Running Head: Nurse Retention Program

Running head: NURSE RETENTION PROGRAM 1
Nurse Retention Program: Improving Nurse Retention in a Home Health Care Organization
Tristan Tran
Touro University, Nevada
In partial fulfillment of the requirements for the
Doctor of Nursing Practice
DNP Project Chair: Dr. Jessica Grimm
DNP Project Members: Dr. Ticey Harris, Dr. Judith Carrion
Date of Submission: January 29, 2019

NURSE RETENTION PROGRAM 2
Table of Contents
Abstract………………………………………………………………………..……..……………3
Introduction…………………………….....…………………………………...………..…………4
Background………………………………………………………..…………..…..………………4
Significance………………………………………………………..……….....…………………...5
Problem Statement……………………………………….……………......………………………6
Purpose Statement……………………………………..……………………..……………………7
Project Question…………………………..………………..………...……………………………7
Objectives……………………………………………………..…….…………..………………...7
Search Terms……………………………………………………………………………………...8
Literature Review……………………………………...………………………………………..…9
Salary and benefits………………….....……………………………………..………………10
Work environment……………………………………………..…………………………….11
Autonomy and control of work hours…………………………..………………..…………..11
What is currently understood……………………………...………………..………………..12
Issues still under investigation……………………….……………..………………………..13
Issues that have not been addressed……………………………..…………………………...13
Controversies……………………………………………….….…………………………….14
Current management……………………………………..…………………………………..14
Theoretical Model: Historical development………………….………………….………………15
Major tenets………………………………………….…………….………………………...15
Application to current practice………………………………..……………………………...16
Application of theory to DNP project.…………….………….……………………………...17
Description of Project Design…………………….……………………..……………………….18
Population of Interest………………………………………................………………………….19
Setting……………………………………………………….…………………………..……….19
Stakeholders………………………………………………………….………………….……….20
Recruitment Methods………………………………………………….……...………………….20
Tools/Instrumentation: Pre and post intervention survey…………….……………….…………21
The NRP………………………………….…………….……………………...……………..22
Educational training materials………………………….………..…………………………..22
Tool for examining nurse retention……….……………..……………………..…………….23
Data Collection and Procedures………………………………..………………………...………23
Intervention/Project Timeline………………………………….……………………...…………24
Ethics/Human Subjects Protection………………………….………………...………………….25
Plan for Analysis/Evaluation………………………………….…………………………………26
Analysis of Results……………………………………….…………………………...…………27
Discussion of Findings………………………………..……………………….…………………33
Significance/Implications for Nursing………………..…………….……………………………34
Limitations……………………………………………….………………………………………36
Areas for Further Dissemination…………………………..………..……………………………37
References…………………………………………………..…………………...……………….38
Appendices…………………………………………………..……………….......………………42
Abstract
The purpose of this project was to implement an evidence-based Nursing Retention
Program (NRP) at the project site which is a Home Healthcare Agency and evaluate its
effectiveness in efforts to improve nurse retention, job satisfaction, and intent to stay. This
project utilized a quality improvement design guided by Lewin’s Change Theory to examine
nurses’ job satisfaction with their work environment, salary and benefits, and autonomy and
control of work schedules and hours. Survey data was obtained pre and post- implementation of
the NRP. Thirty-four home healthcare nurse job satisfaction self-report data were collected with
the Home Health Care Nurses’ Job Satisfaction Scale (HHNJS) survey questionnaire pre and
post NRP implementation. Data analysis were conducted using the Wilcoxon Signed Rank test
and paired-samples t-test. The implementation of NRP improved nurses’ job satisfaction with
work environment, salary and benefits, and autonomy and control of work hours. The
implementation of NRP improved nursing job satisfaction scores at host site. This evidence-
based NRP will assist the practice site in improving employee job satisfaction and intent to stay
through enhancing nurse work environment, improving nurses’ salary and benefits, and
promoting professional autonomy. Findings from this project can be used to guide home health
care agencies to further explore interventions improving retention and intent to stay.
Nurse Retention Program: Improving Nurse Retention in a Home Health Care Organization
Many healthcare organizations are experiencing nursing shortages. Similar to other
healthcare settings, the recruitment and retention of qualified nurses remains a priority in home
health care agencies. Nursing staff turnover is costly as it decreases the organization’s
productivity and the quality of patient care. According to the 2016 National Healthcare Retention
and RN Staffing Report, on average it costs a healthcare institution from $37,000 to $58,400 per
every nurse turnover (Fisher, Jabara, Poudrier, Williams, and Wallen, 2016). Besides costs, nurse
turnover may negatively impact staff morale and patient health outcomes. Hospitals and home
health care organizations in the United States and the world have utilized numerous strategies to
attract and retain nurses. Nonetheless, retention success in home health care has not been well
documented. Home health care organizations are investing efforts in increasing job satisfaction
to improve nurse retention. However, only a small number have succeeded in retaining nurses
through the implementation of an evidence-based retention intervention. They have emphasized
creating a shared-governance work environment, offering autonomy and control of work hours,
and providing better salary and benefits (Ellenbecker, 2007).
Background
Since the inception of the Medicare home health care program, the demand for home
health care nursing professionals has dramatically increased (McCall et al., 2001). As
technological advances allow individuals to receive complex care in their homes, the demand for
nurses in home health care will continue to increase. According to the 2016 National Healthcare
& RN Retention Report, the national nursing turnover rate is 17.1 percent. This number was
previously 16.4 percent in 2014 (Fisher et al., 2016). Many factors influence job satisfaction,
which in turn directly contribute to nurse turnover and retention. Job satisfaction is identified as
the strongest predictor of nurse intent to stay and retention (Ellenbecker, 2003). The more
satisfied nurses are with the jobs, the more likely nurses will stay in those jobs. Factors such as
salary and benefits, shared-governance, and autonomy and flexibility of scheduling in home
health care are associated with job satisfaction. Health care organizations, including home health
care, strive to address the issues surrounding nursing turnover. The host site develops a work
environment that promotes shared-decision making, grants nurses the autonomy to control work
schedules, and offers highly competitive salary and benefits. Evidence from research conducted
in home care indicates that nurses’ job satisfaction is predicted by relationships with the
organization, degree of autonomy and flexibility in scheduling work and work activities, and
adequacy of salary and benefits (Ellenbecker, 2004). Home care organizations have utilized
evidence-based interventions as a guide to improve job satisfaction. The only retention
intervention that made a statistically significance in nurses’ job satisfaction was shared-
governance (Ellenbecker et al., 2006). Studies have demonstrated that autonomy and flexibility
of scheduling work have a moderate impact on job satisfaction and nurse retention (Ellenbecker,
2003). Wages are another variable that have been found to influence nurse retention. According
to Banijamali (2014), the organization may lose nurses if nurses are presented better job
opportunities with higher salary and benefits.
Significance
Nursing shortages have been reported in the home health care industry (Weaver et al.,
2018). Due to technological advancement and the growing number of aging population, the
demand for home health care nurses is expected to increase (Knickman and Snell, 2002).
Consumers prefer to receive care in their home. If nurse retention continues to decrease, the
current problem with nursing shortages across the country will worsen. Nurse retention is
predicted by nurses’ job satisfaction (Buffington, Zwink, Fink, DeVine, and Sanders, 2012). As
the nurse turnover increases, healthcare organizations fear that nurse shortages and job
dissatisfaction will have a negative impact on access to services and the quality of patient care
(Ellenbecker and Cushman, 2001). It is necessary for home health care organizations to
implement a nurse retention program to achieve optimal staff job satisfaction.
According Kooler and Kamikawa (2010), improving nurse retention and reducing
turnover rates improved patient outcomes as well as had significant financial benefits for the
healthcare organization. Nurse turnover is costly. The healthcare organizations spend an
enormous amount of money on advertisement, recruitment, orientation and training (Jones,
2007). In addition, the process of hiring can be lengthy, sometimes taking up to several months.
Work productivity is decreased when nurses intend to leave due to job dissatisfaction (McHugh
and Ma, 2014). There is a growing need for home health care organizations to implement a
retention initiative to increase job satisfaction to lower nurse turnover. Organizations with
positive work environments have lower nurse turnover and higher retention rates (Twigg and
McCullough, 2014).
Problem Statement
As the need for home health care nurses increases due to the growing population of
elderly people, retaining experienced and qualified nursing staff becomes an important concern.
Nurses in home health care agencies experience high levels stress as nursing shortage continues.
It is important to retain existing nursing staff to ensure a sustainable home care workforce for the
future (Maurits et al., 2015). Nurses’ intention to leave is strongly associated with dissatisfaction
with the work environment. The project site expressed concerns with high organizational cost of
nursing turnover. Factors that were identified by this site as contributors to nursing turnover
included wages, autonomy in practice, control of work schedules, and work environment. These
determinants were supported by the literature as well. An evidence-based home care nurse
retention program would ameliorate the issues with nurse retention and turnover through the
implementation of effective strategies that promote shared-governance within the organization,
ensure autonomy, and provide better salary and benefits to attain job satisfaction.
Purpose Statement
The purpose of this project was to implement a Nursing Retention Program (NRP) at the
project site which is a Home Health Agency located in the heart of Las Vegas, Nevada. The
ultimate aim of this project was to implement and evaluate this evidence-based NRP and
improve nurse retention, job satisfaction, and intent to stay at the host site. This NRP would
incorporate retention strategies which include improving job satisfaction, promoting autonomy in
nursing practice and over work schedules, and offering nursing staff highly a competitive salary
and benefits package.
Project Question
Does the implementation of an evidence-based NRP improve nurse retention, job
satisfaction, and intent to stay?
Objectives
The DNP Student completed the following in the timeframe of the DNP Project:
• Within a three month period, the student utilized literature review and project site
assessment to identify the factors that contribute to nurse retention, job satisfaction, and
intent to stay.
• Within a three month period, the student examined the project site’s current situation with
regard to nurse retention, job satisfaction, and intent to stay through the use of a validated
and reliable tool.
• Within a three month period, the student implemented an evidence-based NRP at the
project site.
Search Terms
The PICOT question was utilized to conduct a literature search. The population of
interest was home health care nurses, the intervention was evidence-based NRP implementation,
the comparison was nurse retention rates before and after NRP implementation, the outcome was
nurse job satisfaction and intent to stay, and the time it took for the intervention to achieve an
outcome was three months. Literature review was initially limited to research studies completed
primarily in the U.S. within the last five years. Due to an insufficient number of research studies
investigating home health care nurse retention and job satisfaction, the search was extended
beyond five years. Search terms included home health care, home care nurses, nurse retention
program, nurse retention interventions, nurse burnout, nurse turnover, nurse job satisfaction, job
dissatisfaction, nurse autonomy, intent to stay, and nurse work environments. Search engines
used during database search included PubMed, MEDLINE, and CINAHL. Upon searching the
key terms, more than twenty results returned. Specifically, ‘nurse job satisfaction’ had twenty-
two results generated while ‘nurse work environment’ produced twelve and ‘nurse retention’
yielded eighteen. Based on literature review, nurse retention programs in home health care had
not been developed. However, there have been effective interventions implemented to improve
nurse retention such as creating a positive work environment, salary and benefits, and assuring
the autonomy to schedule work hours to increase nurse job satisfaction.

