Communication and Leadership Strategies for Retaining Registered Nurses: A Descriptive Phenomenological Study ()
1. Introduction
The National Healthcare Retention and RN Staffing Report reported that registered nurse total turnover rates had risen from 11.2% in 2011 to 16.2% in 2016 [1]. The U.S. Department of Bureau of Labor Statistics (2016) estimated the job growth rate for registered nurses from 2014 to 2024 at 16%, or an additional 439,300 jobs, and with 75% of nurse leaders expected to leave the profession by 2020 [2] [3] [4].
Low retention rates for registered nurses are a common problem on a global scale, and healthcare organizations find it difficult to retain qualified registered nurses for the long term [5] [6] [7]. According to Nursing Solutions, Inc. (2017) report, 85.7% of institutions view retention as a “key strategic imperative”, and transformational leaders posture a positive correlation for the intent to stay.
The average turnover costs for a bedside registered nurse range from $37,000 to $58,400 per case, causing an estimated $5.5 million to $8.1 million in annual revenue loss per hospital [8]. The intent to stay or leave among current registered nurses typically involved poor communication and leadership skills, organizations onboarding fewer registered nurses, degrading quality of work-life, and low job satisfaction [9]. It was paramount to define the intent to stay or intent to leave in a profession where 43% of registered nurses with two to four years’ experience express an intention to leave, and in an industry predicting a 16% growth rate until 2024 [10].
Research involving leadership styles helps to advance the knowledge of how communication and leadership influence the intent to stay, or intent to leave within the nursing population. Atefi, Abdullah, and Wong (2014) argued, organizations should observe leadership, and the direct relationship leadership has on a nurses’ intent to stay or intent to leave. Hospitals that improved communication and leadership skills attracted and retained registered nurses by increasing nurse empowerment, increasing nurse job satisfaction, and by decreasing nurse burnout, and emotional exhaustion [11].
Leadership has been shown to improve communication, and inspire, and motivate individuals. However, with the small body of empirical evidence in the current literature, it was difficult to understand how leadership influences nurse retention [12] [13]. The foundation of this descriptive phenomenological study was leadership and communication based on Burns (1978) theory of transformational leadership [14] [15]. Burns (1978) theory of leadership is the focus of four human behaviors: idealized influence, inspirational motivation, intellectual stimulation, and individualized consideration [16].
There is a plethora of literature on retaining registered nurses [17], but a dearth of literature on how communication and leadership influence retention rates for registered nurses. A review of the literature highlights a gap on the influence communication and leadership have on the retention of registered nurses [18] [19]. The available literature explained how communication and transformational leadership was designed to help retention, but does not explain if transformational leadership is being practiced in a dynamic environment, such as a Magnet Hospital, where transformational leadership is a credentialing requirement. This descriptive phenomenological study addressed and explored this gap in the literature.
2. Theoretical Framework
The theoretical foundation of this descriptive phenomenological design research was Burns (1978) theory of transformational leadership. Transformational leadership influences reservation for the individual through organizational commitment [20]. Burns (1978) theory of leadership proposes transformational leadership influences followers, engages the full person, and unites the leader and follower for collective purpose of organizational commitment. This style of leadership recognizes what the follower needs to succeed, and that the leader is capable of responding to those needs. The ability for the leader to positively influence the follower, and heighten organizational commitment is essential to transformational leadership [21].
The theory of organizational commitment is a phenomenon, which compels employees to identify, and grow with their environment; organizational commitment motivates individuals, and groups, beyond their self-interests to share a common goal of commitment within the organization. There is a connection, according to Cohen (2007), between commitment and turnover, and these connections need to be evaluated. Commitment is a psychological contract between the employee and the organization, and any infringement in these expectations by the organization can cause the employee to question further commitment. Organizations should seek new ways to change, grow, and foster collaboration in building trust, and building commitment between employee and organization, and less on avoiding turnover, which is a process that takes time to mature [22].
3. Rational for Evaluating How Communication and Leadership Can Influence Retention of Registered Nurses
The purpose of this descriptive phenomenological study was to explore the lived experiences of registered nurses who perceive a lack of communication and leadership as they related to retention for hospitals in the Western United States. This study also contributes to the limited information available in the literature aimed at retaining registered nurses in a profession that is experiencing phenomenal growth and global shortages simultaneously.
Communication and leadership are two causes for registered nurses leaving the profession, or have influenced a registered nurse’s intent to leave. Registered nurses experienced less support from managers, and administration making retention a major concern in the health care profession. Registered nurses who intended to leave their jobs early reported significantly less autonomy, generational communication differences, and less support from management. It is important for society to understand the influence leadership and communication has on the registered nurse profession if the healthcare industry is to be successful with retention and reducing turnover.
The expectations of registered nurses are changing, and nurse management and leadership must recognize those differences, and change accordingly. This study explores ways to help the healthcare industry reduce conflict, and increase communication and the desire, for registered nurses to stay in a declining industry. Previous studies on intent to leave, and leaving, have left gaps in the knowledge of how to reduce turnover, and organizational policies. The gaps and limitations in the current literature showed a further need for research in the research questions connected to this study, so health care organizations can understand where their current policies are failing. This study addressed and explored those gaps in the literature of leadership and communication as they related to the lived experiences of registered nurses and helped with identifying the difficulties associated with retaining registered nurses.
