, shut down units. If they do not have enough nurses, then they close the unit or stop
providing the service. That is not an option for us. If we do not provide the services, then patients
do not have another option.” The challenges of nurse retention in a safety net hospital outlined
by Alice and Bailey, and identified in all but one manager’s interview, speak to the importance
of addressing nurse retention and being creative in identifying solutions.
The only nurse leader who did not agree with the concept of the mission in the current
nursing environment not creating an organizational barrier was Frankie. Frankie was a front line
nurse manager who had been with the organization for four years but was new to leadership and
admitted to not being familiar with the organization elements outside of their respective unit.

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When I inquired on whether she felt the mission was an organizational barrier, she stated she was
unable to comment.
Safety net hospitals, like Pacific Hospital, have a mission to care for patients regardless
of their ability to pay. This organizational mission puts safety net hospitals in a position to
significantly influence health disparities. Based on the data collected in this study, the mission of
Pacific Hospital, specifically the commitment to serve all and address health disparities, provides
Pacific Hospital with a unique opportunity to attract and retain nurses within the organization. At
the same time, the mission of Pacific Hospital, and other safety net hospitals, can also hinder the
organization’s efforts to retain nurses as the mission puts a unique limitation on the
organization’s ability to respond to a changing workforce and compete with other healthcare
organizations.
Theme 2: Sufficient and Competent Staff are the Most Significant Work Unit Factors
Influencing Nurse Retention
Participants were asked to indicate the level of importance of 12 factors in their decision
to stay with Pacific Hospital. Six factors were identified by more than half of participants as
extremely important and a mean sure of greater than 4.5 – sufficient nursing staff (4.59),
clinically competent colleagues (4.48), quality care is provided (4.59), sufficient
ancillary/support staff (4.48), support for autonomy to practice effectively (4.52), and competent
management (4.56). When focusing specifically on nurses who do not serve in a supervisory
role, four factors had a mean score above 4.5 - sufficient nursing staff (4.86), clinically
competent colleagues (4.64), quality care is provided (4.64), sufficient ancillary/support staff
(4.64).

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In addition to importance, participants were asked to indicate to what degree those factors
existed within Pacific Hospital. Of the six factors identified, three factors were determined to be
mostly present at Pacific Hospital with a mean score above 2.6 or greater - quality care is
provided (2.63), support for autonomy to practice effectively (2.67), and competent management
(2.81). Table 8 displays each factor measured in the survey and outlines the percentage of
participants who identified that factor as extremely important and their perception of the
presence of each factor at Pacific Hospital.
Table 8
Importance and Presence of Factors Associated With Nurse Retention
Importance Presence
Nurse Retention Factor Extremely
Important
Mean Most Mean
Sufficient nursing staff 74.7% 4.59 3.7% 1.89
Clinically Competent Colleagues 62.9% 4.48 51.9% 2.52
Quality Care is Provided 59.3% 4.59 62.9% 2.63
Sufficient ancillary/ support staff 55.6% 4.48 0% 1.85
Support for autonomy to practice effectively 55.6% 4.52 66.7% 2.67
Competent Management 55.6% 4.56 81.5% 2.81
Flexible schedule 51.9% 4.44 74.1% 2.74
Nurses and physician function as a team 40.7% 4.15 37.0% 2.30
Positive relationships with physicians 37.0% 4.04 33.3% 2.22
Manager is engaged on the unit 37.0% 4.19 77.8% 2.78
Recognition of staff for good work 18.5% 3.74 37.0% 2.33

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As the data shows, while approximately 75% of participants stated the importance of
sufficient nursing staff in their decision to stay, only about 4% participants felt like sufficient
nursing staff existed in the organization. The same can be said of sufficient ancillary/support
staff. Similar responses were seen in terms of sufficient ancillary and support staff,
approximately 56% of nurses placed a high level of importance on sufficient ancillary and
support staff as a factor for nurse retention, while 0% of nurses felt like that support staffing was
present at Pacific Hospital. The level of importance placed on sufficient staffing compared with
the participants’ perception of presence within the organization suggests that Pacific Hospital has
an opportunity to improve the nurse retention within the organization.
During the interviews, nurse leaders elaborated on the importance of sufficient staffing in
retaining nurses. Interview participants stressed the importance of staffing as a way to mitigate
burnout and fatigue amongst nurses. They spoke of the importance of recruitment as a strategy
for retention. As Frankie stated, “The more you retain nurses, the more you retain nurses,
because you just have more experience. And the new people who come on, that helps them not
feel so overwhelmed every shift because they have these resources who can help them as they
get their sea legs.”
Elizabeth, a front-line manager, also recognized the gap in staffing within the
organization and spoke to that shift in mindset for the organization from enough positions filled
to positions filled with the right nurse for the job,
I think over the next year or so, it is really becoming more than just the bare minimum of
enough bodies. You need to have enough staff who are trained in whatever specialty area
and are competent in whatever area of nursing that they are in. Ideally safe staffing is

70
having enough people who have enough knowledge and enough experience to take the
best care of the patient.
The importance placed on sufficient and competent staffing paired with the lack of
presence at Pacific Hospital led to this significant finding. As nurse leaders pointed out, there has
been a shift from having enough positions filled to having the positions filled with the right
person to meet the needs of the patients seen at Pacific Hospital. The next section expands on the
concept of a sufficient and competent staff and delves into the challenges and consequences of
having high turnover in a short period of time.
Theme 3: Influx of Newer, Younger, and Greener Nurses Have Helped to Stabilize the
Nursing Workforce but Have Also Led to Underserving the Patient Population in Safety
Net Hospitals
While sufficient and competent staff were identified as key drivers of nurse retention,
study participants, front line nurses and nurse leaders, recognized the reality and impact of the
change in the workforce over the past three years. More than 80% of participants agreed that
there had been a change in the workforce at Pacific Hospital and that change impacted Pacific
Hospital’s ability to fulfill their mission and address health equity. Survey participants were
asked four questions regarding the changes in the workforce and the impact on Pacific Hospital.
Four of the questions were closed-ended questions. The fifth question was an open-ended
question asking participants how the changes in the workforce impact Pacific Hospital’s ability
to fulfill their mission with regard to health equity. Table 9 displays the percentage of
participants who agreed to each question. Eighty-one percent of survey participants agreed that
nurse retention had declined in the three years since the pandemic. This percentage increased to
88% and 92% when asked whether participants felt the changes in the workforce impacted

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Pacific Hospital’s ability to fulfill the mission and whether participants felt the changes in the
workforce impact Pacific Hospital’s ability to address healthcare equity.
Table 9
Participants perception of changes in the healthcare workforce
Survey Question m Std Dev
Nurse retention at Pacific Hospital has declined over the last three
years since the pandemic.
3.54 0.63
Changes in the healthcare workforce impact Pacific Hospital’s
ability to fulfill the mission.
3.46 0.97
Changes in the healthcare workforce impact Pacific Hospital’s
ability to address healthcare equity.
3.46 0.89
Interview participants were asked to elaborate on the changes seen in the workforce and
the impact on health equity. Study participants described an influx of newer, younger, and
greener workforce but many of these nurses are new to the field and lack the experience of the
nurses they are replacing which impacts Pacific Hospital’s ability to fulfill the mission of the
hospital and address healthcare equity.
Elizabeth, a front-line manager, stated, “I understand that there was such a mass exodus
that all of these new hires have come on and they are wonderful but there's just a very steep
learning curve.” Frankie, another front-line manager, further expanded on the lack of training,
It has become a real problem having enough trained staff to take care of our population.
Even when we are fully staffed, if they do not know how to properly treat a patient or