Similar search terms were examined using practice site intranet. There were zero results
returned. The home health care organization did not have any nurse retention program or
guidelines implemented. The practice site recruited new graduate nurses, however, it did not
have retention programs in place to retain existing nurses.
Literature Review
Nurse retention has become a challenging issue for many healthcare organizations,
including home health care. McHugh and Ma (2014) discovered that wage was associated with
job dissatisfaction and intent to leave. Li, Canham, and Wahl (2016) examined how the work
environment can be a predictor for job satisfaction. Studies have reported that positive work
environments improve nurse retention and healthcare organizations with positive practice
environments have lower turnover and higher retention rates of nurses (Twigg and McCullough,
2014). In a systematic review of literature, Halter et al (2017) examined the literature published
in English between 1900 and 2015 to understand which interventions are effective in reducing
nurse turnover rates. Multiple variables influence nurse retention, including salary and benefits,
autonomy, and work environments. Previous studies have also examined the relationships
between job satisfaction and nurse retention. According to Asegid, Belachew, and Yimam
(2014), the final predictors of overall satisfaction were autonomy, work environment, and wages.
By improving nurse salary and benefits, enhancing nurse practice environments, and allowing
nurses the autonomy to practice and schedule work hours, healthcare organizations can improve
job satisfaction, decrease nurse turnover, and increase retention rates (Cushman et al., 2001;
Shader et al., 2001; McHugh and Ma, 2014).

Salary and benefits
One intervention to address nurse shortage and solve retention problems is to increase
wages (Spetz and Given, 2003). A satisfactory wage is a significant factor in job-seeking
behavior and is especially important in keeping workers satisfied in their current positions
(McHugh and Ma, 2014). Wages have a significant effect on job satisfaction and nurse retention.
In some studies, dissatisfaction with wage played the biggest role in nurse turnover (Klopper,
Coetzee, Pretorius, and Bester, 2012; Palmer, 2014). Studies have found that competitive wages
coupled with good benefits may be necessary for home health care organizations to recruit nurses
to fulfill the ongoing home care demands (McHugh and Ma, 2014). Previous studies have
investigated the connection between pay satisfaction, job satisfaction, and nurse turnover intent.
Results indicated pay satisfaction influence job satisfaction and turnover intent. Staff
dissatisfaction with salary and benefits can affect job performance and decrease commitment to
the job and causes nurse turnover (Singh and Loncar, 2010).
In Tai, Bame, and Robinson’s review of nursing turnover research (1998), four of six
studies about nurse retention indicated that retention decreased as job opportunities elsewhere
increased. According to Jarrin et al. (2014), home health nurses work more hours than nurses in
any other setting and are often paid on a salary basis. Even when home health nurses are paid on
an hourly basis, working uncompensated overtime to complete documentation is quite common.
Home health care organizations can ensure nurses competitive salary and benefits by paying
overtime, vacation, holiday, sick, lunch, and offering bonuses and other paid-time-off hours
(McHugh and Ma, 2014).

