Academic Master


Nurse Retention in CCU/Step Down


The role of nurses in patient care is of immense importance because they help the patients and their caregivers in many stages of treatment in hospitals and clinics. Nurses have to bear with a plethora of challenges in their working lives. The nurses in the CCU/Step Down have to face the severe load of work and emergencies that might be nerve-breaking. Some nurses have transferred to different departments due to high-stress levels, and some have moved to various hospitals for competitive salaries. Also, CCU nurses must take turns to float to the step-down unit where nurse to patient ratio is 1:3. Mandatory floating has led to staff dissatisfaction, and many senior nurses have transferred or quit since the change of policy.

The retention of nurses is a global issue because the CCU/Step Down’s working conditions are almost similar worldwide. Turnover rates vary from 15.0% to 44.4% across Canada, the USA, New Zealand, and Australia (Khan et al., 2018). The UK government has included nursing in the shortage occupation list by the Department of Health (D.H.) (Khan et al., 2018). The high turnover in the critical care units has many reasons behind it. A study has found that quality of working life and occupational stress are the top reasons for the intention of nurses leaving their jobs in CCU (Chegini et al., 2019). Moreover, nursing knowledge is vital, and hospitals depend on nurses to provide safe and quality care. Therefore, high nursing turnover results in a loss of experience and knowledge for the nursing units that could take time to regain (Force, 2005). Even in normal conditions, the retention of nurses in the CCU is vital; however, the onset of COVID-19 has intensified the importance of this matter. This research paper will attempt to offer credible solutions to this critical problem by exploring scientific studies and peer review literature.

The clinical practice question (CPQ) in PICOT Format

  1. P- Nurse retention has been an ongoing problem in Cardiac Critical Unit.
  2. I- Intervention such as mentorship program, relational leadership style, and monetary incentives could improve nurse retention.
  3. C- Currently, new hires go through a 3-month ICU program and mandatory rotation to float to the step-down unit where patient to nurse ratio is 3:1 instead of CCU 2:1.
  4. O- The staff member will stay in CCU for more than three years.
  5. T- Manage to collect the anonymous survey in 3 months regarding nurse satisfaction and how long nurses plan to stay in CCU. Moreover, the study would find their grievances and preferences to be helpful in remedial measures.

Nurse retention has been an ongoing problem in Cardiac Critical Care Unit. Nurse retention is influenced by multiple factors such as salary, flexible scheduling, health benefits, retirement program, mentorship opportunities, management and leadership practices and recognition, work environment, and organization focus on retention (Lartey et al., 2014). According to Lartey et al. (2014), the study evident that healthcare settings need a combination of interventions to improve their experienced nursing staff’s retention. Cowden et al. (2011) suggested that the nurse leaders who promote a better work environment by involving all staff members and their idea into account for any decision-making are likely to stay and increase retention among staff. Thus, interventions including these features should be implemented in the hospital to increase nurse retention and improve patient care. A systemic review shows that mentorship programs and monetary incentives also increase the nurse retention rate (Brook et al., 2019). The hospital administration could conduct an online survey and use the findings to aid in the current situation. Hopefully, a combination of various solutions discussed here would improve the situation, and nurses would stay in CCU/ Step Down for three years.

Review of Literature:

The search process of the peered review journal papers is based on accessing multiple (digital) databases, such as OneSearch, Wiley online Library, Allied Health Literature, and PubMed, amongst others. The research papers are short-listed from nurse management and professional development journals with search tailored for literature published within the last ten years (2011-21), narrowing the scope of literature on the subject matter. The search terms are connected with Boolean operators (AND, OR) for achieving results on variables for precision. The search results were limited to English language publications with professional and personal strategies for NUM, which enhances nurse support within ICU settings.