4. Literature Review
There is an overabundance of literature on retaining registered nurses [23], but little literature on how communication and leadership influenced retention rates for registered nurses. The ability of organizations to attract and retain registered nurses, for the long term, has a positive influence on job satisfaction, the economy, and the quality of health care provided to patients and their families. For example, the Western United States reported an 18.4% turnover rate in 2015 among registered nurses in hospitals with 200 - 349 beds, an increase of 3.1% from 2014 [24].
Low retention rates in nursing are a common problem on a global scale, and current management strategies are finding it difficult to retain qualified nurses for the long term. Management focus must be on developing communication and leadership strategies that promote registered nurses’ job satisfaction, and retention [25].
Retention of registered nurses has always been an industry concern, but is more so today, because the dynamics of the workforce are changing. The Millennial Generation requires more personal attention and expects open communication with leadership, and the Millennial Generation will soon become the dominant workforce. According to Sherman (2015) by the year 2020, 50% of the nursing workforce will comprise of the Millennial Generation, and in a multi-generational workforce, organizations are finding it difficult to develop a workplace culture that engages these workers, while maintaining a high retention rate [26].
Health care organizations worldwide are concerned with retention of their registered nursing staff, and how retention influences patient care and cost. Understanding the needs, and the strengths and weaknesses of registered nurses in the workplace is important for retention. The struggle health care organizations are having attracting and retaining registered nurses had, the World Health Organization (WHO), declare retention of registered nurses as vital to avoiding undesirable health care services [27].
Registered nurses have strong feelings about the work environment and expect it to be safe, flexible, and challenging. The Millennial Generation of registered nurses want to communicate by email and texting, and are more ethnically diverse than any previous generation, are impatient, need constant managing, and want immediate feedback. The Millennial Generation is vulnerable to stress, and because of their inability to cope with pressure and to deal with job-related stress, many registered nurses are not capable of dealing with the high demands of the nursing profession [28].
The cost to employers, when the registered nurse leaves the organization is extensive, making the cost of retaining registered nurses important. Overall job satisfaction, and work characteristics within the organization are excellent predictors for determining intention to leave. It is important for organizations to discuss intent to leave and turnover, because the cost of recruiting, hiring, and training today’s registered nurse is between 50% and 200% of the employee’s annual salary, and is increasing [29]. In 2016, the cost for recruiting a qualified registered nurse ranged from $37,000 to $58,400 per turnover in access labor cost, which includes overtime, agency staff, and travel nurses. In 2017, the average time to recruit a qualified registered nurse was 55 to 119 days, and the average cost of onboarding had risen to between $46,000 and $95,600, and the cost is increasing each year.
The demand for registered nurses will continue to rise due to changes in healthcare reform, a retiring workforce, and the changing economy. The Patient Protect and Affordable Care Act, signed into legislation in 2010, was designed to expand insurance coverage to an additional 34 million Americans, and is the most expansive healthcare reform act since the Medicare and Medicaid in 1965. The Affordable Care Act has a direct stimulus on the nation’s preventative healthcare model, including primary care, quality of care, and community healthcare dollars, all of which influence the number of registered nurses available to handle the increase in insured, as well as the retiring Baby Boomers [30]. Predictions are that by the year 2020, 500,000 nurses in the United States will retire, and 590,000 will retire in the European Union [31], which, along with other factors, such as job satisfaction, will have a significant bearing on healthcare organizations.
Registered nurses are leaving the profession due to a lack of job satisfaction driving down the retention levels of recently licensed registered nurses. Reduced job satisfaction comes from a lack of respect by physicians and colleagues, patient to nurse ratios, time management, salaries, stress, and poor management communication techniques. According to Dotson et al. (2014) important factors to keep nurses in their jobs are to increase job satisfaction, increase personal autonomy, reduction in stress, and value congruence. Increasing autonomy leads to higher job satisfaction while helping registered nurses believe they are contributing to patient care. It is necessary for managers and physicians to allow registered nurses to do their jobs and receive recognition for their contributions to patient well-being to ensure retention levels remain high [32].
Burns (1978) theory of transformational leadership [33], empirically measures influence, enthusiasm, and satisfaction among employees. Aligning individual goals to a common mission, trust and support, and managing resources are just a few of the challenges of leadership [34]. Ross et al. (2014) described five leadership practices’, which inspire others. First, inspiring a vision of the future that is exciting and ennobling; second, challenging the current process and seeking ways to change, grow and improve; third, enabling others to foster collaboration and building trust; fourth, encouraging the heart and recognizing individual contributions, excellence, and victories; and fifth, aligning actions, and clarifying personal values by setting the example.
Transformational leadership is the most recognizable practice in healthcare, because transformational leadership inspires registered nurses to perform beyond expectations. Transformational leadership relates to follower autonomy, allows followers to complete their work in the most efficient way, and provides positive support from management to protect against burnout. Empowering leaders influence followers by having a positive relationship through employee engagement, their environment, and cognitive job demands [35].
Health care managers need guidance in developing a positive environment for registered nurses. Strong communication offers guidance and identifies with transformational leadership between management and staff, which encourages trust and respect between leadership and staff. To be successful, registered nurses need autonomy, and knowing the organization supports their decisions [36].
Nurse managers, who understand the importance of communication and excellences in leadership, also understand the meaning of a cohesive workplace. Learning from the experiences of each generation is ensuring the individual, and the team is meeting the overall requirements to be successful. For example, parents of the Millennial Generation taught their children to speak for themselves and voice their opinions, and the Baby Boomers were taught to respect and listen to their elders and speak only when spoken to. Baby Boomers may view the idea of the Millennial Generation voicing their opinion as disrespectful, often misunderstand the intentions of the Millennial Generation, and believe the younger generation should gain more knowledge before criticizing the older generations [37].