Work environment
In home health care, a good work environment is necessary to retain qualified nurses
(Jarrin et al., 2014). Providing nurses with a positive work environment and supportive
management are important variables that influence the decision to stay in the organization. A
positive work environment has shared-governance, a process that promotes shared-decision
making, collaboration, and accountability through workforce recognition and empowerment.
Shared governance is described by nurses as a feeling of fairness, support and a sense of control
nurses from institutions (Ellenbecker, 2004). The more participatory the management style, the
more satisfied nurses are with the jobs and this translates into better retention. Working for an
organization that is supportive, combined with a professional atmosphere, contributes to nurses’
job satisfaction and nurses’ decision to stay with the current positions. Studies have reported that
shared governance is related to empowerment. Nurses in an organization with few opportunities
for professional autonomy, lack of shared governance, felt disempowered by the lack of
influence over practice (Hastings, Armitage, Mallinson, Jackson, and Suter, 2014). Ellenbecker
et al. (2007) discovered that shared governance was the only retention intervention employed by
home health care agencies that made a statistically significant difference in job satisfaction. Job
dissatisfaction occurs as a result of the lack of shared governance. Organizations promote shared
governance by encouraging nurses to participate in the development organizational culture,
policies and procedures, and the decision-making process.
Autonomy and control of work hours
One of the determinants that may be expected to influence job satisfaction is the degree
of perceived autonomy that nurses enjoy in the way they do their job (Asegid, Belachew, and
Yimam, 2014). A primary characteristic of nurses who are successful in home health care is the
ability and willingness to adapt and move toward professional autonomy (Neal, 2000). Nurses
who were more satisfied with their job had greater autonomy and control over the practice
setting (Twigg and McCullough, 2014). The job demand – control model developed by Robert
Karasek (1979) emphasizes the balance of job requirements and autonomy. According to this
model, nurses who encounter high demands at work with little control are more likely to
experience burnout. Home health care nurses who experience a high degree of work stress and a
low degree of autonomy have an increased risk of stress that results in burnout and turnover
intention. The organization can ensure utilize this model to ensure staff autonomy to improve job
satisfaction and retention.
Nurses with the autonomy to schedule their own work hours report higher levels of job
satisfaction. Autonomy allows for work-life balance and has a profound effect on job satisfaction
and retention. Nurses are less likely to leave the jobs when they have the ability to control work
hours and schedules. Autonomy and control of work activities contribute to job satisfaction in
home health care nurses (Ellenbecker, 2004). Nurses have the freedom to decide what services to
provide and when the deadline is. Autonomous health care nursing staff are more engaged in the
work and less likely to consider leaving the home care organization (Maurits et al., 2015). Nurses
with control over patient care decisions and the practice have an increased sense of job
satisfaction. By developing strategies that enhance nurses’ autonomy, organizations are more
likely to improve nursing staff job satisfaction and retain nurses. Studies have found that control
over nursing practice and nursing autonomy empower nurses and motivate the job satisfaction
and retention (McLure, 2004).
What is currently understood. The relationship between autonomy and nurse retention
has been examined. Healthcare organizations, including in the home health care sector, are
identifying and implementing evidence-based interventions to improve job satisfaction and nurse
retention. The strategies to strengthen retention rates include creating a favorable work
environment that promotes shared governance, increasing salary and benefits, and providing
nurses autonomy. Improvement in job satisfaction through the establishment of shared-
governance, autonomy, and satisfactory salary and benefits contribute to increased nurse
retention. Most studies of job factors that are associated with turnover in nursing have been
limited to hospital nurses and previous studies have described autonomy as an antecedent of
nurses’ work engagement (Maurits et al., 2015). Home health care nurses are satisfied with the
autonomous role.
Issues still under investigation. While the results from previous research studies
indicate a positive relationship between group cohesion and retention, not enough research has
been conducted to investigate its relationship to nurse retention in home health care. In addition,
the nurses’ gender, age, educational level, sociocultural backgrounds, and past experiences
relating to retention rates are still being investigated. Some studies have documented that nurses’
age and educational level significantly influence job satisfaction (Abdullah Al Maqbali, 2015).
Older and experienced nurses are more likely to be satisfied with the current job (Abdullah Al
Maqbali, 2015).
Issues that have not been addressed. Future studies need to examine nurses’ work
ethics, regardless of age, education, or prior experiences. It is important to assess personal
characteristics since there can be countless of factors that may influence job satisfaction.
Furthermore, the nurses’ relationships with colleagues, patients, and administrators play a
significant role in nurse retention. Researchers should address these components. The level of
job satisfaction among home health care nurses may be higher when they receive support from
peers.
Controversies. The relative impact of wage on nurse retention may vary in different
countries (McHugh and Ma, 2014). Interventions that improve the work environment may be
more important than wages. Simmons et al. (2001) compared the work attitudes of home health
care and hospital nurses and reported that home health care nurses have less anger and frustration
than hospital nurses. Job stress influences job satisfaction by affecting intent to stay. Gender
differences affect job satisfaction. Generally, male nurses are less satisfied with the job
(Abdullah Al Maqbali, 2015). Discrepancies exist in research. Some studies suggested that less
experienced nurses are more satisfied with themselves and some reported that more experienced
nurses are more likely to be satisfied (Abdullah Al Maqbali, 2015). The level of job satisfaction
also decreases in younger generation of nurses. Younger nurses are less satisfied with the job due
to less experience and education. While studies have indicated that individual nurse
characteristics (i.e. age, experience, marital status, marital status, education, and gender) affect
nurse retention, what is known comes from investigation in hospital settings and no studies have
been conducted concerning the effects of individual nurse characteristics for nurses working in
home health care settings (Ellenbecker et al., 2008).
Current management. To address nursing shortage, the practice organization recruits
new graduate nurses to join the home health care agency. Although the organization provides
new graduate nurses an opportunity to choose their own patient assignment, some require
additional support. Despite organizational support, the nurse retention rate remains low. The
organization conducts field staff meeting quarterly to address concerns. Evidence-based home
health care nursing retention program will improve job satisfaction and reduce nurse turnover.
Nurses are less likely to leave the job if the healthcare organizations provide them a favorable
work environment, promote autonomy, and offer competitive salaries. Nurses’ job satisfaction
with higher retention rates produce quality care and improved patient outcomes. Factors of
shared governance, autonomy, and competitive pay play a role in nursing retention.
Theoretical Model
Historical development
Imogene King is the founder of the Theory of Goal Attainment. The theory was
developed in the early 1960s and published in 1971 when the founder created her own theoretical
framework after gathering information from a review of the published works at the time, through
discussions with her colleagues, and attending professional conferences. Imogene King states
that the goal of a nurse is to help patients maintain their health so they can function on their own.
Nurses are responsible for promoting, maintaining, restoring health, and caring for the sick,
injured and dying. The Theory of Goal Attainment is relevant to the profession of nursing based
on the application of its major tenets to current nursing practice.
Major tenets
The Theory of Goal Attainment has three interacting systems: the individual or personal
system, the group or interpersonal system, and the society or social system. Each system has its
own unique concepts. Within the individual or personal system, the attainments of goals are
influenced by several factors including perception, self, growth and development, body image,
personal space, and time. For the group or interpersonal system, the concepts associated are
interaction, communication, transaction, role, and stress. Finally, major concepts involved in the
social system include organization, authority, power, status, and decision-making. The Theory of
Goal Attainment was based on an overall assumption that the focus of nursing is human beings
interacting with the environment, leading to a state of health for individuals, which is an ability
to function in social roles (Alligood and Tomey, 2010).
According to Imogene King, nursing is a process of action, reaction and interaction by
which nurse and client share information about their perception in a nursing situation, a process
of human interactions between nurse and client whereby each perceives the other and the
situation, and through communication, they set goals, explore means, and agree on means to
achieve goals (Alligood and Tomey, 2010). Environment is defined as the background for
individual interactions. Individuals are defined as human beings who are rational and able to
communicate their thoughts, actions, customs, and beliefs through language. Human beings
possess similar abilities to perceive, to think, to feel, to choose, to set goals, to select the means
to achieve goals, and to make decisions.
The Theory of Goal Attainment is based on a philosophy of human beings and open
systems model. Nursing is an interaction process between the nurse and patient. Nurse and
patient mutually communicate information about their perceptions, share concerns, establish
goals, and then explore means to attain these mutual goals. If role conflict is experienced by
either the nurse or the patient (or both), stress in the nurse-patient interaction will occur and
patient quality of care and safety are affected. The theory is useful and applicable to nursing
practice through the emphasis of nurse-patient relationships.
Application to Current Practice
Based on the Theory of Goal Attainment, when a nurse and patient interact, a transaction
will occur and mutually established goals will be attained. If mutual goals are accomplished,
satisfaction will occur. If transactions are developed in the nurse-patient interactions, growth and
development will be improved. If the nurse and patient’s perceptions of role expectations and
performance are similar, transaction will occur. Perception is an important concept in the
personal system since it directly influences the nurse’s behaviors, personal goals and beliefs. The
social system discusses how the nurse interacts with colleagues, superiors, and subordinates. In
this system, the nurse and organization share common goals, values, and interests. The personal
and social systems greatly influence the patient quality of care. For example, the nurse’s role as a
patient caregiver and advocate is to ensure that patients receive the optimal care provided by the
organization. If the care delivered is suboptimal and deemed unsafe, patients will not attain
quality health outcomes. The nurse’s goals are to help individuals maintain their health so they
can function their roles. In other words, nurses are responsible for helping patients achieve
optimal health and ensuring patient satisfaction. When the organization and nurses do not share
the same goals and prioritize patient’s safety, nurses will not experience personal growth and
development.
Application of theory to DNP project
The Theory of Goal Attainment is applicable to the DNP project, specifically the nurse
retention program. According to Imogene King, nurses need to interpret information in the
nursing process to plan, implement, and evaluate nursing care. These tasks are important and
necessary to ensure that all patients receive optimal outcomes. Based on the Theory of Goal
Attainment, nurses and patients have mutual goals that focus on promoting and restoring
patients’ health. Inadequate autonomy and a suboptimal work environment are two factors that
will likely prevent the interaction of nurse and patient from occurring, thus hindering the process
of transaction from happening.
According to the Theory of Goal of Attainment, growth and development will not occur
if adequate interaction between nurse and patient does not take place. Nurses want to attend to
their patients’ needs and have time to interact with them, educate them, and develop a
relationship with their patients. However, such activities cannot occur when nurses are
overwhelmed with high work demands. Nurses are more likely to achieve their goals and provide
effective nursing care if organizations supported team nursing and provided them with a better
work environment with autonomy and control of work activities.
Nurses and patients would fail to communicate their problems and concerns, to establish
mutual goals, and to explore means to achieve them if they were not given enough time for
interaction. Nurses’ goals are to promote, maintain, and restore health. Without accomplishing
these goals, nurses may find the work dissatisfying and with less meaning when they work in an
environment that is not conducive to helping patients move toward recovery. The Goal
Attainment Theory is utilized to develop a nurse retention program in a home health care
organization.
Description of Project Design
This DNP Project utilized a quality improvement design. The project implementation was
guided by Lewin’s Change Theory. The practice site was a home health care organization with
an average nurse turnover rate of thirty percent. The implementation of an evidence-based NRP
was necessary to change the current organizational culture in efforts to improve nurse retention,
job satisfaction, and intent to stay. The population of interest was nursing staff, including full-
time, part-time, and per diem nurses. The variables in this project were nurses’ work
environments, autonomy and control of work hours, and salary and benefits. The purpose of the
project was to implement an evidence-based NRP at practice site to improve nurse retention, job
satisfaction, and intent to stay.