Monekey (2013) research focuses on the impact of leadership behaviors on nurse job satisfaction within a critical care setting. The job satisfaction of nurses directly impacts patient safety, work performance, and productivity, turnover and retention level, quality of care, etc. The research focuses on positive feelings toward work settings and leadership because they impact the overall job satisfaction of nurses, although interpersonal relationships play a critical role among nurses. For example, organizational empowerment is directly proportional to job satisfaction, mainly when nurses’ inputs are accommodated at the policy level. The available studies suggest that leadership behavior plays an instrumental role in positively or negatively affecting the work climate, which means a direct impact on the financial health of an organization. Amongst other things, development plans can be used to increase leadership effectiveness at an organization, and that requires enhancing leadership practice. Healthcare organizations can play its critical role in increasing the job satisfaction of the nurses through the identification of potential activities within the organization. The goal of the leadership is to recognize, attract, and retain critical care nurses, which also positively impacts achieving organizational goals and competitive advantage. The research findings of Monekey (2013) aim to establish a strong relationship between the job satisfaction of critical nurses through studying ‘managerial leadership.

However, Vergara’s (2017) research focuses on the implementation of a ‘mentorship program’ aimed at decreasing retention level and job satisfaction within critical care settings. A 45-bed critical care department is the unit of analysis for a hospital-based mentorship program, which produced positive results in terms of yearly turnover rates and increasing overall job satisfaction of the staff. The basis for the hospital-based mentorship program is to positively influence the two major issues facing health care organizations, which requires thought-full policy-making at the leadership level. Recent healthcare reform legislation has reshaped healthcare organizations’ operations. It establishes an atmosphere of work environment where nurse professionals work optimally for the well-being of patients and their respective families. The current industry trends suggest an estimated shortage of nurses in healthcare settings due to the intensified needs of the retired ‘Baby Boomers,’ coupled with 30,000 US dollars annual cost to an organization due to a one per cent increase in turnover rate. The theoretical model of the research is based on the review of the existing literature and focuses on ‘change’ that can transform the conditions of the critical care unit. For example, Everett Roger’s diffusion of innovation theory suggests that facilitation to the adoption of change because it results in transformation, with the assistance of five qualitative, that is, relative advantage, compatibility, treatability, simplicity, and observation.

Similarly, Tourangeau et al.’s (2013) research explores the phenomenon of nurse retention levels within acute care settings and the generation-specific disincentives, which either discourage or promote the respective retention level. The existing literature suggests that a nurse’s strategies and preferences differ a great length across generational cohorts. The research attempts to bridge the research gap with evidence-based generation-specific nurse strategies through data of 9904 registered nurses working in the two states of Canada, that is, Ontario and Alberta. The data is collected through a cross-sectional survey with nurse feedback on preferences for incentives and disincentives that discourages or encourages to retain the job. The survey items of the research are the product of the focus group discussions (FGDs), which explored the determinants of nurse retention. The research analysis suggests that there exist eight out of ten incentives and eight out of fifteen disincentives for remain employed with significant differences across the nurse generations. Research findings indicate that the respondents most frequently mention the two incentives: manageable nurse-patient ratios, coupled with the reasonability of workload.

Wright et al., (2017) research focuses on the role of inflexible work schedules in the life work-life of the nursing profession through assessing nurse turnover and job satisfaction. The research findings of Wright et al. (2017) confirm the already established relationship between job satisfaction and nurse retention, preceding significant predicting the latter. The available literature on the subject matter suggests that the major contributor to job satisfaction is nurse practitioners’ educational opportunities and autonomy within acute care hospital settings. The research project illustrated the implementation of computer-based self-scheduling system for nurse practitioners which has the potential to impact the overall job satisfaction in affirmative manner. The research concludes with a note for development educator staff, that is, the key role ‘self-scheduling may play in increasing autonomy, reducing hospital costs, improving turnover, and providing professional development. The research is based on NR surveys that generated a sample of 1,317 and 1,492 for the year 2012 and 2015, respectively. The intervention is the self-scheduling program, which is provided parallel with the existing electronic health record software. The outcome of the research is the assessment of the amount of initiative, independence, and freedom required and permitted for the completion of daily activities in the life of nursing work.