Communication is vital for a professional registered nurse and is an essential part for patient care and job satisfaction. It may be possible to avoid 40,000 patient deaths in the United States by promoting positive relationships and encouraging staff involvement in decision-making. In a positive practice environment, patients reported greater satisfaction with their quality of care, and research shows there was a 10% reduction in mortality and failure-to-rescue rates in hospitals that promote leadership and communication.
Communication is important, because in most cases, one party has the privilege of having more knowledge than the other has party has, but sometimes age is not a determining factor of that knowledge. It is Important for intergenerational cohorts to understand each other’s social and cultural experiences, and generational differences to establish a line of communication. Respectful communication between generations is possible, and is also essential for retention of registered nurses, and for the best quality of patient care [38].
5. Methodology
Research Method and Design
Approval for this research was granted through the Grand Canyon University Institutional Review Board to explore the lived experiences of registered nurses who perceived a lack of communication and leadership as they related to retention. Qualitative methodology was best suited for this research, because philosophically, qualitative research allows each person with a common experience with others, to express their lived experiences from their perspective of cultural, experiential, environmental, and other influences [39]. Descriptive phenomenology allows the participant to describe reality in their personal view, which allows the researcher to better understand their common experiences from an individual perspective [40].
Study Participants and Demographics
The researchers recruited nine registered nurses willing to provide vital information about the factors of how their daily lived experiences were influenced by communication and leadership, which the researchers believe can determine retention levels. The study was represented by seven females (78%), and two males (22%) registered nurses.
A demographics questionnaire was used to obtain additional characteristics such as gender, level of education, current hospital unit, years as a registered nurse, and years employed at current hospital. One registered nurse who participated (10%) in the study was 18 to 35 years of age. Four registered nurses (45%) were aged 35 to 50 years of age, and four registered nurses (45%) were 50 to 74 years of age. One participant (10%) held an Associate’s Degree, four participants (45%) held a Bachelor’s Degree, and four participants (45%) held a Master’s Degree.
The participants were asked to identify what unit within the hospital they currently worked. The categories were Emergency, Intensive Care Unit (ICU), Natal Intensive Care Unit (NICU), Labor & Delivery, Operating Room, and Other Units which included Psychiatric, Senior Emergency Care Unit (SECU), and Direct Observation Unit (DIU). Three of the participants (33%) worked in the ICU, and six of the participants (67%) worked in other departments within the hospital.
Each participant was asked how many years of experience they had as a registered nurse. Two of the participants (22%) had 1 to 7 years of experience as a registered nurse, four participants (33%) had 7 to 15 years of experience, and three of the participants (45%) had more than 20 years of experience as a registered nurse.
The participants were asked about how long they had been employed as a registered nurse in the hospital. Six participants (67%) had been working 1 to 10 years in the hospital, two participants (22%) had been working for 10 to 20 years, and one participant (11%) had been working more than 20 years at their current hospital.
Data Collection
The data collection implored open-ended semi-structured, in-depth one-on-one interviews, and observation notes recorded during the interviews to explore the lived experiences of registered nurses working in a hospital environment. The interviews were 60 to 90 minutes in length with in-depth probing questions into the lived experiences of communication and leadership as they relate to retention of registered nurses. The interviews and data collection were in a natural setting to help the participants relax, and be open about their lived experiences to help discover the participants feeling, perceptions, and thoughts [41].
Three of the participants elected to be interviewed in person, and signed the informed consent form at the prearranged location just prior to the interview. The interview recordings were captured on an audio a tape recorder. The six participants who elected to do the interview with Zoom conference call signed the consent form by electronic mail using DocuSign prior to the date and time of the Zoom call. The interview audio was saved on a tape recorder, and also recorded and saved on a computer file with the Zoom option. To ensure the confidentiality of the participants, each person was assigned a pseudonym chosen by the researchers. All identify factors of the participants such as name and location of hospital, names of co-workers, managers, departments, units, or unit floors were eliminated from the study. During the interviews the researchers made notes of the participants’ reaction to individual questions such as non-verbal gestures, and tone of voice. The researcher maintained strong ethical considerations while protecting the participants identity and data, on a secure password protected flash drive, and on a password protected external hard drive. All hand transcribed transcripts are secured in a locked cabinet, and all the data collected will be destroyed after three years. All of these safeguard measures meet the Institutional Review Board requirements.
Semi-Structured Interviews
The one-on-one semi-structured interviews were conducted in a private setting to insure the privacy of the participants. The interviews were either audio or video recorded, or both. The research questions were open-ended, and allowed the researchers, and the participants to respond with follow-up questions to the gratification of each before moving on to the next question. The instrument used for interviewing the participants was an in-depth set of seven questions, and 18 probing questions, on communication and leadership designed specifically for this research project. The researchers found it difficult to locate previous qualitative studies, which included a questionnaire instrument on how communication and leadership can influence retention of registered nurses.
The researchers elected to design the instrument used for interviewing the participants, which was approved by a panel of four Ph.Ds. The broad themes of this study were support, role models and leaders, communication, and characteristics necessary to encourage registered nurses to remain in the profession. To understand the lived through experiences of registered nurses these open-ended questions explored how communication and leadership influenced retention from both a professional and, a personal point of view.