Work environment, autonomy and control of work hours, and salary and benefits were
factors influencing nurse retention, job satisfaction, and intent to stay. The operations
coordinator, chief operations officer, chief financial officer, and nursing administrator of the
home health care facility expressed an interest retaining qualified nurses and improving job
satisfaction thus supported the implementation of an evidence-based NRP. This DNP Project had
been authorized at the project site by the operations coordinator and nursing administrator.
Data collection was completed before and after the NRP implementation and involved
review of employee retention data through human resources employment records and
administration of surveys to assess job satisfaction and intent to stay. Questionnaire surveys were
labeled pre-intervention and post-intervention. The survey was distributed to all participating
nursing staff members after all consents were received and permission to proceed was obtained
from the organization’s CEO.
Population of Interest, Setting, Stakeholders, and Recruitment Methods
Population of Interest
The population of interest was thirty-four registered nurses and licensed practical nurses,
including full-time, part-time, and per diem, who provide home health care services. Certified
nursing assistants, speech therapists, occupational therapists, and physical therapists were not
included the project. According to the organization policy, the first ninety day was considered a
probationary period, therefore, nurses with less than three months of employment did not meet
the inclusion criteria. Nurses who participated in this project already completed the probationary
period.
Setting
The DNP Project took place at a private home health care agency in Las Vegas, Nevada.
The practice organization is one of the largest home health companies in Southern Nevada with a
daily patient census of approximately three hundred. The company was established since
September 1994. It offers nurses a competitive compensation package which includes a $5000
sign on bonus, $25,000 MetLife insurance policy for full-time employees, and employee stock
ownership plan after one year of employment. Employees would receive an average of nineteen
percent of the yearly income back in retirement benefits every year.
Full-time nurses would visit six to eight home patients a day, while part time nurses
would visit four. In January 2018, the company hired nine nurses. After four months, six nurses
left the organization. On average, the company had thirty percent nurse turnover rate. The home
health care organization mission and vision include providing high quality patient care through
nurse empowerment, professional development, and nurse practice autonomy.
Stakeholders
Stakeholders in this project included the chief executive officer (CEO), operations
coordinator, chief operations officer, chief financial officer, nursing administrator (also known as
director of nursing), and nursing managers from different departments. These individuals were
interested in improving nurse retention, job satisfaction, and intent to stay. The key stakeholders
were operations coordinator, chief operations officer, and nursing administrator. The DNP
student collaborated with the identified key stakeholders to develop a NRP for the organization.
Recruitment Methods
The operations coordinator allowed the DNP student to participate in the company’s field
staff meeting to introduce the purpose of the project and explain the importance of nursing staff
engagement during the pre- and post-intervention implementation. The recruitment process
involved the DNP student presenting the project aims to nursing staff during the meeting and
requesting for their cooperation to implement organizational change. A total of thirty-four
participating full-time, part-time, and per diem nurses currently employed by the home health
care agency were given a sealed envelope containing a cover letter providing a brief introduction
about the purpose of the project, consent information, and instructions for completing the survey
during a regularly scheduled staff meeting (Appendix C). Participation in the project was
voluntary and anonymous.
The DNP student attended a mandatory staff meeting with all participating nurses before
and after implementation of NRP. The NRP was ready for implementation by the end of
October. The questionnaire surveys were distributed during the staff meetings. To increase the
response rate, the DNP student attended every staff meeting to encourage participants to
complete the questionnaire. In addition, email reminders were sent at biweekly intervals to
nurses who had not yet responded. Once questionnaire surveys were completed, nursing staff
returned it in a sealed envelope and placed it in a locked box provided by the DNP student.
Incentives to participate in the study included a five-dollar gift card once all surveys were
returned.
Tools/Instrumentation
Pre and Post Intervention Survey
The survey instrument utilized in this project was the Home Health Care Nurses Job
Satisfaction Scale (HHNJS). The questionnaire survey was developed by Dr. Carol Ellenbecker
(2001) and was based on a theoretical model that integrated the findings of empirical research
related to job satisfaction. Numerous scales had been developed to measure nurses’ job
satisfaction, however, only the Home Health Care Nurses’ Job Satisfaction Scale was created
specifically to measure job satisfaction of home health care nurses (Ellenbecker and Byleckie,
2005). The Home Health Care Nurses’ Job Satisfaction Scale was a reliable and valid scale for
measurement of job satisfaction of home health care nurses. The HHJNS contained 30 items,
each of which was rated on a 5-point scale: 1 = strongly agree, 2 = agree, 3 = neutral, 4 =
disagree, and 5 = strongly disagree. The 30 items measured nine factors hypothesized to
comprise job satisfaction (Ellenbecker, Porell, Samia, Byleckie, and Milburn, 2008). Ellen and
Byleckie (2005) established the validity and reliability of the HHNJS for a sample of home
health care nurses (Cronbach’s alpha = 0.79). Ellenbecker et al (2008) used the HHNSJ in a
descriptive correlation study of home health care nurses in six New England states. Nine
observed factors of the HHNJS were organizational characteristics, relationship with patients,
autonomy and professional pride, group cohesion with peers, relationship with physicians, salary
and benefits, stress and workload, autonomy and flexibility in work scheduling, autonomy and
control of work activities. Job satisfaction was derived from these nine factors. Participating
nurses completed the survey indicating their intent to stay with current position was higher when
they rated their job satisfaction.
The DNP student contacted Dr. Ellenbecker via email and permission was granted for the
student to use the HHNJS scale in the DNP project (Appendix A).
The NRP
The evidence-based nurse retention program (NRP) was designed to improve nurse
retention rates. The NRP created a positive practice environment that promoted autonomy and
shared governance aimed to improve job satisfaction. To ensure that the NRP was appropriate
for practice organization, the DNP student collaborated with project mentor and key stakeholders
to develop and implement the NRP that aimed to improve nurse salary and benefits, work
environment, and practice autonomy (Appendix F). The proposed NRP was reviewed and
approved by key stakeholders on October 3rd, 2018.
Educational Training Materials
Staff development is essential and has been associated with job satisfaction and employee
retention. Prior to delivering educational training materials to the nurses and stakeholders at
practice organization, the DNP student examined their relevance and validity with the project
mentor. Educational training included concepts of communication, time management, and
strategies to improve nurse work hours and schedules were reviewed. The DNP student
presented data from the HHNJS psychometric study to stakeholders and nurses at practice site
for educational purposes (Appendix B).
Tool for Examining Nurse Retention
The Home Health Care Nurses’ Job Satisfaction scale (Ellenbecker and Byleckie, 2005)
consisted of domains that examined the nurses’ relationship with peers, relationship with
organizations, relationship with physician, salary and benefits, stress and workload, relationship
with patients, professional pride, autonomy and control. The job satisfaction scale had a three-
item intent to stay scale embedded. The tool was validated and the DNP student received the
author’s permission to use it in the DNP project (Appendix E). Cronbach’s alpha coefficients for
each of the nice subscales ranged from 0.64 to 0.83. The correlations between the Home
Healthcare Nurses’ Job Satisfaction Scale and Mueller and McCloskey Satisfaction Scale was
0.79, indicating good criterion-related validity (Ellenbecker and Byleckie, 2005).