Evidence-Based Practice Model; the Close Collaboration Model:

Evidence-based practice ensures effective patient care by promoting effective decision-making about the ongoing situation. It is an integrated outcome of provided research, expertise in clinical professional, and the overall preferences of individuals under consideration. There are numerous models of evidence-based practice to enhance the efficiency of professional work. These models are, in fact, multiple phases, which comprise of several interconnected and interlinked steps. The main elements are formulating a team, critical review of available pieces of evidence, productive criticism, and strict evaluation of the outcomes, and finally, the dissemination of these outcomes for future work and functioning. Among these available models, the close collaboration model is the most efficient one.

The close collaboration model aims to build multiple resources and training of those mentors who can play an influential role in evidence-based practice. The selection of this model comprises of two main reasons. First, the detailed step-by-step procedure of this model, and secondly, the main stakeholders are mentors who can enhance the efficiency of the system manifold. This model revolves around three available dimensions and units of the system. These are available pieces of evidence, clinical experts, and the preferences of the patients. The selection of this model is of the reason that it needs the comprehensive and integrated practice of the stakeholders, mainly the mentors. These mentors are expected to facilitate and ensure sustainable EBP throughout the respective organization to whom they belong. For this purpose, the said model comprises of seven steps. These include the cultivation and creation of inquiry spirit among the said personals, which lead to asking vigorous clinical questions on PICOT format. Further steps go on with the collection of pieces of evidence, their critical appraising, and integration of the best available pieces of evidence with experts and patient preferences, and finally, the evolution of the outcomes and decimation of these outcomes.

Evidence-Based Change to Address the Problem/Issue:

The evidence base change is the availability of any framework and plan for the organization providing care to patients. The said framework should have the capacity to guide and set plans for the main stakeholders of such an organization. These may include transformations in the organization, multiple processes, various metrics, and tools. The respective management tries hard to deploy the said transformation and also takes care in investing their sources in this regard. For example, the step-by-step identification of the problem of the client suffering from nausea and vomiting can be an evidence-based change. In this regard, the performance is based on the review of the literature regarding this problem, applying their respective information, and gains the confidence of the client to solve the problem and issue.

Furthermore, the evidence base change to address the problems of infection is a hot topic at the time. The first thing that should be considered well is the critical situation of the patient. It is the last option of the respective patient to have treatment in the hospital. In this way, the nurses can play a pivotal role in gaining the confidence of the said patient. The respective staff should play a role in handling the patient before it goes towards critical situate regarding the evidence-based change. The prescribed steps in this regard include keeping the healthcare environment neat and clean, the utility of personal protection equipment and clothing, practice proper precautionary steps to take utmost care, and using the prescribed and correct practice to infringe the infection from further spread. The said evidence-based change needs the administration to take necessary steps and act vigorously as soon as possible to change the situation for desired goals and targets of healthcare.


The numerous methods are available by which the change will be implemented in this regard. These said methods need a step-by-step implementation in an orderly manner to get maximum output and benefit. The first one is clarity about the concept of change. To probe various reasons and question why there is a need for change and what type of change is required in the said practice is the key factor. The other method is to implement change by determining the impacts and aftereffects of the change. The smooth running of any action, as well as any organization, has to undergo drastic effects. The determination of these effects is meaningful.

Furthermore, the other method of change is developing the communication strategy within the organization. This strategy comprises of two-way flow of communication either to an individual or to any specific group of individuals. The main focus is the communication of change and handling the feedback in this regard as well as the management of this feedback. Another method of change is providing effective and comprehensive training to the stakeholders. The main focus of this method is to change in behavior and skills of the person to get effective results. The training should be goal-oriented and goal-focused. However, the most effective method in this regard is to implement a support structure. The main focus of this method is to determine where support is required and what will be the effect of this support.