The interviews lasted between 60 to 90 minutes each, generating a minimum of 12 pages of data per interview. Adequate time was allowed for the primary and probing questions to be answered by the participant, as well as any additional questions that surfaced from the observation notes being taken by the researchers, or questions the participant might ask of the researchers. After the participant had answered the original question the researchers asked any follow-up probing questions that had been captured on direct observation notes during the conversation. Probing questions helped enrich the conversation and the data collected. Additionally, time was allowed for any follow-up questions from the researchers or the participants at the end of the interview process.
Member checking was employed to ensure the validity of the study. At the conclusion of the interviews the researcher clarified the participants contact information for the purpose of member checking. Each participant was requested to participate in member checking to ensure categories and themes of the participants meaning of their answers was accurate. After the interviews were transcribed to Microsoft Word each participant was notified by electronic mail, and asked to check the interview for accuracy, and to make any changes they deemed necessary. The researcher asked each participant to respond within seven days of receipt of their transcribed interview. Three of the participants did not respond after the transcriptions were delivered within the seven-day allotted time. One participant returned the transcription with one grammar change. Another mentioned typographical errors in the transcription, and clarified a statement they had made, and these were all corrected by the researchers. Four participants were happy with the transcriptions and did not recommend any changes. A non-response by any participant was not interpreted as a limitation or bias to the study.
Data Analysis
The researchers conducted a thematic analysis design outlined by Van Manen (2014). The thematic understanding is the act of seeing the meaning by epoche, and the reduction, in the whole story, individual paragraphs, and individual sentences. The descriptive phenomenological study interview served a very specific purpose for collection data on experiential accounts, not on personal perceptions, or interpretations. Coding and qualitative analysis was revealed with the collection of all data, and then analyzed using three principal stages outlined in Giorgi (2009), and Van Manen (2014). 1) Reading the whole transcription to get a sense of the whole description. 2) Determination of the meaning units contained within the description, and at the same time understanding they are not the only meaning units to consider. 3) Transformation of participant’s natural attitude expressions into phenomenological psychologically sensitive expressions, or finding the results in the descriptions, and not with theories or hypotheses.
At the conclusion of the interviews the researcher clarified the participants contact information for the purpose of member checking. Each participant was requested to participate in member checking to ensure categories and themes of the participants meaning of their answers were accurate [42]. The interviews were transcribed as soon as possible after the interviews were concluded. Transcribing the interviews thoroughly was an important step in analyzing the interviews, and all interviews were read and re-read thoroughly to gain overall meaning. The most informative responses grouped in coherent broad topics, and interview direct observation notes and memos assisted with the coding and analysis.
Each interview was hand coded which allow the researcher to better understand the lived experiences of the participants, and to produce something rich, recognizable, and meaningful, so the researcher could better understand any reflective insights, or distinct meanings of the phenomenon. The researchers then used qualitative MaxQDA software to further identify themes, topics, issues, similarities, and differences between participants [43]. When the initial coding was completed the researchers observed there were many words, and phrases that were similar, and found it necessary to conduct a seconded coding cycle [44]. The purpose of this second cycle coding was so the researchers could draw a connection between the research participants lived experiences of a common phenomenon. The three concepts used for the coding cycle were open coding, axial coding, and selective coding.
Open coding identified specific pieces of data where the researcher reduced a mass of codes to units of meaning; Axial coding explored how each of the categories relate to each other and determine which are the principal codes and which codes are secondary; Selective coding exposed the substance of the study, and incorporated all the elements into categories, which provided understanding of the phenomenon under evaluation, and allowed similar codes to be grouped together.
After open, axial, and selective coding was completed, the researcher identified each category and five distinct themes emerged. Each of these themes are presented in the following section, followed by results discussion, and recommendations for future research.
6. Emergent Themes
Theme 1: Transparency
It was the result of the participant answers that the first theme to emerge from the responses was transparency. All nine participants believed that transparency with communication and leadership was important to the success of the unit and for themselves professionally. Transparency was the result of engagement within the unit, management, and support. A growing body of research demonstrates factors such as how high job demands, and low job support are correlated with stress, organizational commitment, and retention in the nursing profession [45]. Fischer (2016) concluded there is a significant correlation between leadership behavior, and job satisfaction and organizational commitment, which can influence retention.
Engagement. The responses from the nine participants of commitment to the organization included engagement.
Participant RSP-5 believed engagement and communication were synonymous, “Well as far as communication from shift to shift between the nurses that’s critical because without the communication we would not be able to do our job and practice safely.”
RSP-7 said, “trying to get something conveyed to the next two shifts can be somewhat frustrating at times.”
RSP-5 said that values and communication are the “backbone” of the organization. Most of the participants believed without engagement and open communication the unit eventually fail.
RSP-10 replied to the question by saying, “The more transparency the organization has, and I think the more line nurses know what’s going on at the administrative level and the management level the greater the commitment will be.”
Management. The participants were apprehensive about management, leadership, and transparency. Most of the participants were concerned that management were not open and forthcoming with internal decisions that would affect the nursing staff. Registered nurses feel open communication with management is necessary for a unit to be successful and is important for retention.
For example, RSP-8 said, “You have to have the communication with your managers and the administration to keep a good workforce going. Open communication with management can create a sense of loyalty and have a family atmosphere which most registered nurses seem to enjoy. Transparency between administration, management and staff can create a better foundation organizational commitment.”