Data Collection and Procedures
Data collection was conducted before and after the NRP implementation and involved
review of employee retention data and administration of surveys. To determine the effects of the
NRP, the DNP student communicated with human resources to determine how many nurses
resigned from the organization before and after implementation of the NRP at monthly intervals.
The practice organization accountant and human resources personnel provided the DNP student
with ample information about nurse retention rates before and after NRP implementation.
Confidentiality was maintained and no names of participants were discussed.
Initial data was collected via surveys during a live staff meeting at the time of
implementation and at the six-week mark after the intervention. Survey pre- and post
intervention data were collected from the same nurses to compare changes in responses
pertaining to job satisfaction and intent to stay. Questionnaire surveys were distributed to
participating nursing staff and all survey responses were kept anonymous. The response rate goal
was set at greater than 75 percent. Questionnaire (Appendix H) consisted of inquiries about
salary, benefits package, opportunity to grow, relationship with administration, group cohesion
with peers, and control over work and schedules.
Intervention/Project Timeline
During the last week of October 2018, nursing staff employment records in human
resources was examined prior to implementation of the intervention to review the current nurse
turnover rates. Nurses’ salary and benefits, work schedules including daily census and patient
assignment were also reviewed. An introduction letter (Appendix G) about the DNP Project was
distributed to eligible nursing staff. A copy of the letter was kept with human resources and
nursing administrator. Thirty-four nurses were asked to complete the pre-intervention survey
before implementation of the NRP. Pre-intervention survey was distributed on October 22, 2018.
The NRP was implemented on October 26, 2018. All pre-intervention questionnaires were
collected on this day.
During the first week of November 2018, the DNP student attended a mandatory nursing
staff meeting to reinforce the significance of the DNP Project and address any questions or
concerns that participating nurses may have. During this meeting, the DNP student provided
education on the NRP and its important components. The NRP went live on November 1st. A
copy of the survey was available in human resources.
During the second week of November 2018, the DNP student visited the practice
organization to follow up. Participating nursing staff received a follow-up email from the DNP
student as a reminder that the intervention had begun. Nurses were encouraged to speak up if
they had questions or concerns about the intervention.
During the third week of November 2018, the DNP student informally interviewed
nursing staff at the home health organization when they came to pick up their weekly paycheck.
The purpose of the brief interview was to address questions and assess for difficulties
surrounding NRP. Weekly documentation of nursing staff feedbacks about their practice
environment, compensations, and autonomy to schedule work hours and days was performed.
Participating nurses were asked to complete a post intervention survey during the last week of
November. All post intervention questionnaires were distributed on November 26th and collected
by November 30th. Data analysis was completed by the second week of December and findings
were presented to practice site on December 14th. During week 14 of DNP Project III, the project
results were presented to DNP faculty.

Ethics/Human Subjects Protection
The Institutional Review Board (IRB) determination forms were submitted per Touro
University Nevada (TUN) policy and the project fell under the category of TUN quality
improvement project, which did not require IRB review. The practice site did not have an IRB
committee and therefore did not require an IRB review of the project. The DNP Project involved
investigation of nursing staff perceptions of the workplace. The project examined nursing staff
job satisfaction related to the practice environment, salary and benefits, and autonomy to
schedule work. The project did not include patients. Pre-and post-guideline implementation
questionnaires presented minimal risk to participating nurses who completed questionnaires
anonymously. To protect the privacy and confidentiality of participants, there were no personal
information identified and the questionnaires were numbered one to thirty-four. The participants
memorized the numbered pre-implementation questionnaire and wrote it on their post-
implementation questionnaire. This process allowed the project leader to link participant
responses of the before and after implementation of the NRP.
The DNP Project was considered a quality improvement project that required participants
to fill out a questionnaire before and after intervention. Risks to participate in this project were
minimal. By participating in the project, home health care nurses provided information to
employers about job satisfaction and intent to stay with the organization. Participants in this
project were compensated with a Starbucks gift card.
Plan for Analysis/Evaluation
Thirty-four participants were asked to return thirty-four questionnaires numbered from
one to thirty-four. The participants memorized the pre-intervention questionnaire number and
recorded the same number in the post-intervention questionnaire. The project leader compared
individual responses. Survey data were collected before and after the implementation of NRP.
The questionnaire response categories of a five point Likert item were coded 1 to 5. To evaluate
the significance of intervention, a Wilcoxon signed rank test was used to compare for change:
nurses’ job satisfaction and intent to stay. The thirty-item questionnaire was converted into an
identical set of scales for pre and post intervention. Scores were tallied. The Wilcoxon signed-
ranked test was selected to determine whether there was a difference in nurse job satisfaction and
intent to stay before and after a program implementation. The Statistical Package for the Social
Sciences (SPSS) Statistics was used to perform a Wilcoxon signed-rank test to analyze pre-
questionnaire results and post-questionnaire results. The expected outcome was that the
implementation of the NRP was significant in improving nurse job satisfaction and their intent to
stay. Nurse retention was measured by the levels of nurses’ job satisfaction and intent to stay.
The DNP Project statistical analysis was submitted to a statistician for review and the use of
Wilcoxon signed rank test was recommended.
Analysis of Results
Data calculations and analysis were conducted using the Statistical Package for the Social
Sciences (SPSS). The HHNJS scale used in this project for pre and post testing included items
addressing salary, benefits, autonomy, control, and work environment (Appendix B). A
comparison of the pre-intervention results and post-intervention results was performed
(Appendix I). Statistical significant increase in satisfaction scores was found in areas of work
environment, pay scale, benefits package, job flexibility, control of scheduling work and time.
No statistical significance was found pertaining to satisfaction with administration, salary, and
team communication.
WILCOXON SIGNED RANKS TEST

Pre-Test Post-Test
4.58
4.58
4.46
4.5
4.37
4.33
4.29
4.25
4.25
4.12
3.96
4
3.54
3.33
2.96
2.58
1.79
1.58
Q1 Q3 Q15 Q16 Q18 Q24 Q27 Q28 Q30
Table 1. Wilcoxon Signed Ranks Test Statistics
Item on HHNJS Pre-Testing Post-Testing p-value (2-tailed) Z

Question 1 (Q1) 4.46 4.58 .180 -1.342
Question 3 (Q3) 4.00 4.25 .034 -2.121
Question 15 (Q15) 1.79 1.58 .025 -2.236
Question 16 (Q16) 3.33 3.54 .059 -1.890
Question 18 (Q18) 2.96 2.58 .014 -2.460
Question 24 (Q24) 4.25 4.37 .083 -1.732
Question 27 (Q27) 4.33 4.50 .046 -2.000
Question 28 (Q28) 4.29 4.58 .020 -2.333
Question 30 (Q30) 3.96 4.12 .046 -2.000
The HHNJS questionnaire consisted of 30 items, nine were relevant to the project:
satisfied with relationship with administration (question 1), opportunity to grow (question 3), pay
scale needs to be upgraded (question 15), my salary is satisfactory (question 16), benefits
package is not as good (question 18), open lines of communication with team (question 24),
more flexibility than others (question 27), have control over scheduling my time (question 28),
have little control over work (question 30). Each question had a 5-point Likert-type scale: 1 =
strongly disagree; 2 = disagree; 3 = neutral; 4 = agree; 5 = strongly agree. Questions 1, 3, 16, 24,
27, and 28 followed this scale. Questions 15, 18, and 30 were negatively worded questions,
therefore, they were reverse scored: 1 = strongly agree; 2 = agree; 3 = neutral; 4 = disagree; 5 =
strongly disagree. A score of 5 indicated highest satisfaction while a score of 1 denoted lowest
satisfaction. For this project, the HHNJS scale was utilized to measure three components of job
satisfaction: salary and benefits, autonomy and control, and work environment.
A Wilcoxon Signed Rank Test did not reveal a statistically significant increase in nursing
staff satisfaction with administration following implementation of the NRP protocol: z = -1.342,
p > .05 with a small effect size (r = 0.19). The median score increased from pre-implementation
(Md = 4.46) to post-implementation (Md = 4.58), a difference of 0.12 for question 1.
A Wilcoxon Signed Rank Test revealed a statistically significant increase in nursing staff
satisfaction with work environment (question 3) following implementation of the NRP protocol:
z = -2.121, p < .05 with a medium effect size (r = 0.30). The median score increased from pre-
implementation (Md = 4.00) to post-implementation (Md = 4.25), a difference of 0.25.
satisfaction with pay scale (question 15) following implementation of the NRP protocol: z = -
2.236, p < .05 with a medium effect size (r = 0.32). The median score decreased from pre-
staff satisfaction with salary (question 16) following implementation of the NRP protocol: z = -
1.890, p > .05 with a small effect size (r = 0.27). The median score increased from pre-
satisfaction with benefits package (question 18) following implementation of the NRP protocol:
z = -2.460, p < .05 with a medium effect size (r = 0.36). The median score decreased from pre-
staff satisfaction with team communication (question 24) following implementation of the NRP
protocol: z = -1.732, p > .05 with a small effect size (r = 0.25). The median score increased from
pre-implementation (Md = 4.25) to post-implementation (Md = 4.37), a difference of 0.12.
satisfaction with job flexibility (question 27) following implementation of the NRP protocol: z =
-2.000, p < .05 with a small effect size (r = 0.29). The median score increased from pre-
satisfaction with control over scheduling (question 28) following implementation of the NRP
protocol: z = -2.333, p < .05 with a medium effect size (r = 0.34). The median score increased
from pre-implementation (Md = 4.29) to post-implementation (Md = 4.58), a difference of 0.29.
satisfaction with control over work (question 30) following implementation of the NRP protocol:
z = -2.000, p < .05 with a small effect size (r = 0.29). The median score increased from pre-
A paired-samples t-test was conducted to evaluate the impact of the NRP implementation
on nurses’ scores on the satisfaction with relationship with administration before and after the
NRP intervention. There was no statistically significant increase in satisfaction scores from pre-
testing (M = 4.46, SD = .83) to post-testing (M = 4.58, SD = .58), t(23) = -1.37, p > 0.05 (two-
tailed). The mean increase in job satisfaction score was -.125 with a 95% confidence interval
ranging from -.314 to .064. The eta squared statistic (.07) indicated a moderate effect size.
Table 2. Paired-Samples t-Test
Item on HHNJS Pre-Testing Post-Testing p-value (2-tailed) Significant increase in