The Measurement of Practice Change:

The practice change depends upon randomized trials and examining the systemic reviews regarding new designs, the interpretation, explanation, and application of the work done to date. It is measured and judged in this aspect to pave the future line of action. The main focus in measurement is determining and informing the respective quarters about the effect of said change in the organization and future impacts. The helpful metrics regarding the measurable outcomes comprise both conventional and modern tools. These include the medical record audit in a traditional way or by using multiple technological applications. The database collected by the computer records and staff appointed in this concern is also meaningful. The other indicators include request slips, diaries, and encounter forms. These tools and metrics determine the satisfaction of the stakeholders and retention of the staff in prescribed capacity.

Evaluation Plan:

The evolution plan is of immense importance to determine the efficiency of any system and any change in the said organization. The specific expertise and techniques are required to formulate the evaluation plan and to execute it. The required information should be enlisted in a questionnaire form. The said questionnaire with proper techniques should be interviewed from the respective stakeholders before implementing specific change and at the end. Evaluation should comprise of three phases. These are pre-change evaluation, secondly, during the phase of change, and the last one is post-change. After that, the comparison among these can guide future planning and further decisions.


Hence, it can be conclude that the practice role of nurses in the medical healthcare system is of vital importance. They are the backbone of the healthcare system to provide utmost care to patients. Their right to a satisfactory job is critical in this aspect. The time to time improvement and change in evidence-based practice leads to the efficiency of the system manifold. The practice change should be systematic and goal-oriented. The different models can be adopted to address this change with proper methods. For better quality assurance, there should be a comprehensive evaluation program.


Brook, J., Aitken, L., Webb, R., MacLaren, J., & Salmon, D. (2019). Characteristics of successful interventions to reduce turnover and increase retention of early career nurses: A systematic review. International Journal of Nursing Studies91, 47-59.

Chegini, Z., Asghari Jafarabadi, M., & Kakemam, E. (2019). Occupational stress, quality of working life and turnover intention amongst nurses. Nursing in Critical Care.

Cowden, T., Cummings, G., & Profetto-McGrath, J. (2011). Leadership practices and staff nurses’ intent to stay: A systematic review. Journal of Nursing Management19(4), 461–477.

Force, Mary VanOyen. (2005). The relationship between effective nurse managers and nursing retention. The Journal of Nursing Administration35(7-8), 336–341.

Khan, N., Jackson, D., Stayt, L., & Walthall, H. (2018). Factors influencing nurses’ intentions to leave adult critical care settings. Nursing in Critical Care24(1), 24–32.

Lartey, S., Cummings, G., & Profetto‐McGrath, J. (2014). Interventions that promote retention of experienced registered nurses in health care settings: A systematic review. Journal of Nursing Management22(8), 1027-1041.

Li, H., Liu, Y.-L., Qiu, L., Chen, Q.-L., Wu, J.-B., Chen, L.-L., & Li, N. (2014). Nurses’ Empowerment Scale for ICU patients’ families: An instrument development study. Nursing in Critical Care21(5), e11–e21.

Moneke, N., & Umeh, O. J. (2013). How leadership behaviors impact critical care nurse job satisfaction. Nursing Management44(1), 53-55.

Tourangeau, A. E., Thomson, H., Cummings, G., & Cranley, L. A. (2013). Generation‐specific incentives and disincentives for nurses to remain employed in acute care hospitals. Journal of Nursing Management21(3), 473-482.

Vergara, J. Y. (2017). Implementation of a mentorship program to increase staff satisfaction and retention in critical care. Nurse Leader15(3), 207-212.

Wright, C., McCartt, P., Raines, D., & Oermann, M. H. (2017). Implementation and evaluation of self-scheduling in a hospital system. Journal for Nurses in Professional Development33(1), 19-24.



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