RSP-4 mentioned “organizational transparency was important for success in the unit”, and continued with, “without transparency and organizational commitment your organization will soon fail.”
RSP-12 responded by saying, “It is important to the organization if you want to retain the people that are committed to the values and the mission statement of the organization.”
Support. Proper support is important to registered nurses, and important to the safety of the patient. On some hospital units there is an established ratio between registered nurses and patients, which most registered nurses feel management falls short on preserving.
RSP-4 mentioned that understaffing, or being short staffed when nurses call out, changes the registered nurse to patient ratio, and can make it difficult to ensure patient safety.
RSP-5 mentioned that the unit has a “three to one ratio, but many days there is a five to one registered nurse to patient ratio, and, that’s insane”.
Being understaffed seems to be a common argument with the participants, and maybe an issue in the hospital all nine of participants are employed.
RSP-11 mentioned, “everywhere I have worked has been understaffed.”
Theme 2: Cohesive Workplace
The second theme to emerge was a cohesive workplace, which is the result of interaction between nurses of three different generations: Baby Boomers, Generation X, and Generation Y. All three generations work together every day and success on the floor is dependent on the generations working together. It is essential for a multi-generational workforce to understand their differences, for the most seasoned workers to act as mentors, and for all generations to understand the different modes of communication. A multi-generational workforce is unavoidable, and their interactive communication and leadership styles are important factors to be considered for retention levels [46].
Differences. There are many differences of attitude, work habits, and a willingness to learn between the three generations. Some of the differences are positive, and some of the differences are negative. However, all the participants agree these differences must be challenged if success is to be achieved.
For example, when RSP-5 was asked what differences were observed between the generations RSP-5 said, “Baby Boomers come to work they do their job, Generation X are more passive, Millennial’s sometimes thinking they know it all.”
There are also differences in how generations articulate learning, or changes. When asked about changes in technology RSP-7, who identified as a Baby Boomer said, “… why fix it if it isn’t broke?”
When RSP-10, who identified as Generation X, believes there is a difference in the generations, and especially with the Millennials, and believes the Millennials require more “coddling”, and things have to be “spelled out” for them to understand.
RSP-11 who identified as a Generation X mentioned Baby Boomers were, “hard to get to know”, but could not give a specific example.
RSP-12 responded to the question by saying, “Millennials feel they are entitled, or maybe it’s not just entitlement, but also an arrogance.”
Mentors. The fourth behavior dimension of transformational leadership is; individual consideration for mentoring, coaching, and continuous training activities. Nursing is a very dynamic profession, however one thing that is changing is the willingness of some of the older nurses to mentor the younger nurses. As new registered nurses begin working in the unit, the older generations need to share their knowledge.
Hospitals carrying Magnet status attract and retain registered nurses by increasing nurse empowerment, increasing nurse job satisfaction, and decreasing nurse burnout and emotional exhaustion. Participant RSP-9 has been driven to teach the younger generation. She said, “I lucky to have some of the older generations as teachers to walk me through step-by-step.”
It is important, as a new registered nurse on the unit, for the older generations to share their knowledge. Nursing is a profession that is very dynamic, however one thing that is changing is the willingness of some of the older nurses to mentor the younger nurses.
There are nurses that believe it is difficult at times to find a mentor, because Baby Boomers and Generation X do not believe Millennials have the same desire and the drive to be registered nurses as they did. Consequently, it may be difficult to find a mentor.
For example, RSP-11 said “You know it was really tough when I first became a nurse because you know there was that saying nurses eat their young… and it was really, really hard to gain their trust.” “… it is harder today for Millennials, because the older generations do not think Millennials take this career serious.”
Social Media. Technology has changed the atmosphere of the nursing profession. Many believe that Millennials are mostly distracted by social media, when in reality all three generations are affected. When asked how social media affects the generations.
RSP-8 expressed concerns with the attitude of the Millennials when they first came to the floor fresh out of school, and how the Millennials do not want to work as hard on the job, and are pre-occupied with social media. “I think it’s hard because the younger generation doesn’t want to work as hard as they need to work. These kids are sitting there playing on their phones, listening to music, and reading.”
However, when RSP-5 was asked the same question there was an emotional response, and showed visual signs of frustration as noted in the observation notes, and responded by saying, “I feel like they (Baby Boomers and Gen X) come in and are acting like kids and these are not kids. They are looking at Facebook when I’m giving a report, and these are Gen Xers and they’re Baby Boomers you know but I mean that’s why I am not on Facebook right now. That’s the biggest deterrent to communication from my shift, because they are all on social media.”
Experience. In nursing relying on the experience of those who have come before you or have been to classes on the different technologies or changes in policy is important. Registered nurses fresh out of school need to be willing to reach out and learn from the experience of registered nurses already working in the unit they are assigned.
RSP-10 shared his experience as being mutual with all generations, even though the majority of the nurses who entered his unit have years of experiences. “I don’t think I have noticed a huge difference necessarily with people older than me or younger than me. In this working environment, everybody kind of communicates at a certain level.”
RSP-12 Expressed having a horrible experience with the older nurses, “My experience has been horrible. They (Baby Boomers) don’t have the patients to teach and so they (Millennial) are easily frustrated.
RSP-5 summed it up by saying, “There is a stigma that goes with every generation.”
Theme 3: Passion
The third theme of passion emerged when participants were describing their personal commitment to their career as a registered nurse. This theme developed while coding the participants interviews. There was no developed research question for this subject, but seven of the nine participants voluntarily expressed their passion for their profession as a registered nurse, thus passion emerged as a theme applicable to the first research question.