72
how to manage a new complex diagnosis or if they are not trained or comfortable taking
care of our patients, it does not do a whole lot of good.
This gap in experience has led to several challenges in patient interactions, quality,
safety, and access. Charlie, a front-line manager, reflected on the interactions between patients
and staff. In response to how the retention challenges impact services delivered, Charlie stated,
It plays out in our patient interactions because people have not had that quality
precepting. They (newer and younger nurses) have not received teaching in those trauma
informed skills and how to deliver, you know care to people who have been traumatized,
who have concurrent mental health disorders, substance use disorders, right.
Another participant, Bailey, expanded on the impact of newer nurses in the workforce at Pacific
Hospital stating,
I worry that it is both sort of in those objective quality metrics but also in those more
subjective measures, we've seen a rise in workplace violence and patients acting out. I
believe some of that is the environment that we have gone through, and that people are
definitely more at that crisis than they were. But also worry that it is in part because we
do not know how to deliver care in the same way we used to be used to, right.
Alice, a senior leader at Pacific Hospital, identified the same challenge but questioned
how much the organization itself is accountable for this shift. They explained,
We have not been able to provide the education. We have not been able to provide the
classes that we used to. We have had a huge influx of people coming in the door. And so,
what of that do we own? What of that are we bringing to work? Our own crisis, our own
trauma and not being able to interact and deliver on our mission in the same way that we
used to.

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As the organization navigated the workforce transitions, it is evident that the influx of a
newer, younger, and greener workforce have not been able to deliver care in the same manner as
the nurses that they are replacing. Table 10 consolidates the comments related to the challenges
of a newer, younger, and greener workforce specifically from the inpatient nurses on the openended survey questions. As participants outlined, this shift in the workforce has led to declines in
objective quality metrics as well as subjective measures such as patient interactions and patient
experience. These barriers ultimately lead to underserving the patient population in safety net
hospitals.
Table 10
Participant feedback on changes in the workforce
Inpatient Nurses Responses to Open-Ended Questions Within the Survey
Pacific Hospital cares for underserved populations but the changes in the workforce have
made it that Pacific Hospital is now underserving those that we aim to care for. We have been
unable to truly meet the demands that come with working in healthcare because of the changes
in the workforce.
It is better now than a year ago, but when we were so short staffed, I did not feel able to
properly care for my patients.
Because of staffing issues, the ability to address care and resources available to patients are
limited because of limited time and ability to interact with the patients.
difficulty to provide adequate care to all patients when short staffed
It is hard to really fulfill the mission when you are understaffed, undertrained (full of travel
nurses and new graduates), and underfunded as an institution
It is hard to provide quality care to a population that is very in need but also very challenging
to work with, without adequate staffing.
Less seasoned and less engaged staff leads to the burnout of people who are seasoned and or
care as they end up taking more on themselves.
Shorter staffing = less opportunity and time to adequately address individual social needs of
patients sometimes (less time/resources to research cultural needs of pts), also fewer
healthcare translator resources.
Not enough staff, not enough time to take care of the whole patient, lots of needs not being
met for the "whole" patient
Decreased staffing numbers mean decreased ability to offer services or create new programs
that would help our population

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Inpatient nurses within this study clearly identified a high level of importance on
organizational mission and the need for sufficient and competent nursing staff to influence their
desire to stay with the organization. However, for Pacific Hospital to deliver on the mission of
the organization and address healthcare equity, Pacific Hospital must not simply retain nurses, it
must also prepare nurses to deliver care to the unique population served by the safety net
hospital. By not addressing the training and preparation for nurses, Pacific Hospital is at risk of
underserving the population by providing poor patient interactions and delivering inadequate or
poor-quality care. The next section outlines the strategies that leaders have implemented and
their alignment to the identified needs of the nurses.
Theme 4: Effective Retention Strategies Were Aimed at the Organizational Culture and
Individual Needs or Wants of Nurses.
Nurse leaders were asked to identify strategies that they have implemented or were
considering to address nurse retention. For each strategy provided, participants were also asked
to identify the effectiveness of that strategy. All six nurse leaders outlined an array of strategies
that were implemented or being evaluated to address nurse retention. Participants spoke to the
need for a variety of strategies to increase nurse retention. They shared strategies to improve the
work environment, systems, and processes within the organization. However, the strategies that
participants described as most effective were aimed at either the organizational culture or the
individual needs and wants of nurses, specifically they spoke of importance and effectiveness of
shared governance and pay.
Shared Governance
Shared governance was one of the strategies all six interview participants highlighted as
an organizational strategy to support nurse retention within the organization. Shared governance

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was described by Bailey as a way to let nurses have more control over the factors that matter
most to nurses, specifically staffing. Bailey described the importance of staffing ratios, also
known as nurse-patient ratios, and the decision to let front line staff make that decision as
opposed to senior leadership.
Staffing ratios are a hard balance, you don’t want to be locked in because some patients
might need two nurses to one patient, and in another case, there could be the need for one
nurse to two patients. So, we may need to shift, and we wanted to give the nurses the
empowerment to do so. For the staff to be a part of that and to weigh in and to say when
it works and when it is not working, empowers them to help make the quality and safety
of care better.
Elizabeth also spoke to how shared governance in decision-making empowers staff to have more
control over their workload and determine what are the staffing levels needed to support quality
care for patients. When asked how shared governance supports retention, Elizabeth commented
“Our nurses really want to have a say and do have a say in the day-to-day workings of Pacific
Hospital. I think feeling like you have influence, and you have a voice is something that is really
special about Pacific Hospital and helps to retain staff.”
Shared governance was also described as one of the foundational elements for the
hospital and their recognition as a Magnet hospital. The Magnet Recognition Program was
developed by the American Nurses Associated (ANA) to recognize health care organizations for
quality patient care, nursing excellence and innovations in professional nursing practice
(American Nurses Association, 2019). In describing the value of Magnet and shared governance,
Alice stated, “Magnet is all about nursing shared governance and having nursing drive the
quality and the outcomes for the patients and have a very strong voice at the table. So that

76
certainly helped us from a nursing retention perspective becoming a magnet organization.”
Denise expanded on the importance of shared governance and how the Magnet designation sends
a message to nurses within the organization as well as potential recruits, “Our team is really
proud of our Magnet recognition. It helps retain and it also helps recruitment. Nurses look for
Magnet organizations to work for because they know they will be treated differently and have a
voice.”
Pay
Participants identified several other strategies implemented at an organizational level
with varying degrees of success. From the data, shared governance was identified as the biggest
influencer at an organizational level in terms of nurse retention. Another organizational element
that had a significant impact that was identified from the study was pay. Seventy- one percent of
survey participants identified pay adjustments as a significant organizational factor that
influences nurse retention. Nurse leaders also perceived a positive effect on nurse retention;
however, senior leaders and front-line managers had differing perspectives of the consequences
of these pay increases outside of retaining nurses. Each interview participant reflected on pay
increases that had recently been implemented within the organization. Response from the frontline managers focused on how pay adjustments translated to value and appreciation for nurses.
Their comments focused on the ability to compete with community organizations or staffing
positions that offered much higher salaries throughout the pandemic. Senior leaders also spoke to
pay disparity in comparison to community hospitals and staffing agencies, however their
responses briefly highlighted the benefits pay increases have to retaining nurses and quickly
turned to focus more on the long-term impacts of the pay adjustments. Senior leaders spoke to
whether the adjustments are sustainable, and how to maintain them when the organization as a