satisfaction scores
Question 1 (Q1) 4.46 4.58 .185 no
Question 3 (Q3) 4.00 4.25 .031 yes
Question 15 (Q15) 1.79 1.58 .022 yes
Question 16 (Q16) 3.33 3.54 .057 no
Question 18 (Q18) 2.96 2.58 .009 yes
Question 24 (Q24) 4.25 4.37 .083 no
Question 27 (Q27) 4.33 4.50 .043 yes
Question 28 (Q28) 4.29 4.58 .016 yes
Question 30 (Q30) 3.96 4.12 .043 yes
on nurses’ scores on the satisfaction with work environment (“opportunity to grow”) before and
after the NRP protocol was implemented. There was a statistically significant increase in
satisfaction scores from pre-intervention (M = 4.00, SD = 1.18) to post-intervention (M = 4.25,
SD = .79), t(23) = -2.30, p < 0.05 (two-tailed). The mean increase in job satisfaction score was -
.250 with a 95% confidence interval ranging from -.474 to -.025. The eta squared statistic (.19)
indicated a large effect size.
on nurses’ scores on the satisfaction with job pay scale before and after the NRP protocol was
implemented. There was a statistically significant increase in satisfaction scores from pre-
intervention (M = 1.79, SD = .78) to post-intervention (M = 1.58, SD = .50), t(23) = 2.46, p <
0.05 (two-tailed). The mean increase in job satisfaction score was .21 with a 95% confidence
interval ranging from .033 to .383. The eta squared statistic (.21) indicated a large effect size.
on nurses’ scores on the satisfaction with job salary before and after the NRP protocol was
implemented. There was no statistically significant increase in satisfaction scores from pre-
intervention (M = 3.33, SD = 1.00) to post-intervention (M = 3.54, SD = .72), t(23) =-2.00, p >
0.05 (two-tailed). The mean increase in job satisfaction score was -.208 with a 95% confidence
interval ranging from -.423 to .006. The eta squared statistic (.15) indicated a large effect size.
on nurses’ scores on the satisfaction with job benefits package before and after the NRP protocol
was implemented. There was a statistically significant increase in satisfaction scores from pre-
intervention (M = 2.96, SD = 1.19) to post-intervention (M = 2.58, SD = .88), t(23) = 2.84, p <
0.05 (two-tailed). The mean increase in job satisfaction score was .375 with a 95% confidence
interval ranging from .102 to .648. The eta squared statistic (.26) indicated a large effect size.
on nurses’ scores on the satisfaction with team communication before and after the NRP protocol
was implemented. There was no statistically significant increase in satisfaction scores from pre-
intervention (M = 4.25, SD = .94) to post-intervention (M = 4.37, SD = .77), t(23) = -1.81, p >
interval ranging from -.267 to .018. The eta squared statistic (.12) indicated a moderate effect
size.
on nurses’ scores on the satisfaction with job flexibility before and after the NRP protocol was
implemented. There was a statistically significant increase in satisfaction scores from pre-
intervention (M = 4.33, SD = .564) to post-intervention (M = 4.50, SD = .589), t(23) = -2.14, p <

interval ranging from -.327 to -.006. The eta squared statistic (.17) indicated a large effect size.
on nurses’ scores on the satisfaction with control over scheduling before and after the NRP
protocol was implemented. There was a statistically significant increase in satisfaction scores
from pre-intervention (M = 4.29, SD = .624) to post-intervention (M = 4.58, SD = .503), t(23) =
-2.60, p < 0.05 (two-tailed). The mean increase in job satisfaction score was -.292 with a 95%
confidence interval ranging from -.524 to -.059 The eta squared statistic (.23) indicated a large
effect size.
on nurses’ scores on the satisfaction with control over work before and after the NRP protocol
was implemented. There was a statistically significant increase in satisfaction scores from pre-
intervention (M = 3.96, SD = .55) to post-intervention (M = 4.12, SD = .34), t(23) = -2.145, p <
interval ranging from -.327 to -.006. The eta squared statistic (.17) indicated a large effect size.
Discussion of Findings
The purpose of this project was to design and implement a NRP and determine if this
intervention would increase job satisfaction scores and improve nurse retention rates in a home
healthcare organization. Thirty-four nurses were recruited to participate in this project. Before
implementation of the NRP, twenty-four out of thirty-four nurses submitted the pre-intervention
questionnaire by the designated deadline. Data analysis was conducted on the twenty-four pre
and post-intervention questionnaires collected. In the pre-testing period prior to NRP
implementation, majority of the participating nurses indicated high satisfaction with

