High rates of nursing turnover where staff voluntarily leave or transfer from their primary employment position to another position in nursing, or to another profession  (described as between 12%  to greater than 50% turnover ) are a problem currently affecting many countries [1, 4, 5]. In Australia, few studies have examined nursing turnover rates [6, 7], however recent reports indicate a turnover rate in one state (New South Wales) of 1 per cent to 1.4 per cent per month [8, 9]. A term used to define significant turnover “churn”, is defined as involuntary staff movement, where nurses are moved to other positions or locations within the organization. It is also important to consider this aspect of turnover also as such staff movement can negatively impact upon skill-mix, scheduling and continuity of care .
Minimising turnover rates is an important priority for health service managers for a number of reasons. Firstly, turnover is costly for health care organizations with a pilot study in Australia estimating turnover costs at $A16,634 per nurse . Secondly, turnover affects the roles , morale and stress levels of remaining staff, impacting upon nurse productivity [1, 12]. Finally, turnover impacts on patient safety and outcomes with registered nurse (RN) turnover found to be related to both increased infection and subsequent hospitalization ; an increased likelihood of medical error [1, 14]; and reduced patient satisfaction .
Factors contributing to nursing turnover
In order to reduce the rate of turnover, it is necessary to identify exactly which factors contribute to this phenomenon. A number of descriptive studies from different countries have used surveys to examine some of the reasons for nurse turnover [6, 14, 16]. However the mechanisms that underpin nurses’ decisions to leave are not well understood .
In the international literature, the work environment has been identified as one important factor in nurse turnover. For example, Aiken and colleagues in their research in the US, Canada, England, Scotland and Germany, found that low morale, management issues, workload, and the amount of time spent on non-nursing tasks all contributed to turnover . In Canada, Leiter and Maslach  found that burnout or exhaustion mediated the occurrence of turnover. Another study by Rhéaume and colleagues  found that a key component of the work environment, foundations for quality nursing care, was the top predictor of the variance in turnover. In the US, Johnson and Rea  found that workplace bullying was associated with turnover from both the organization and the nursing profession. Finally, in Taiwan, Chen and co-workers found that distributive justice, workload, resource adequacy, supervisory/kinship support, and job satisfaction were strongly associated with intention to stay or leave one’s job .
Yet, whilst factors related to the work environment are important contributors to nurse turnover, such research tends to focus on the behaviour of the “average nurse” . This is problematic, because it is possible that individual differences between nurses and groups of nurses are also influential in turnover [23, 24]. For instance, one Australian study found that for some nurses individual affective professional commitment was significantly related to intention to change professions . Other individual factors which may play a role in turnover are generational membership and age [26, 27] or years of experience .
Reducing nursing turnover
Of the research which has examined ways to reduce nursing turnover, Gess and colleagues found that changing organizational processes, so that the nursing staff had additional autonomy and were offered rewards and recognition for their work improved organizational commitment, and decreased turnover . In another study, Porter and co-workers instituted a nursing labour management partnership (NLMP) program, which encouraged a collaborative approach between management and the nursing union . This collaborative approach was found to improve satisfaction and reduce turnover.
There is little Australian research on the causes of nurse turnover. Additionally, of the research which has been done, most of it has been in the form of survey data, or quantitative analysis, rather than qualitative studies . This could result in a limited understanding of factors associated with nurse turnover. Whilst quantitative data can provide a broad snapshot of the findings, survey data usually lacks the rich insight needed to gain a better understanding of the causes of turnover. Qualitative research provides a deeper understanding and insight into the everyday realities of the nursing work environment from the perspectives of nurses themselves.
Purpose of the study
This study adds to the small body of qualitative knowledge into experiences of nurse turnover in public hospitals [31, 32], and aims to provide insight into;
nurses’ perceptions of the working environment on medical surgical wards;
factors contributing to nursing turnover from the perspective of nurses in hospitals in Australian states and territories; and
possible strategies to improve working environments and improve retention.
This study therefore sought to ask “What factors in the work environment do nurses themselves believe are related to turnover, and what retention strategies do they propose?”