Career Choice. When asked the question of who may have influenced their career choice to be a registered nurse a common theme developed.
RSP-4 responded by saying, “I have known that I wanted to go into healthcare since I was really young.”
RSP-5’s mother was a registered nurse and RSP-5 wanted to be a registered nurse for as long as they could remember.
RSP-6 replied, “My cohorts taught me how much we can do for patient, and how much we can learn about everything. You know, so I do love my job.”
Love of Career. During their individual interviews each respondent had stories of their experiences as a registered nurse, and how those experiences had reinforced their passion for their chosen occupation. RSP-7 mentioned during the interview that they had transferred out of state for a couple of years to another hospital and had some difficulties with the administration. But said, “coming back here revitalized my love to the career field.”
RSP-11 said “I know this sounds cliché, but I just want to help people. I have saved lives.”
RSP-5 summed up by saying, “I like what I do. If I didn’t I would have done something different along time ago instead of waiting 34 years.”
And RSP-8 said, “I will stay in the profession until I die or retire.” All these responses show a dedication that may be difficult to find in another profession.
Theme 4: Collaboration
Collaboration was the fourth theme to develop when each participant described how their lived experiences between leadership and registered nurses contributed to, or diminish retention. Understanding leadership behavior relating to retention is important in an industry where interpersonal communication is essential from leadership, and cohorts, for driving people to a common goal. High involvement and interaction of leadership encourage work performance, and commitment of employees.
Interaction. In the hospital unit it is important for registered nurses, doctors, vendors, and other departments interact, and how those departments interact can determine the success of the unit. When the researcher asked the question of experience regarding different leadership qualities.
RSP-4 responded by saying, “So we had different services on our unit, and it was very interesting working with different providers, having to base your care off of the leadership of somebody else it’s kind of hard to do”. The researcher interpreted the meaning as, the unit relies on the collaboration of several people, including outside vendors to help support the registered nurses and patients, and having to rely on them to make the right decision is difficult, but they successfully manage.
However, RSP-7 said that one unit, “demanded” loyalty from the nurses and would put blind ads out for replacement of those nurses that the directors and managers felt were not loyal to them. After relocating back to the West coast RSP-7 mentioned they really like working on this current unit, and one advantage to working together for several years is each nurse and manager knows the other’s strengths and weakness, and they work together to solve and issues.
Commitment. Burns’s (1978) theory of leadership is the focuses on four human behaviors: idealized influence, inspirational motivation, intellectual stimulation, and individualized consideration [47].
The first behavior dimension of transformational leadership is; inspirational motivation. This study on retention concluded job dissatisfaction among registered nurses includes a lack of leadership support and communication, high workload, and lack of autonomy. The semi-structured interview questions focused on nurses’ values and beliefs, work environment, and motivation. An unexpected theme that appeared in this study was the passion for nursing. Although there were no designed questions for this study on the passion for the profession, several of the participants volunteered data.
Understanding why registered nurses are so passionate about their profession could be important to retention. RSP-4 said, “I have known that I wanted to go into healthcare since I was really young… I was always interested in how the human body works and helping people.” RSP-6 said, “My cohorts taught me how much we can do for patients, and how much we can learn about everything… You know, so I do love my job.” RSP-8 summed it up by saying, “I will stay in my profession until I die or retire.”
When the asked question directed at commitment to the organization several of the participants used transparency, levels of leadership, and backbone of the organization to describe their vision of commitment. Each participant found that commitment was not only their duty, but also the duty of the organization. The organization should be committed to the nursing staff as much as the nursing staff is committed to the organization.
RSP-8 responded by saying. “Commitment is the backbone of the organization.”
RSP-10 responded by saying, “The more transparency the organization has and I think the more line nurses know what’s going on at the administrative level and the management level the greater the commitment will be.”
RSP-11 responded by saying “that commitment is important to me, because it makes me feel happy.”
RSP-12 mentioned organizations that are committed to the values and mission will see a greater commitment by the nursing staff.
Retention. The participants in this research were very outspoken when it comes to retention. All the participants believe that retention is important to the organization, and the staff, and can have an effect on moral and absenteeism. Retention covered several topics like commitment, leadership, favoritism, and burnout.
RSP-12 spoke of the difference between a boss and leader, and how this can determine retention levels for the department. RSP-12 responded by saying, “being a good leader and being about your team, verses being a boss and being about your own ego”, “I left that position because I just got tired of the stupidity.”
RSP-11 responded by saying if the “organization is committed and wants to retain your nurses and you want to make your nurses happy and you want to make them stay and work for you.” The researcher interpreted this to mean that the organization must be as committed to the staff, as they expect the staff to be committed to the organization for there to be high retention levels.
RSP-9 responded to a question about members of the department creating a positive or negative work environment, and referenced a bad flu season by saying, “we were so burnt out, and the new director came in and the very first meeting she looked at us and said, your staffing issues are your guys fault, you guys have no idea what is hard work.” RSP-9 went on to say that this is no way to talk to the staff, and the unit lost several nurses over that comment by the director.
Theme 5: Leadership
The fifth, and final, theme to emerge related to how leaders motivate registered nurses go beyond immediate self-interest. All nine participants answered the questions pertaining to transformational leadership. Did they understand the meaning of transformational leadership? Did they believe transformational leadership was being practiced in their department.