administration, work environment, team communication, job flexibility, and control over
scheduling of work time. All these items on the questionnaire (Q1, Q3, Q24, Q27, Q28, Q30)
were given a score of 4 or higher. The three areas that received poor satisfaction scores were pay
scale, salary, and benefits package. These items (Q15, Q16, Q18) received a score of 3 or lower.
One month after implementation of the NRP, the results indicated there was no
statistically significant relationship between the NRP and satisfaction scores pertaining to
satisfaction with administration, salary, and team communication. Although the difference in
satisfaction scores was negligible, there was improvement. For satisfaction with administration,
the score was 4.46 before NRP implementation which increased to 4.58 in post-testing. For
satisfaction with salary, the score was 3.33 in pre-test which increased to 3.54 in post-test. For
satisfaction with team communication, the score was 4.25 in pre-implementation of NRP which
increased to 4.37 in post-implementation. Post-testing results indicated statistically significant
increase in satisfaction scores relating to the work environment, pay scale, benefits package, job
flexibility, control of scheduling work and time. These findings are consistent with the
determinants of employee retention identified in previous studies (Christeen, 2015; Ellenbecker
et al., 2008). Overall, the desired outcomes and objectives of the project have been met: factors
contributing to nurse retention, job satisfaction, and intent to stay were identified; the
implementation of the NRP to increase nursing staff job satisfaction was successful. Through the
implementation of NRP, nursing job satisfaction scores have improved at host site.
Significance/Implications for Nursing
The objectives of this DNP Project were to develop and implement an evidence-based
nurse retention program to improve job satisfaction and nurses’ intent to stay at the home health
care organization. Buerhaus (2008) predicted a deficit in registered nurses (RNs) in the United
States with projected shortages of 285,000 RNs by 2020 and 500,000 RNs by 2025. The
development of an effective nurse retention program is one strategy to enhance the nursing
shortage in home health care. The creation of a positive nurse practice environment,
improvement in salary and benefits, and the promise of autonomy to self-schedule are
interventions proven to increase job satisfaction and nurse intent to stay.
The creation of a positive work environment that allows for nurse autonomy in decision-
making and participation in workplace governance may lower rates of nurse intention-to-leave
(Van den Heede et al., 2011). With an increasing demand for nurses, home health care agencies
develop strategies to increase retention. There is strong evidence that the independence and
professional autonomy in the role of home health care nurses is the major aspect of job
satisfaction (Ellenbecker, 2004). Additionally, the provision of health insurance and other
benefits may reduce the odds of nursing staff turnover (Luo, Lin, and Gastle, 2012).
By understanding the determinants of nursing retention, home healthcare agencies can
retain employees in a time of critical nurse shortages and increased patient demand (Ellenbecker
et al., 2008). The implementation of the NRP at the practice site has the potential to produce
significant results that other home health care organizations can follow to improve job
satisfaction to reduce nurse turnover. Findings from this project can be used to guide home
health care agencies to further explore interventions improving retention and intent to stay. The
practice site currently has a thirty percent turnover rate and the nursing shortage limits the
agency from providing more home health care services. This evidence-based NRP will assist the
practice site in improving employee job satisfaction and intent to stay through enhancing nurse
work environment, improving nurses’ salary and benefits, and promoting professional autonomy.
Limitations
This project has several limitations. The results of this project may be applied to home
healthcare setting, however, will require further investigation to determine generalizability in this
population. One major limitation in this project is the lack of participation from eligible nursing
staff. Although the response rate was 70 percent, it was acceptable since the response rates for all
groups of health care professionals has been declining over the last 20 years. Reasons for low
response rates include a lack of time, lack of knowledge, lack of funding, nurses’ poor
attitude/perception towards studies, and increasingly busy work schedules and stressful jobs
(Nkrumah, Atuhaire, Priebe, and Cumber, 2018; Asch, Jedrziewski, and Christakis, 1997; Hill,
Fahrney, Wheeless, and Carson, 2006). During the recruitment period, thirty-four home
healthcare nurses at the host organization expressed interest in the project. Prior to the NRP
implementation, twenty-four out of thirty-four nurses submitted the pre-intervention
questionnaire. Post-intervention, response rate was less than fifty percent. The data collection
deadline was extended three times to improve response rates.
Other limitations in this project include a small sample size and a brief time period of the
intervention which followed the NRP implementation. With a small sample size of twenty-four
nurses, the survey might not have accurately measured the home healthcare nurses’ self-reported
job satisfaction. The project took place over a six-week period at one single home healthcare
company. Post-intervention questionnaires were collected from nurses only one month after the
NRP implementation. This project has not examined the long-term outcome of the NRP on the
nurses’ job satisfaction, cost savings or retention over time.

Areas for Further Dissemination
Home healthcare nursing has the potential to decrease healthcare costs while providing
safe and high-quality care to improve health outcomes and reduce hospital stays. Home care
nurses provide patients a valuable service which focuses on a healthier lifestyle. In addition, the
use of home care nurses will assist in reducing costs, and assist in the reduction of the number of
hospital and long term care facility admissions (Romagnoli, Handler, and Hochheiser, 2013).
The findings in this project are to be presented to the nursing staff and stakeholders at the host
organization. Dissemination activities include summaries for stakeholders, educational sessions
with staff and policymakers, development and implementation of guidelines (Curtis, Fry,
Shaban, and Considine, 2016).
The NRP is included in the host organization employee handbook and has the potential to
assist other home healthcare agencies to improve recruitment and retention of home care nurses.
Understanding the determinants of home healthcare nurse retention can help this agency and
potentially other similar agencies retain nurses in a time of severe nurse shortage and increased
patient demand. In this project, job satisfaction, job benefits, comparable wages, and autonomy
influenced nurse intent to stay and retention.
This project will be submitted to the doctoral project repository at Doctors of Nursing
Practice website. Additionally, this project will be submitted for publication in The Home Care
Practice and Management Journal within three months.

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Appendix A. Permission to Use Home Health Nurse Job Satisfaction Scale

Appendix B. Home Health Nurse Job Satisfaction Scale

Appendix C. The Elements of Nurse Retention Program
Autonomy Salary and Benefits Work Environment
RN have control over practice Sign-on bonus No micromanagement

RN have control over work Vacation and life insurance Opportunity to grow, open
hours communication
RN have control over work Medical, dental, and vision Professional conferences and
schedules benefits. Retirement benefits webinars
RN manage their own patient 401K, employee stock Shared-governance, decision-
load each day ownership plan making process
Appendix D. Educational Training Materials
Nurse Turnover Cost
• Advertising and recruitment

• Vacancy costs (e.g., paying for agency nurses, overtime, closed beds, hospital
diversions, etc.)
• Hiring
• Orientation and training
• Decreased productivity
• Termination
• Potential patient errors, compromised quality of care
• Poor work environment and culture, dissatisfaction, distrust
• Loss of organizational knowledge
• Additional turnover
Nurse Retention Benefits
• Reduction in advertisement and recruitment costs

• Fewer vacancies and reduction in vacancy costs
• Fewer new hires and reduction in hiring costs
• Fewer orientees and reduced orientation and training costs
• Maintained or increased productivity
• Fewer terminations and reduction in termination costs
• Decreased patient errors and increased quality of care
• Improved work environment and culture, increased satisfaction, increased trust
and accountability
• Preserve organizational knowledge
• Easier nurse recruitment
Appendix E. Tool for Examining Nurse Retention

Appendix F. Home Health Care Nurse Retention Program
PHILOSOPHY
Caring Nurses Inc. recognizes the importance of nurse retention and job satisfaction to reduce
nurse turnover and provide quality of delivery related to home health care services.
GOAL
Home health care agency creates a positive work environment for nurses by providing them an
opportunity in decision-making, competitive salary and benefits, and granting them professional
autonomy and control of work hours to attain high level of job satisfaction to improve job
retention.
SALARY AND BENEFITS

• Paid vacation: All full-time nurses will receive one week (forty hours) after 1000 hours
(one year) of employment.
• Paid holiday: All full-time and part-time nurses will receive holiday pay for working on
New Year Day, Memorial Day, Independence Day, Labor Day, Thanksgiving Day, and
Christmas Day for start of care visits.
• Mileage reimbursement: All nurses will be reimbursed $5 per visit for mileage.
• Provision of uniforms: All full-time and part-time nurses will receive one lab coat one
time on hire.
• Health insurance for employee and family members: All full-time nurses will be offered
medical and vision benefits. The company will cover 50% of the premium for Medical
insurance and 100% of the premium for Vision insurance. For dependents, nurses will be
responsible for full payments.
• 401k plan: All full-time nurses will receive 401k upon completing 1000 hours and one
year of employment.
• Employee stock ownership plan (ESOP): All nurses will be offered ESOP after
completing 1000 hours and one year of employment.
• Continuing Education: All full-time and part-time nurses will be offered nursing CEUs
provided by the company and CE courses approved by the Nevada State Board of
Nursing. In addition to receiving hours, nurses will be paid to attend classes.
• Tablets: All full-time and part-time nurses will receive a tablet for business use with
TigerConnect text messaging application, email, and access to patient chart.
AUTONOMY AND CONTROL OF WORK SCHEDULES

• Control over work activities: All nurses will develop their own nursing care plan.
• Control of work hours/days: In accordance with patient preferences, all nurses will be
able to schedule their own working hours and days, without any limitations.
• Nurses can schedule to work any day and any time as long as they accommodate their
patients' schedules and fulfill the hour requirements. Full-time is considered 25 hours
average per week with Start of Care visit equaling 2 hours.
• Control of daily patient assignment: All nurses will create their own patient
assignment. Nurses will determine how many patients they will visit in a day, not to
exceed eight patients per day. The organization promotes work life balance, therefore,
working overtime is not encouraged.
• Independence in nurse-patient relationships: All nurses will establish rapport with their
own patients.
• Autonomy in the profession: All nurses will practice within their scope and report patient
outcomes and/or changes in condition directly to appropriate medical providers.
WORK ENVIRONMENT
• Promote shared-governance: Administrators and organizational leaders will empower all
nurses to participate in decisions making processes that affect patient care and nursing
practice.
• Promote accountability and responsibility: All nurses will have the opportunity to attend
weekly interdisciplinary team meeting to discuss about their patients’ progress.
• Professional development opportunities: All nurses will have the opportunities to
attend up to three classes related to home health care funded by the company.
• Recognition of nursing excellence: All nurses will be recognized for demonstrating
outstanding nursing work measured by patient clinical outcomes and a decrease in
hospital readmissions. Nurses will receive a Recognition Award in the form of a plaque
and a gift card.
• Open communication: All nurses will report their problems and concerns to
organizational leaders and there will be a follow-up within a 24-hour period.
• Participative and supportive management: By enforcing a zero-tolerance policy to
prevent incivility, bullying behavior, and lateral/horizontal violence in the workplace.
APPROVALS
Chief Executive Officer: Roger Corbin Date: October 3rd, 2018
Chief Operations Officer: Cremson Turfley Date: October 3rd, 2018
Administrator: Lori Comstock Date: October 3rd, 2018
Controller: Adele Newberry Date: October 3rd, 2018