77
whole is tasked with delivering on a mission that is not compensated at a rate to sustain the pay
adjustments made. Table 11 displays the responses from front-line managers and senior leaders
and demonstrates the differing opinions offered by the respective leaders.
Table 11
Leadership Reflection on the Impact of Pay Adjustments
Front Line Managers Senior Managers
Pay has been a huge driver in nurse retention.
Nurses got huge, huge raises and to say it
bluntly and it matters.
The biggest one we did, and what we had to
do, was adjust pay but it has long lasting
implications. We gave a very competitive
increase particularly to our nursing staff to try
to narrow the band between what you would
make with us vs the community or as a
traveler.
I think it’s literally making people feel more
valued and I think that's a great thing. I think
that (pay increases) have been very effective.
We did make a decision to try to be more
competitive in pay, which has put us in a very
bad financial situation.
I would say there has been a peak interest in
wanting to feel valued. I think that has been a
theme and value was shown in the increased
pay nurses received and it also equated to
increased visibility and appreciation.
It all circles back to us making sure we're
being adequately funded for what we do. We
are already challenged around to be
financially stable right now partially due to
the price increases with our nurses.
We have just proven that we can pay a fair
labor rate and keep staff. But this makes our
job harder to figure out how to keep the doors
open around all the services that we want to
be able to offer due to the fact we are not
appropriately compensated for that mission.
(In reference to pay increases) … it is a risk
and it is a reward.
Healthcare is definitely going through a
reckoning. I think some of our challenges that
are more near term versus longer term are
going to be because we cannot really afford
some of the decisions that we have made
related to some of those pay increases.

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Nurse leaders at Pacific Hospital recognized the need to respond to the changing
workforce and implement changes aimed directly at increased nurse retention at Pacific Hospital.
While there is no silver bullet to retain nurses, nurse leaders perceived their efforts to create an
organizational culture around shared governance and empowering nurses had a significant
impact on nurse retention. Nurse leaders believed the adjustments to the organizational culture at
Pacific Hospital in combination with financial investments in the nursing workforce, have been
successful in retaining nurses, even though it places an additional burden on the Pacific Hospital
and their ability to deliver on the mission due to financial constraints.
Summary of Findings
The purpose of this study was to examine the impact of the Great Resignation on nurses’
intention to leave in safety net hospitals and strategies nurse leaders are developing to increase
retention. This study focuses on the challenges unique to safety net hospitals in responding to the
existing and accelerated workforce shortage. This analysis identified four main themes. (1)
Mission of the organization is the most significant organizational factor influencing nurse
retention and the most significant organizational barrier. (2) Sufficient and competent staff are
the most significant work unit factors influencing nurse retention. (3) Influx of newer, younger,
and greener nurses have helped to stabilize the nursing workforce but have also led to
underserving the patient population in safety net hospitals. (4) Effective retention strategies were
aimed at the organizational culture and individual needs or wants of nurses.
Data analysis indicated that changes within the workforce since the pandemic have
created opportunities and barriers for safety-net hospitals. Safety-net hospitals have the
opportunity to use their mission as a competitive advantage for recruitment and retention.
Despite some leaders’ perception that the mission is not as critical in retention as previous

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generations, nurses at Pacific Hospital are influenced to stay within the organization because of
their commitment to the mission. As the data show, nurses share the same commitment to the
organization as the senior leaders who have been with the organization for many years, and they
also prioritize the ability to deliver on that mission which includes sufficient and competent staff
within the unit. In response to the pandemic, the high turnover and lack of sufficient and
competent staff has led to nurses to feel like the care provided lacks the same standard of care,
led to poor quality outcomes, poor patient interactions, and inability to serve the patients that rely
on the safety net hospital. The final chapter will use these findings to present evidence-based
recommendations for nurse leaders to address nurse retention.

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Chapter 5: Discussion and Recommendations
Previous research has shown the importance of nurse retention in the face of a looming
global healthcare workforce shortage (Fry, 2022; Unruh & Zhang, 2012). While retention is
important for all healthcare systems, this study focused on the challenges unique to safety net
hospitals. The purpose of this study was to examine the impact of nursing shortages in safety net
hospitals, which were exacerbated in the wake of the coronavirus pandemic and the Great
Resignation that followed, and strategies health care executives have implemented to increase
nurse retention in support of their mission with regard to health equity. By focusing on safety net
hospitals, this study hoped to contribute to safety net hospital’s retention plans and to support
their ongoing efforts to address health equity. This study was guided by the following research
questions:
1. What key factors influence a nurses’ decision to stay at Pacific Hospital?
2. How do nurses and nurse leaders perceive changes in the healthcare workforce have
impacted Pacific Hospital’s ability to fulfill their mission with regard to health equity?
3. What system, processes, or practices have nurse leaders at Pacific Hospital developed to
address nurse retention?
The objective of this fifth and final chapter is to propose evidence-based recommendations
for practice, based on the study’s findings, that Pacific Hospital, and other safety net hospitals,
can adopt to increase nurse retention. This chapter begins with a discussion of findings, followed
by recommendations for practice, recommendations for future research, limitations and
delimitations, and conclusion of this study.

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Discussion of Findings
This section provides a review of the findings discussed in Chapter 4 and relative to
existing literature. The Burke-Litwin Organizational Change and Performance model provided
the theoretical framework for this study. Utilizing the Burke-Litwin model helped to identify
how the workforce changes related to the nursing shortage and global pandemic influenced
organizational factors at the transformation level and transactional level and ultimately nurse
retention at Pacific Hospital.
Four themes emerged from the mixed methods study. These themes were: (1) Mission of
the organization is a significant organizational factor influencing nurse retention and a significant
organizational barrier; (2) A sufficient and competent staff is a significant work unit factor
influencing nurse retention; (3) An influx of newer, younger, and greener nurses has helped to
stabilize the nursing workforce but has also led to underserving the patient population in safety
net hospitals; and (4) Effective retention strategies were aimed at the organizational culture and
individual needs or wants of nurses. Some of the findings were consistent with existing literature,
others highlighted gaps within the literature. The following provides a detailed discussion of
each thematic finding and its alignment with the Burke-Litwin Organizational and Performance
model.
Theme 1: Mission of the Organization is a Significant Organizational Factor Influencing
Nurse Retention and a Significant Organizational Barrier
Safety net hospitals, like Pacific Hospital, have a clearly defined mission to care for
patients regardless of their ability to pay (Sarkar et al., 2020). While the sample size for this
survey was relatively small in relation to the population, eighty-one percent of inpatient nurses
from this study agreed that the mission of Pacific Hospital had a positive influence on nurse