Transformational leadership relates to follower autonomy. This allows followers to complete their work in the most efficient way, and protect themselves from burnout. In a Magnet hospital management continuously interacts with registered nurses, and the nurses report more involvement in hospital affairs. Magnet Hospitals promote a positive work environment for registered nurses, and providing quality patient care.
A commonality between the participants was most of them really did not understand what transformational leadership was, and did not know transformational leadership was the number one criterion for the hospital to become a Magnet hospital. However, most did agree that transformational leadership was not being practiced in their unit, department, or organization.
Guidance. The participants divulged interesting responses when asked about transformational leadership and Magnet hospitals. The American Nurses Credentialing Center promotes the Magnet Recognition Program, which favors nurse retention by focusing on nurse well-being and transformational leadership. Transformational leadership is the first of five criteria set forth by the American Nursing Credentialing Center for a hospital to reach Magnet status [48].
However, the registered nurses interviewed for this study do not believe transformational leadership is being promoted within the departments, even though they worked in a Magnet hospital. Transformational leadership is defined as those individuals who create a supportive and positive work environment, maintain an honest and open relationship to build trust, increase job satisfaction, and go beyond their immediate self-interest for the sake of the organization.
A primary question asked of the participants was; What are your lived experiences as a registered nurse with transformational leadership within your department? RSP-7, who works in Magnet Hospital and understands transformational leadership, replied, “It is rare here”, “And I just don’t; I have not seen any for so long here.” Participant RSP-10 works in a Magnet Hospital and was not aware of transformational leadership. After the researcher explained the fundamentals of a transformational leader, the participant replied, “I haven’t had any (laughing very hard). In that ten years of nursing, I have never seen transformational leadership.”
Transformational leadership is a process which encourages management to interact with and guide employees to better themselves and promote a positive workplace. When asked the questions concerning transformational leadership within the department, and if they worked in a Magnet hospital.
RSP-4 said “Yes, I do work in a Magnet Hospital”, but did not believe that transformational leadership was being practiced in the department.
When RSP-5 was asked if they knew the definition of transformational leadership RSP-5 replied, “I’m not quite sure I understand the word transformational.” After a brief discussion of what transformational leadership is, RSP-5 replied, “I think a lot of them are supportive, but only when it supports their needs, but I think for the most part they are not.”
Autonomy. One of the features of transformational leadership is allowing the employee to be autonomous and to resolve issues on their own with minimal guidance.
When RSP-6 was asked to give a definition of transformational leadership RSP-6 replied, “Open communication, willing to discuss the situation.” When the researchers asked to explain further, RSP-6 replied, “Give us more freedom of choice. I mean trust nurses’ judgement.”
RSP-10 did not work for a Magnet hospital, and thought transformational leadership was a “Buzz word”. When asked for a definition of transformational leaders replied, “Transformational leadership would be leadership that advances the needs of the organization through empowering employees making the employee a little more important than they are normally considered.” When asked transformational leadership was being practiced. RSP-10 replied (laughing really hard) “I haven’t had any. In 10 years of nursing I have never seen transformational leadership”.
7. Discussion
The purpose of this descriptive phenomenological study was to explore the lived experiences of registered nurses who perceive a lack of communication and leadership as they relate to retention for hospitals in the Western United States. Descriptions of the lived experiences of registered nurses were sought from the participants of the study and discussed to understand the influence communication and leadership can have on registered nurse retention. This study used a descriptive qualitative phenomenological design to explore the lived experiences of registered nurses who perceive a lack of communication and leadership as they relate to retention of employment. Additionally, this study helped fill the gap in the literature of the influence communication and leadership has on retention of registered nurses to expand the limited body of work on this topic.
Congruency with Theory. It was the researchers contention that communication and leadership do have an influence on retention of registered nurses working in a hospital. There does appear to be a connection between communication and leadership as it pertains to commitment and turnover. Commitment is a psychological contract between the employee and the organization, and any infringement in these expectations by the organization can cause the employee to question further commitment. Organizations that want to see change, and growth, should foster collaboration in building trust, and building commitment between employee and organization. Burns (1978) theory of leadership proposes transformational leadership influences followers, engages the full person, and unites the leader and follower for collective purpose of organizational commitment.
As expected the researchers did find a connection between the lived experiences of registered nurses, and how communication and leadership developed a working environment, which improved retention of registered nurses. In theory transformational leadership proposes exceptional leadership to improve the relationship between leader and follower, and increase retention. When applied transformational leadership addresses registered nurses within their environment where communication and leadership are necessary for maintaining organizational commitment, which may increase retention rates for registered nurses.
Congruency with Literature. The themes which emerged in this study appear to align with, and contribute to the limited quantity of information available aimed at retaining registered nurses in a profession that is experiencing phenomenal growth and global shortages simultaneously. Nurses make up the largest percentage of healthcare providers, and the significant focus of this study addressed retention of registered nurses. According to the literature, retention of registered nurses is a recognized global priority, and an ongoing concern in the United States [49]. Many factors influence retention of registered nursing including communication and organizational leadership, autonomy, work-life balance, job related stress, and staffing shortages. Registered nurses’ value their relationship within the organization, which is largely based on communication and leadership, which influence job satisfaction, and increases retention levels [50]. A growing body of research demonstrates factors such as how high job demands, and low job support are correlated with stress, organizational commitment, and retention in the nursing profession. Fischer (2016) concluded there is a significant correlation between leadership behavior, and job satisfaction and organizational commitment, which can influence retention.