Appendix G. Introduction Letter of DNP Project to Practice Site
Dear Caring Nurses’ Amazing Nurses,

My name is Tristan Tran. I am a nurse practitioner and a DNP student at Touro University. This
summer I am working on my doctorate thesis.
My DNP project is about implementing an evidence-based nurse retention program in a home
health care organization.
I am incredibly fortunate to have Caring Nurses’ support and allow me the opportunity to carry
out my project.
I have a 30-question survey that will examine your current work environment, job satisfaction
level, and overall intent to stay with the organization.
Your feedback is greatly appreciated.
This quality improvement project is all about you. I hope you will participate in this project
because your voice matters.
Sincerely,
Tristan Tran, APRN
Appendix H. Pre and Post-intervention Survey
QUESTIONS ANSWERS
1. I am satisfied with relationship with Strong Agree Agree Neutral Disagree Strongly Disagree
administration. 1 2 3 4 5
2. I have the power to change practice. Strong Agree Agree Neutral Disagree Strongly Disagree
1 2 3 4 5
3. I have opportunity to grow. Strong Agree Agree Neutral Disagree Strongly Disagree
1 2 3 4 5
4. I have authority to adopt standards Strong Agree Agree Neutral Disagree Strongly Disagree
of care. 1 2 3 4 5
5. Administration decision interfere Strong Agree Agree Neutral Disagree Strongly Disagree
with my work. 1 2 3 4 5
6. Patients satisfied with the care I Strong Agree Agree Neutral Disagree Strongly Disagree
provide. 1 2 3 4 5
7. I have helped patients. Strong Agree Agree Neutral Disagree Strongly Disagree
1 2 3 4 5
8. Patients relationship are rewarding. Strong Agree Agree Neutral Disagree Strongly Disagree
1 2 3 4 5
9. The care I provide adheres to Strong Agree Agree Neutral Disagree Strongly Disagree
professional standards. 1 2 3 4 5
10. Independence is required in my job. Strong Agree Agree Neutral Disagree Strongly Disagree
1 2 3 4 5
11. I am proud to talk of work. Strong Agree Agree Neutral Disagree Strongly Disagree
1 2 3 4 5
12. Work is important and worthwhile. Strong Agree Agree Neutral Disagree Strongly Disagree
1 2 3 4 5
13. I would recommend my job. Strong Agree Agree Neutral Disagree Strongly Disagree
1 2 3 4 5
14. I would choose home care again. Strong Agree Agree Neutral Disagree Strongly Disagree
1 2 3 4 5
15. My pay scale needs to be upgraded. Strong Agree Agree Neutral Disagree Strongly Disagree
1 2 3 4 5
16. My salary is satisfactory. Strong Agree Agree Neutral Disagree Strongly Disagree
1 2 3 4 5
17. For me, it would be difficult to find Strong Agree Agree Neutral Disagree Strongly Disagree
job. 1 2 3 4 5
18. Benefits package is not as good. Strong Agree Agree Neutral Disagree Strongly Disagree
1 2 3 4 5
19. I am overwhelmed by all the work I Strong Agree Agree Neutral Disagree Strongly Disagree
have. 1 2 3 4 5
20. If I had more time, I could do Strong Agree Agree Neutral Disagree Strongly Disagree
better. 1 2 3 4 5
21. I am able to cope with Strong Agree Agree Neutral Disagree Strongly Disagree
documentation. 1 2 3 4 5
22. I have a good amount of Strong Agree Agree Neutral Disagree Strongly Disagree
collegiality. 1 2 3 4 5
23. I have peers I can rely on. Strong Agree Agree Neutral Disagree Strongly Disagree
1 2 3 4 5
24. There are open lines of Strong Agree Agree Neutral Disagree Strongly Disagree
communication with team. 1 2 3 4 5
25. I am treated as a professional. Strong Agree Agree Neutral Disagree Strongly Disagree
1 2 3 4 5
26. Physicians value my input. Strong Agree Agree Neutral Disagree Strongly Disagree
1 2 3 4 5
27. This job is more flexibility than Strong Agree Agree Neutral Disagree Strongly Disagree
others. 1 2 3 4 5
28. I have control over scheduling my Strong Agree Agree Neutral Disagree Strongly Disagree
time. 1 2 3 4 5
29. I am frustrated because of Strong Agree Agree Neutral Disagree Strongly Disagree
programmed activities. 1 2 3 4 5
30. I have little control over work. Strong Agree Agree Neutral Disagree Strongly Disagree
1 2 3 4 5
Appendix I. Data Analysis with Wilcoxon Signed Rank Test and Paired-Samples T-Test

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Running head: NURSE RETENTION PROGRAM 1

Touro University, Nevada

In partial fulfillment of the requirements for the

Doctor of Nursing Practice

DNP Project Chair: Dr. Jessica Grimm

DNP Project Members: Dr. Ticey Harris, Dr. Judith Carrion

Date of Submission: January 29, 2019

The purpose of this project was to implement an evidence-based Nursing Retention

Many healthcare organizations are experiencing nursing shortages. Similar to other

through the implementation of an evidence-based retention intervention. They have emphasized

and providing better salary and benefits (Ellenbecker, 2007).

evidence-based interventions as a guide to improve job satisfaction. The only retention

opportunities with higher salary and benefits.

implement a nurse retention program to achieve optimal staff job satisfaction.

healthcare organization. Nurse turnover is costly. The healthcare organizations spend an

enormous amount of money on advertisement, recruitment, orientation and training (Jones,

implementation of effective strategies that promote shared-governance within the organization,

and benefits package.

Does the implementation of an evidence-based NRP improve nurse retention, job

satisfaction, and intent to stay?

and reliable tool.

the autonomy to schedule work hours to increase nurse job satisfaction.

have retention programs in place to retain existing nurses.

Shader et al., 2001; McHugh and Ma, 2014).

Salary and benefits

an hourly basis, working uncompensated overtime to complete documentation is quite common.

(McHugh and Ma, 2014).

positive work environment has shared-governance, a process that promotes shared-decision

making, collaboration, and accountability through workforce recognition and empowerment.

organization that is supportive, combined with a professional atmosphere, contributes to nurses’

shared governance is related to empowerment. Nurses in an organization with few opportunities

governance by encouraging nurses to participate in the development organizational culture,

policies and procedures, and the decision-making process.

Autonomy and control of work hours

satisfaction and retention.

and retention (McLure, 2004).

nurses autonomy. Improvement in job satisfaction through the establishment of shared-

ethics, regardless of age, education, or prior experiences. It is important to assess personal

home health care settings (Ellenbecker et al., 2008).

Current management. To address nursing shortage, the practice organization recruits

on the application of its major tenets to current nursing practice.

to function in social roles (Alligood and Tomey, 2010).

According to Imogene King, nursing is a process of action, reaction and interaction by

to achieve goals, and to make decisions.

practice through the emphasis of nurse-patient relationships.

Application to Current Practice

Application of theory to DNP project

of transaction from happening.

work environment with autonomy and control of work activities.

Description of Project Design

satisfaction, and intent to stay.

from the organization’s CEO.

Population of Interest, Setting, Stakeholders, and Recruitment Methods

percent of the yearly income back in retirement benefits every year.

nurse empowerment, professional development, and nurse practice autonomy.

requesting for their cooperation to implement organizational change. A total of thirty-four

voluntary and anonymous.

Pre and Post Intervention Survey

they rated their job satisfaction.

approved by key stakeholders on October 3rd, 2018.

Educational Training Materials

mentor. Educational training included concepts of communication, time management, and

Caring Magazine, 27(1), 43–47. 

about their jobs. Home Healthcare Nurse, 24(5), 315–324. 