82
retention. When disaggregating the data by supervisory or non-supervisory roles, the majority of
participants, 92% and 72% respectively, agreed that the mission of the organization positively
influenced nurse retention. The data also showed that 88% of nurses with fewer than 10 years of
experience at Pacific Hospital indicated that they strongly agreed or somewhat agreed that
mission was an important factor in their decision to stay at Pacific Hospital, compared to 67% of
nurses with more than 10 years of experience at Pacific Hospital. Interestingly, nurse leaders
from this study, specifically those in senior leadership positions, perceived that the mission of
Pacific Hospital was not as influential to nurses, especially to nurses who had recently joined the
organization or profession, than nurses themselves reported. The difference in perception
amongst nurses and nurse leaders highlights the importance of this study, as limited research was
found showing a correlation between the mission and nurse retention. This finding also
demonstrates an opportunity for Pacific Hospital to lean on their mission as a strategy for nurse
retention.
As mentioned, there appears to be little research that focuses specifically on how the
mission of a safety net hospital influences nurse retention; however, there is research that
demonstrates a correlation between organizational commitment and nurse retention (Macedo et
al., 2016; Vagharseyyedin, 2016).). Organizational commitment is defined as the psychological
attachment an employee has to an organization (Neves et al., 2022). Macedo et al. (2016) found a
correlation between organizational commitment and job retention indicating that higher
commitment to the system is associated with higher job retention in nurses. Vagharseyyedin
(2016) expanded on this finding, suggesting nurses' organizational commitment is influenced by
various factors related to personal characteristics, leadership and management, organizational
context, and characteristics of job and work environment. Therefore, it may be plausible to

83
assume that the mission of the safety-net hospital is a factor that influences organizational
context within the organizational commitment, which in turn suggests that the mission can
influence nurse retention.
While the mission demonstrates an opportunity for Pacific Hospital in retaining nurses, it
was also identified as a barrier or organizational obstacle. Based on the data collected in this
study, Pacific Hospital’s mission to serve all regardless of their ability to pay provides Pacific
Hospital with a unique opportunity to attract and retain nurses. At the same time, the mission of
Pacific Hospital was described as an organizational barrier to retain nurses as the mission puts a
limitation on the organization’s ability to respond to a changing workforce and compete with
other healthcare organizations. Five of the six nurse leaders in this study shared how the mission
of Pacific Hospital does not generate revenue, placing additional burdens on the safety net
hospital when it comes to competing with other hospitals and organizations who are better
compensated for the care they deliver. Nurse leaders explained how Pacific Hospital’s
commitment to ensure access to health services, regardless of a patient’s ability to pay, results in
losses of revenue and fewer operational dollars for Pacific Hospital to meet the needs of their
workforce. The experiences shared by nurse leaders are consistent with existing literature. The
2000 Institute of Medicine report (2020) questioned safety-net hospitals' financial viability due
to their role in providing widespread access for patients. Studies have shown that safety-net
hospitals, on average, have lower baseline levels of financial performance as compared to nonsafety-net hospitals (Gafney & Michelson, 2023; Gilman et al., 2015; Reiter, 2014). The existing
literature is consistent with the findings of this study and demonstrates the unique challenges to
safety net hospitals like Pacific Hospital when it comes to nurse retention.

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Research question one sought to explore key factors influencing nurse retention at Pacific
Hospital. The findings of this study suggest that the mission of Pacific Hospital is a
transformational factor that positively influences nurse retention by influencing transactional
factors like the work environment and the individual needs and wants of a nurse. Simultaneously,
the mission was shown to be a transformational factor that influences the systems, processes, and
policies within the organization by placing additional challenges for nurse leaders to navigate in
their efforts to improve nurse retention. The next section discusses transactional factors that
influence nurse retention at Pacific Hospital.
Theme 2: Sufficient and Competent Staff are the Most Significant Work Unit Factors
Influencing Nurse Retention
This finding emerged from the importance placed on sufficient and competent staffing
paired with the lack of presence at Pacific Hospital. Seventy-five percent of participants placed a
high level of importance on sufficient nursing staff in their decision to stay, while only about 4%
of participants felt like sufficient nursing staff existed in the organization. Similar responses were
seen in terms of sufficient ancillary and support staff, with approximately 56% of nurses placing
a high level of importance on sufficient ancillary and support staff as a factor for nurse retention,
while 0% of nurses felt like that support staffing was present at Pacific Hospital. As nurse
leaders pointed out, recruitment efforts within Pacific Hospital were previously focused on
reducing the vacant positions. The focus of recruitment efforts shifted to filling the vacant nurse
positions with the right person to meet the needs of the patients seen at Pacific Hospital.
According to previous studies, sufficient staffing in the work environment are positively
attributed to nurse retention (Aiken et al., 2012; Lee et al., 2015; Sasso et al., 2019). Staffing, or
patient-nurse ratios, is associated with nurses’ workload, job satisfaction, and burnout (Chen et

85
al, 2019). In a cross-sectional study by Chen et al., researchers found that an increased patient–
nurse ratio would increase nurses’ intention to leave their job. Further, a meta-analysis of thirteen
cross-sectional studies showed a higher patient-to-nurse ratio had a higher risk for burnout, job
dissatisfaction, and intent to leave, with significant effect sizes ranging from 1.05 to 1.08 (Shin et
al., 2018). Similarly, Dutra et al. (2018) and Hayward et al. (2016) found that staffing adequacy
was not a predictor of a nurses’ job dissatisfaction, but it was found to influence a nurses’
intention to leave and the perception of a higher patient-to-nurse ratio may increase workload
demands, which could further contribute to nurses’ intentions to leave. When nurses perceived
staffing in the unit was adequate, nurses were significantly less likely to leave their current
nursing position (Sasso et al., 2019)
This theme paired with the earlier thematic finding by identifying factors at the
transformational and transactional level within the Burke Litwin Organizational Performance and
Change Model. The mission of the organization serves as a transformational factor influencing
nurse retention; sufficient and competent workforce staffing serves as a transactional factor
influencing nurse retention. While the mission of the organization may be beneficial to the
retention of nurses at Pacific Hospital, if a sufficient and competent workforce is not consistently
present, that can negatively influence nurse retention.
Theme 3: Influx of Newer, Younger, and Greener Nurses Have Helped to Stabilize the
Nursing Workforce but Have Also Led to Underserving the Patient Population in Safety
Net Hospitals
For Pacific Hospital to deliver on the mission of the organization and address healthcare
equity, Pacific Hospital must not simply retain nurses, it must also prepare nurses to deliver care
to the unique population served by the safety net hospital. Eighty-eight percent of nurses agreed

86
that the changes in the workforce impacted Pacific Hospital’s ability to deliver on its mission.
Ninety-two percent agreed that the changes in the workforce impacted Pacific Hospital’s ability
to address nurse retention. Nurse leaders elaborated on the impact of the changing workforce by
pointing out that from their perception turnover had led to a larger percentage of new nurses in
the workforce, including nurses that are new to the profession of nursing and/or new to the
organization within the unit. Nurse leaders also provided examples of the difference in
competency of these nurses when it comes to dealing with the patient population seen at Pacific
Hospital. The influx of this newer, younger, and greener workforce helped to fill positions and
support sufficient staffing in the unit, but nurses from this study felt the staff were not prepared
to treat patients seen at Pacific Hospital, which has negatively impacted Pacific Hospital’s ability
to fulfill its mission, specifically as it relates to health equity. Nurse leaders provided examples
like poor patient interactions, lower quality scores, and an increase in workplace violence to
illustrate the inability to fulfill the mission. By not addressing the training and preparation for
nurses, Pacific Hospital is at risk of underserving the population by providing poor patient
interactions and delivering inadequate or poor-quality care.
This theme is consistent with existing literature that demonstrates a correlation between a
strong healthcare workforce and better health outcomes (Liu & Eggleston, 2022; Amiri &
Solankallio, 2019; Robinson & Wharrad, 2001). Focusing specifically on the younger and
greener workforce, research has recently emerged demonstrating the impact of the Covid-19
pandemic on nursing education and preparing nurses for the profession. Dewart et al. (2020) and
Leaver et al. (2022) suggest that limited clinical experiences for students have created a pipeline
of nurse graduates with difficulties in filling the gaps being left by experienced nurses.
Healthcare is a labor-intensive industry that relies on well-trained healthcare professionals to

87
deliver services (Harris et al., 2020) Additionally, for healthcare organizations to deliver
healthcare services and meet healthcare goals and targets, the organization must secure a
sufficient, adequately supported, and well performing healthcare workforce (Birkhäuer et al.,
2017). Cinaroglu (2023) explored the interrelationship between human resources, quality of care,
and health outcomes and found a strong interrelationship between the three factors, specifically
between the number of nurses, hospital admissions, and mortality rates. The absence of a
sufficient and competent healthcare workforce has been linked to quality and safety issues, poor
patient outcomes, and missed care which aligns with the findings of this study.
This theme addressed research question two of this study which sought to explore how
nurses perceived the changes in the workforce had impacted Pacific Hospital’s ability to fulfill
their mission in regard to health equity. In response to the reflection and experiences of nurses in
this study, Pacific Hospital has an opportunity to improve the training and preparation of nurses
joining the workforce in order to meet the needs of the patients and fulfill the mission to address
health equity. The next section focuses on the third and final research question of this study and
discusses the strategies that Pacific Hospital has effectively implemented to address nurse
retention.
Theme 4: Nurse Leaders Have Applied Multiple Retention Strategies Aimed at the
Organizational Culture and Individual Needs or Wants of Nurses
Nurse leaders from this study identified multiple strategies that were implemented in
response to the declining nurse retention; however, two strategies were identified to be the most
effective of all the strategies that were implemented – shared governance and pay. Existing
literature has demonstrated that shared governance and pay can increase nurse retention (Gordon
& Cole, 2023; Lal, 2021; Min et al., 2023; Sasso et al., 2019; Swanson et al., 2023). In this

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study, shared governance was identified by all six nurse leaders as a critical strategy toward
nurse retention. Nurse leaders shared how shared governance was utilized at Pacific Hospital to
empower nurses to have more control over their workload, staffing, and to drive quality care for
patients. Giving nurses control of their practice is the core of a shared governance framework
(Lal, 2021). In addition to the benefits outlined by nurse leaders in the study, shared governance
has been shown to be a mutually beneficial activity that supports nurse engagement, improves
quality in the work environment and increases job satisfaction (Gordon, 2016; Swanson et al.,
2023). Shared governance is also positively associated with connecting employees to the mission
of an organization (Reid & Cole, 2023).
In addition to shared governance, nurse leaders stressed the importance and effectiveness
of pay adjustments that were made to retain nurses. The literature cites many factors that
contribute to nurse retention and pay is repeatedly identified as a leading factor (Bimpong et al.,
2020; Min et al., 2023; Sasso et al., 2019). A meta-analysis demonstrated a positive association
between job satisfaction and pay (Judge et al., 2010). Focusing specifically on nurses, pay has
been shown to support nurses’ job satisfaction by demonstrating value to the nurse (Bimpong et
al., 2020) As important as pay may be in retaining nurses, Saaeed et al. (2023) discovered pay
satisfaction is not a mitigation for lack of organizational commitment or lack of job satisfaction.
While pay is consistently associated with job satisfaction which supports nurse retention, pay
alone cannot mitigate the absence of other known factors that support nurse retention such as
organizational commitment or staffing.
Recommendations for Practice
The following section provides recommendations to increase nurse retention based on the
findings of this study. Three recommendations are outlined in this section as an opportunity to

89
increase nurse retention and address concerns related to fulfilling the mission of Pacific Hospital,
specifically as it relates to addressing health equity. The three recommendations align with the
findings from participants in this study while taking into consideration the reality of a global
nursing shortage. The recommendations include: (1) Adjustments to the care model; (2)
Expansion of the nurse fellowship program; and (3) Implement virtual care nurses. Table 12
below outlines how each recommendation aligns with the findings of this study. Shared
governance and pay are not directly linked to any of the recommendations below; however, the
shared governance model plays a vital role in the implementation and change management
needed to implement each model. The role of shared governance in each of these findings is
shared in the following section.

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Table 12
Evidence Based Recommendations for Practice
Recommendation Relationship to Key Findings Literature Support
Alternative Care Model 1. Mission of the organization is a
significant organizational factor
influencing nurse retention and a
significant organizational barrier.
2. Sufficient and competent staff are the
most significant work unit factors
influencing nurse retention.
3. An influx of newer, younger, and
greener nurses have helped to
stabilize the nursing workforce but
have also led to underserving the
patient population in safety net
hospitals.
Endacott et al., 2022
Duffield et al., 2021
Molle & Allegra, 2021
Butler et al., 2019
Expansion of the Nurse
Fellowship Program
1. Sufficient and competent staff are
the most significant work unit
factors influencing nurse retention.
2. An influx of newer, younger, and
greener nurses have helped to
stabilize the nursing workforce but
have also led to underserving the
patient population in safety net
hospitals.
Asber, 2019,
Maxwell, 2011,
Olson- Sitki et al., 2012,
Trepanier et al., 2012
Implement Virtual Care
Nurses
1. Mission of the organization is a
significant organizational factor
influencing nurse retention and a
significant organizational barrier.
2. Sufficient and competent staff are
the most significant work unit
factors influencing nurse retention.
3. An influx of newer, younger, and
greener nurses have helped to
stabilize the nursing workforce but
have also led to underserving the
patient population in safety net
hospitals.
Cloyd & Thompson,
2020
Dechert et al.,, 2023,
Perpetua et al., 2023
Schuelke et al., 2019,
Savitz et al., 2023

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Recommendation 1: Alternative Care Model
While efforts to reduce or maintain a certain patient-to-nurse ratio will support nurses’
intentions to leave and consequently nurse retention, these efforts also rely on a hospital’s ability
to fill all the available vacancies and additional positions created from changes in the patient-tonurse ratio. The current nurse shortage is a potential barrier to this solution as the organization is
already having trouble in fulfilling existing positions. However, there are alternative care models
or staffing models, such as team nursing or buddying, that do not rely solely on registered nurses
that have been implemented and proven to be successful. Endacott et al. (2022) described a team
nursing model as a team of nurses and non-nursing staff who work together to deliver and
monitor care for a group of patients. Similarly, buddying is described as one nurse paired with a
non-nursing staff member to care for a group of patients. In team nursing models and buddying,
the nurse serves as a team leader supervising non-nursing staff and performing direct patient care
that non-nursing staff are not qualified, licensed, or trained to provide (Duffield et al., 2010).
Other team members provide task-based direct patient care to assigned patients based on the
complexity of the task (Duffield et al., 2010).
Alternative care models have been shown to improve job satisfaction, engagement, and
retention by enhancing the work environment (Butler, 2021; Fernandez et al., 2012). In addition
to the improvements to the work environment, this model has been shown to improve some
patient outcomes such as mortality, fewer medication errors, fewer emergency codes and
decreased falls (Becket et al., 2021; Butler, 2021; Dickerson & Latina, 2017; Dobson & Drexler,
2007; Fernandez et al., 2012). From a nurses’ point of view, Molle and Allegra (2021) found that
nurses perceived the alternative staffing models as beneficial and that they increased efficiency
in patient care. Jones and colleagues (2022) found alternative care models are associated with

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self-perception of reduced workload and high quality of care. Lastly, as newly registered nurses
are increasingly a significant proportion of the workforce in acute medical and surgical units,
working alone in the traditional patient-to-nurse ratio may not be the best method to learn how to
provide care (Duffield et al., 2010). Alternative care models may provide inexperienced or newer
nurses with a better environment for providing care.
The study’s findings show that nurses place a high level of importance on the mission of
Pacific Hospital as well as sufficient and competent staffing in determining whether to stay with
the organization. The study’s findings also show that the mission of the organization provides a
significant organizational barrier to nurse retention. The goal of an alternative care model is to
provide additional staffing support and increase the efficiency of existing nursing staff and
support nurses in fulfilling the mission of the organization. The advantage of an alternative care
model is the model does not require adding additional nursing positions to the organization,
which reduces some of the financial burden and mitigates some of the barriers the mission places
on the organization. However, the risk of an alternative care model is not being able to fill the
support positions, placing additional workload burdens on the existing nursing staff and
hindering their ability to fulfill the mission of Pacific Hospital.
Recommendation 2: Expansion of the Nurse Residency Program
Nurse residency programs (NRP) are specially designed programs to support new nurses
transitioning into professional practice as a licensed registered nurse. NRPs were identified in the
Institute of Medicine’s 2010 report, “The Future of Nursing” as one of eight key
recommendations to guide the nursing profession and advance the health of Americans. NRPs
consist of a detailed orientation curriculum to support a new graduate nurse as they transition
into practice. NRPs vary in length of program and structure but have been shown to increase first

93
year nurses’ retention following program implementation (Asber, 2019; Maxwell, 2011; OlsonSitki et al., 2012; Trepanier et al., 2012). In 2011, Maxwell (2011) found an acute care hospital
in Georgia saw their retention rates for new graduates increase from 50% in 2006 to 100% in
2009 following the implementation of a one-year NRP, hiring of a clinical nurse specialist to
oversee the program, and alignment of their program with the University Hospital
Consortium/American Association of Colleges of Nurses Nurse Residency Program. Similar
results were seen by Olson-Sitki et al (2012) who found new graduate nurses retention increased
from 86.5% to 91% over two years at a Magnet-designated medical center, and Trepanier et al.
(2012) who studied nurse retention across a 15 hospital sites within a healthcare corporation.
Trepanier et al. saw the average nurse retention rate across all sites increase from 63.2% to
93.6%, following implementation of a structured nurse residency program. While nurse
residency programs may vary in structure and length, studies show the formally defined and
established nurse residency program developed in partnership by the University Hospital
Consortium/American Association of Colleges of Nurses and Versant have been associated with
retention rates in the 90% to 100% range.
Nurse residency programs have proven to be beneficial in retaining new nurses, and they
can also be beneficial in retaining experienced and existing nurses. Nurse preceptorship has been
shown to positively contribute to a nurse’s intention to stay and reduce turnover (Jönsson et al.,
2021). Nurse residency programs offer the opportunity for experienced nurses to serve as nurse
preceptors, either by participating in the delivery of the curriculum of the nurse residency
program or by serving in a mentoring role for a new nurse. NRPs also provide professional
development opportunities for existing nurses who find pairing with a new nurse allows them to

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sharpen their tools, stay up to date on the latest trends, and practice in different settings such as
clinical nurse educators (Jönsson et al., 2021).
NRPs present Pacific Hospital with an opportunity to improve the training and education
of new nurses joining the workforce and simultaneously support existing nurses by improving
the competency of colleagues and providing precepting opportunities.
Recommendation 3: Implement Virtual Care Nurses
Virtual care nurses (VCN) are remote-working nurses who provide care and services
through telephonic or video technology at the bedside (Cloyd & Thompson, 2020).
Implementation of a virtual care nurse within the inpatient setting is an evidence-based strategy
that can be utilized to support nurse workload and consequently nurse retention (Savitz et al.,
2023). From an organizational standpoint, this strategy supports healthcare leaders by addressing
efficiencies and maximizing the use of existing resources. VCNs also provide an opportunity to
retain experienced nurses by providing them an option to transition from the bedside but
continue to support the organization.
In addition to retaining nurses, studies have recently emerged showing the effectiveness
of implementing a virtual care nurse with a range of responsibilities (Dechert et al., 2023;
Perpetua et al., 2023). Study findings reveal that nurses had a positive attitude towards
technology to enhance efficiency, communication, and sustainability (Marcus & Clark, 2021).
Schuelke and colleagues (2020) found that there was no significant change in missed care.
Studies focused on quality of care have mainly shown similar outcomes as traditional care
models (Schuelke et al., 2019; Perpetua et al., 2023; Savitz et al., 2023) Virtual nursing is not
perfect, but outcome data continue to demonstrate a positive impact to nurses, including early
indications of a 35% reduction in nurse turnover (Advisory Board, 2022). Together these studies

95
suggest that virtual care nurses have the potential to improve staff experience, patient satisfaction
and costs associated with the delivery of care.
The findings of this study show that the mission of the organization is a significant
organizational factor influencing nurse retention and a significant organizational barrier. The
findings of this study also show a desire for nurses to have sufficient and competent colleagues,
as well as a need to support new nurses transitioning to practice. Virtual Care Nurses can be
implemented in a variety of ways. Depending on the desires of Pacific Hospital, implementation
can focus on meeting some or all of the significant factors nurses identified in this study.
Implementation of technology within the inpatient setting is an evidence-based strategy that can
be utilized to support nurse workload and consequently nurse retention. This strategy supports
nurses as it provides the opportunity to reduce the burden of some nursing tasks allowing nurses
to efficiently meet patient needs and fulfill the mission of Pacific Hospital. This strategy also
supports healthcare leaders in mitigating some of the challenges caused by the mission of the
organization by addressing efficiencies and maximizing the use of existing resources. Unlike the
previous recommendations, this strategy does rely on additional nursing staff to implement but it
also provides existing nurses an opportunity to transition from the bedside and still support the
organization’s mission, ultimately supporting the retention of experienced nurses.
Limitations and Delimitations
According to Creswell and Creswell (2018), limitations are influences that the researcher
cannot control. Limitations for this study include response biases and timing. Response bias, or
social desirability bias, occurs when survey participants are hesitant to tell the truth when it could
be perceived as negative or unfavorable (Robinson & Leonard, 2019). While efforts were made
to maintain confidentiality, there remains a concern that participants may have been hesitant to

96
provide honest responses based on the nature of the study and my position within the
organization, even though my position is in a different division of the organization.
In addition to the potential for response bias, there was also a concern regarding the
timing of the survey and the level of participation. Pacific Hospital implemented an
organizational strategy related to wage and benefits in the months prior to the administration of
the survey. Pacific Hospital is also a trauma hospital with seasonal peaks in volume. While
efforts were made to mitigate the seasonality of nurse’s workload, the study failed to gain a large
sample size potentially due to the timing of other surveys initiated at Pacific Hospital. This
survey was administered at the same time or close to the organization’s annual workplace
survey, their workplace equity survey, and end of year performance reviews. I believe the timing
of this research study significantly limited participation in this study. It is also possible that the
limited participation is a representation of the bandwidth of the nurses at Pacific Hospital.
Delimitations are the boundaries set by the researcher (Creswell & Creswell, 2018) A
delimitation for this study lies within the conceptual framework of this study. This study utilized
three of the twelve factors within the Burke Litwin Organizational Performance and Change
model. Focusing this research on a few factors within the framework introduced the opportunity
for key factors related to nurse retention to be missed or omitted from the findings. Additional
delimitation for this study related to the participants of this study. This study focused on the
perception of nurses within the inpatient setting of an urban academic medical center. The
experiences and perceptions of nurses in the inpatient setting may not reflect the experiences and
perception of nurses in other settings of the safety net hospital such as outpatient care settings,
home health, or care coordination or at other safety net hospitals in different settings. This study
also only surveyed nurses who are currently working at Pacific Hospital. The study was not

97
designed to capture the opinions or perceptions of those who had worked at Pacific Hospital and
choose to leave.
Recommendations for Future Research
Safety net hospitals are in a unique position to improve health disparities and support the
US healthcare systems’ effort to improve health equity due to their mission and the patient
population they serve. The hospital's ability to fulfill their mission is dependent on their ability to
recruit and retain staff to deliver care. This study focused on efforts to retain nurses at a safety
net hospital. The findings of this study were based on a limited sample size but revealed that the
mission of the safety net hospital is an important factor to nurses when it comes to nurse
retention. While the mission of a safety net hospital could be associated with organizational
commitment, limited research was available to determine whether this finding is consistent with
other safety net hospitals or unique to Pacific Hospital. Additionally, further research should be
done to explore the perception of nurses at other safety net hospitals. Research should not only
focus on the nurses who work within the hospital, but future research should consider nurses who
have left safety net hospitals as well as future nurses' perception of safety net hospitals and how
their perception impacts the safety net hospital’s ability to recruit. Given the looming global
healthcare workforce shortage, it is important to understand how to attract nurses to a safety net
hospital as well as how to retain them.
In addition to efforts to recruit and retain nurses, future research should look at the impact
of alternative care models on patient outcomes. This study contributed to an ongoing
conversation regarding nurse retention with many providing similar recommendations to explore
alternative models for delivering care. Whether it is the implementation of healthcare technology
or adjustments to the care team, these efforts to maximize the available workforce can support

98
nurse retention as well as impact the level of services provided to patients. As health systems
explore and are incentivized to transition from the transitional model of care for cost savings or
efficiencies, additional research is warranted to determine whether implementation of these
strategies, whether it is technology or alternative care models, create disparities of care for
different patient populations.
Conclusion
This study examined nurse retention in a safety net hospital and how the hospital
responded to a nursing shortage exacerbated by workforce changes related to the global
pandemic and the Great Resignation in order to fulfill their mission. The theoretical framework
utilized was the Burke Litwin Organizational Performance and Change model. The framework
guiding this research study helped explore how changes in the external environment, the existing
nursing shortage that was exacerbated by the Great Resignation, influenced transformational and
transactional elements within Pacific Hospital that impacted the organization’s ability to retain
nurses. The findings of this mixed method study are based off a limited sample size but show
that Pacific Hospital has successfully implemented some effective strategies to retain nurses and
also has an opportunity to explore additional strategies that align with factors that matter most to
the nurses Pacific Hospital wishes to retain. This study proposed three recommendations for
practice that could be implemented to support nurse retention efforts: 1) Implement an
alternative staffing model; 2) Implement a Nurse Residency Program; and 3) Implement Virtual
Care Nurses. These strategies aligned with the factors that were identified within the study as
most important to inpatient nurses, while also balancing the reality of a global healthcare
workforce shortage. Additionally, the findings of this study shed light on the challenges Pacific

99
Hospital had in fulfilling their mission for addressing health equity. This study underscores the
challenges safety net hospitals face in addressing nurse retention and the significance of these
challenges in terms of health equity for patients that are treated at Pacific Hospital, or similar
safety net hospitals.
Overall, the findings suggest that Pacific Hospital can improve the effectiveness of their
nurse retention strategies by aligning their approach with the factors that matter most to nurses –
Mission and Sufficient and Competent Staffing. This study reiterated findings from previous
studies, related to the importance of sufficient and competent staffing in addressing the needs of
nurses to retain them. This study also illustrated a gap in the research in terms of how the
mission of the organization, specifically a safety net hospital, can be a retention factor. This
research study demonstrated an opportunity for Pacific Hospital to lean on their mission as a
strategy to retain nurses, while balancing the additional hardships placed on a safety net hospital.
Strategies that align with the factors that matter to nurses will likely increase nurse retention and
support the efforts of Pacific Hospital in fulfilling their mission, while simultaneously reversing
some of the negative outcomes Pacific Hospital has experienced over the last three years.
The global healthcare workforce shortage has placed an emphasis on retention for
healthcare leaders around the world. With a growing and aging population and predicted
shortages of 18 million nurses by 2030, retention is not only important for the operations of a
healthcare system, but it is also critical for the patients who rely on these services (World Health
Organization, 2013). The U.S. healthcare system is challenged to provide care to a growing
population while balancing rising costs, smaller operating margins, and health disparities. In a
safety net hospital like Pacific Hospital, the magnitude is even greater as safety net hospitals play
an integral role in addressing health equity in the US healthcare system. Therefore, nurse

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retention in a safety net hospital is not just good business, effective nurse retention means more
access and better patient outcomes for the most vulnerable members of the community.

101
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Appendix A: Survey Protocol
Question Open or
closed?
Level of
Measurem
ent.
Response options RQ Concept being
measured
1. Are you a nurse at Pacific
Hospital?
Closed Yes
No
2. Do you work in an inpatient
setting at Pacific Hospital?
Closed Yes
No
3. Nursing Degree Closed Nominal ADN
BSN
Other
4. Years of nursing experience? Closed Ratio 0-3 years
4-6 years
7-9 years
10-12 years
13 -15 years
16 – 18 years
19 – 21 years
22 – 24 years
25+ years
Prefer not to answer
5. Years of nursing experience at
this hospital?
Closed Ratio 0-3 years
4-6 years
7-9 years
10-12 years
13 -15 years
16 – 18 years
19 – 21 years
22 – 24 years
25+ years
Prefer not to answer

121
6. Present Practice location Closed Nominal Administrative
Ambulatory
Critical Care
Emergency
Medical/Surgical
Other:
This study is on the factors related to nurse retention. For the following items, please indicate the level of importance to you in your
decision to STAY with Pacific Hospital
7. Flexible scheduling Closed Ordinal 1 - 5 1 Retention Factors
8. Competent Management Closed Ordinal 1 - 5 1 Retention Factors
9. Management that supports staff Closed Ordinal 1 - 5 1 Retention Factors
10. Recognition of staff for good
work
Closed Ordinal 1 - 5 1 Retention Factors
11. Manager is engaged in the unit Closed Ordinal 1 - 5 1 Retention Factors
12. Clinically competent colleagues Closed Ordinal 1 - 5 1 Retention Factors
13. Sufficient nursing staff Closed Ordinal 1 - 5 1 Retention Factors
14. Sufficient ancillary/support
staff
Closed Ordinal 1 - 5 1 Retention Factors
15. Positive relationships with
physicians
Closed Ordinal 1 - 5 1 Retention Factors
16. Nurses and physicians function
as a team
Closed Ordinal 1 - 5 1 Retention Factors
17. Support for autonomy to
practice effectively.
Closed Ordinal 1 - 5 1 Retention Factors
18. Quality care is provided Closed Ordinal 1 - 5 1 Retention Factors
19. Mission of the organization
aligns
Closed Ordinal 1 - 5 1 Retention Factors
To what degree do the following factors exist within Pacific Hospital? (Rarely exists, exists some of the time, exists most of the
time)
20. Flexible scheduling Closed Ordinal Rarely
Some
Most
1 Retention Factors

122
21. Competent Management Closed Ordinal Rarely
Some
Most
1 Retention Factors
22. Management that supports staff Closed Ordinal Rarely
Some
Most
1 Retention Factors
23. Recognition of staff for good
work
Closed Ordinal Rarely
Some
Most
1 Retention Factors
24. Manager is engaged in the unit Closed Ordinal Rarely
Some
Most
1 Retention Factors
25. Clinically competent colleagues Closed Ordinal Rarely
Some
Most
1 Retention Factors
26. Sufficient nursing staff Closed Ordinal Rarely
Some
Most
1 Retention Factors
27. Sufficient ancillary/support
staff
Closed Ordinal Rarely
Some
Most
1 Retention Factors
28. Positive relationships with
physicians
Closed Ordinal Rarely
Some
Most
1 Retention Factors
29. Nurses and physicians function
as a team
Closed Ordinal Rarely
Some
Most
1 Retention Factors
30. Support for autonomy to
practice effectively.
Closed Ordinal Rarely
Some
Most
1 Retention Factors

123
31. Quality care is provided Closed Ordinal Rarely
Some
Most
1 Retention Factors
32. Are there any factors not listed
that would influence your decision
to stay with the organization?
Open Open 1 Retention Factors
The following questions are related to your perception of the changing workforce, to what degree do you agree with the following
statements?
33. Nurse retention at HMC have
declined over the last 3 years
since the pandemic
Closed Ordinal 1 - 5 2 Impact to mission
34. Nurse vacancies at HMC have
increased over the last 3 years
Closed Ordinal 1 - 5 2 Impact to mission
35. HMC’s mission positively
influences nurse retention
Closed Ordinal 1 - 5 2 Impact to mission
36. Changes in the healthcare
workforce impact HMC's
ability to fulfill the mission.
Closed Ordinal 1 - 5 2 Impact to mission
37. Changes in the healthcare
workforce impact HMC's
ability to address healthcare
equity.
Closed Ordinal 1 - 5 2 Impact to mission
38. Changes in the healthcare
workforce impact HMC's
ability to address healthcare
equity.
Closed Ordinal 1 - 5 2 Impact to mission
39. How have changes in the
workforce impacted HMC's
ability to fulfill their mission
with regard to health equity?
Closed Ordinal 1 - 5 2 Impact to mission
40. Have you thought about or
explored leaving this organization
in the last 3 years?
Closed Nominal Yes
No

124
41. Have you thought about or
explored leaving the healthcare
industry in the last 3 years?
Closed Nominal Yes
No
Demographics
42. Age Range Closed Nominal Boomers: 1946
– 1964
Generation X: 1965
–
1976
Millennials: 1977
-1995
Generation Z: 1996
–
2015
Prefer not to answer
43. How would you describe your
Race/Ethnicity?
Closed Nominal American Indian or
Alaska Native
Asian
Black or African
American
Hispanic, Latino, or
Spanish Origin
Middle Eastern or North
African
Native Hawaiian or
Pacific Islander
White
Prefer to self-identify.
Prefer not to answer
44. How would you describe your
gender?
Closed Nominal Female
Male
Nonbinary
Prefer to self-describe:
Prefer not to answer

125
45. Current Employment Status Closed Nominal Full Time
Part Time
Intermittent/Per Diem
46. What is your full time
equivalent (FTE)?
Closed Ratio 0.9
– 1.0
0.7
– 0.8
0.5
– 0.6
0.3
– 0.4
0.1
– 0.2
47. Are you in a supervisory or
leadership position?
Closed Nominal Yes
– No
48. If yes, would you be willing to
participate in an interview to
discuss retention strategies as part
of this research study?
Closed Nominal Yes
– No

126
Appendix B: Interview Protocol
First, thank you for agreeing to participate in this study. I anticipate the interview should
take about an hour. If we are disrupted due to patient care or if we need additional time after the
hour, I will find additional time on your schedule to resume. Before I start with the interview
questions, I wanted to go over the focus of this study and give you a chance to ask any questions.
As I mentioned in my email, I am a doctoral student at USC and am conducting a study on the
nurse retention at safety net hospitals in the era of the Great Resignation. I am focused on
healthcare leaders’ perception of changes to the healthcare workforce and the strategies and
solutions that have been implemented or in development to address nurse retention.
I want to assure you that I am strictly functioning as a researcher today. I recognize the
role that I play in the healthcare system and want to assure you that I will not be making any
judgements or take any of your comments personally. My goal for this study is to understand
your perspective. I also want to assure you that anything you say in this interview is confidential.
The data from this study will be compiled into a report and your confidentiality will be protected
at each step of this study. To make sure that I am accurately capturing your words, I plan to use a
recorder to capture our conversation and I will provide you with a summary of the interview. I
will also be happy to provide you a copy of the final report if you are interested. I’m going to
pause there and ask if it’s okay to proceed with the recorder for this interview?
Do you have any questions before we get started and I turn on the recorder?
1. What is your role?
2. How long have you worked in healthcare?
3. How long have you worked in this organization?
4. How long have you been in a supervisory leadership role?

127
5. The pandemic and resulting Great Resignation have had a major influence in the
workforce, what changes have you seen in the nursing workforce over the last 2-3 years?
6. How have these changes impacted nurse retention strategies in this organization?
7. What strategies have been implemented to address nurse recruitment?
a. Do you think these strategies have been effective?
b. What has made them successful or unsuccessful?
8. What strategies is your organization considering or evaluating to address nurse retention?
9. What strategies have you seen or heard of from other organizations?
a. Do you think those strategies would be effective at Pacific Hospital?
10. How does this organization’s status as a safety-net hospital help or hinder efforts to retain
nurses?
11. Are there any other factors unique to this organization that help or hinder efforts to retain
nurses?
12. Is there any other information I should know about the organization’s efforts to retain
nurses?

Abstract (if available)

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Asset Metadata

Creator Hollman, Katherine (author)

Core Title Don’t leave: a safety net hospital’s response to retain nurses during a nursing shortage

School Rossier School of Education

Degree Doctor of Education

Degree Program Organizational Change and Leadership (On Line)

Degree Conferral Date 2024-05

Publication Date 01/04/2024

Defense Date 12/13/2023

Publisher Los Angeles, California (original), University of Southern California (original), University of Southern California. Libraries (digital)

Tag health disparities,nurse retention,OAI-PMH Harvest,retention,safety net hospital

Format theses (aat)

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Krop, Cathy (committee chair), Lynch, Douglas (committee member), Young, Bessie (committee member)

Creator Email Khollman@usc.edu

Permanent Link (DOI) https://doi.org/10.25549/usctheses-oUC113800515

Unique identifier UC113800515

Identifier etd-HollmanKat-12588.pdf (filename)

Legacy Identifier etd-HollmanKat-12588

Document Type Dissertation

Format theses (aat)

Rights Hollman, Katherine

Internet Media Type application/pdf

Type texts

Source 20240105-usctheses-batch-1118 (batch), University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the author, as the original true and official version of the work, but does not grant the reader permission to use the work if the desired use is covered by copyright. It is the author, as rights holder, who must provide use permission if such use is covered by copyright.

Repository Name University of Southern California Digital Library

Repository Location USC Digital Library, University of Southern California, University Park Campus MC 2810, 3434 South Grand Avenue, 2nd Floor, Los Angeles, California 90089-2810, USA

Repository Email cisadmin@lib.usc.edu