The theme transparency developed when participants described their lived experience, and how communication contributed to or diminish the experience of organizational commitment. Individual responses appear consistent with the literature with respect to all the participants belief that communication is important for commitment to the organization, and the safety of staff and patients. The participants were apprehensive about management, leadership, and transparency. Most of the participants are concerned that management is not open and forthcoming with internal decisions that would affect the nursing staff. Registered nurses feel open communication is necessary for a unit to be successful and is important for retention. Research question one contained a reference to communication. Every participant described their lived experience of how communication can contribute to or diminish registered nurse retention with the unit or the organization. Questions concerning communication and commitment to the organization were the first questions asked, and those questions raised subsequent questions. It was the result of the participant answers that the theme of transparency emerged through the responses. A growing body of research demonstrates factors such as how high job demands, and low job support are correlated with stress, organizational commitment, and retention in the nursing profession [51]. Fischer (2016) concluded there is a significant correlation between leadership behavior, and job satisfaction and organizational commitment, which can influence retention.
The theme cohesive workplace developed how a relationship between Baby Boomers, Generation X, and Millennials is important. It is important for the three generations to develop an interactive form of communication. The findings align with the literature that there are many differences between the generations. The nurses, of all three generations, expressed the importance of a mentor. The younger generation is concerned the older generations would not mentor them, and the older generation believes the younger generation is difficult to work with.
A cohesive workplace is the result of interaction between nurses of three different generations: Baby Boomers, Generation X, and Generation Y. All three generations work together every day and success on the floor is dependent on the generations working together. Learning from each person’s experiences, and recognizing and understanding generational differences, and sharing positive information. The possibilities are high that Baby Boomers, Generation X, and the Millennial Generation will work together in the same workplace, which will increase the possibilities of communication differences between the generations. A multi-generational workforce is unavoidable, and their interactive communication and leadership styles are important factors to be considered for retention levels.
The theme passion developed during the course of the interviews when the researcher asked participants if any one person had reinforced their decision to be a registered nurse, or caused them to question their intent to stay in the profession. The researcher interpreted the individual responses to mean that registered nurses are dedicated to the profession, and passionate about their jobs and their decisions to become a registered nurse. To the researchers these responses also imply that it will take more than subpar leadership to convenience most registered nurses to leave the profession. The researchers then interpreted the responses to mean that, being a registered nurse is not just a job, it is a lifelong commitment to help people.
The lived experience describing participants passion for the career of a registered nurse. This theme developed while coding the participants interviews. There was no developed research question for this subject, but seven of the nine participants voluntarily expressed their passion for their profession as a registered nurse, thus passion emerged as a theme applicable to the first research question.
The theme collaboration developed when questions addressed the issue of how leadership can influence retention of registered nurses. During this part of the interview participants described their lived experiences as registered nurses, and the influence leadership had on retention in their units. The responses given when participants were asked if leadership has ever caused them to question their decision to stay within their department, position, or occupation. The responses interpreted by the researchers to mean that it depends on the leadership of individual units, and how the participant interpreted that leadership style.
Each participant described how their lived experience of collaboration between leadership and registered nurses can contribute to or diminish retention. Understanding leadership behavior related to retention is important with 75% of nursing leaders expected to leave the profession by 2020 [52]. Healthcare is an industry where interpersonal communication is essential from leadership for driving people to a common goal. High involvement of leadership encourages work performance, and commitment of employees.
The theme leadership developed when participants described their lived experiences with transformational leadership within their departments. The replies to the questions by individual registered nurse were interpreted by the researchers to mean, the participants do not experience transformational leadership within their departments, even though the majority of the hospitals the participants worked for had reached Magnet status.
The lived experience of how leaders motivate registered nurses go beyond immediate self-interest. All nine participants answered the questions pertaining to transformational leadership, if they understood the meaning of transformational leadership, and if they thought transformational leadership was being practiced in their department. Transformational leadership may be the most recognizable practice in healthcare because transformational leadership inspires registered nurses to perform beyond expectations. Transformational leadership relates to follower autonomy, allows followers to complete their work in the most efficient way, and provides positive support from management to protect against burnout. In high performing Magnet hospitals, management continuously interacts with their staff and registered nurses report more involvement in hospital affairs. Magnet Hospitals promote a positive work environment for registered nurses, and providing quality patient care.
Unexpected Theme. The unexpected theme that appeared from this study was passion. Although, there were no designed questions for this study on passion, several of the participants volunteered data. Understanding why registered nurses are so passionate about their profession could be an important link to retention.
RSP-4 said, “I have known that I wanted to go into healthcare since I was really young… I was always interested in how the human body works and helping people.”
RSP-6 said, “My cohorts taught me how much we can do for patients, and how much we can learn about everything… You know, so I do love my job.”
RSP-8 summed it up by saying, “I will stay in my profession until I die or retire.”
Limitations. The limitations of this descriptive phenomenological design study include the final number of participants volunteering to complete the one-on-one interviews. This research is also limited to registered nurses in the Western Region of the Unites States, and may not reflect communication and leadership in the lived experiences in other parts of the United States, or even on a global scale. The results of this research may be different in hospitals, or healthcare institutions outside, or within the same geographical area, as policies may differ. Research participants are limited to registered nurses, and may not represent the attitudes and working conditions of Certified Nurse Aide (CNA) or Licensed Practical Nurse (LPN). Limitations also include the researchers’ interviewing and coding experience, and bias, and limitations within the existing timeframe to conduct the interviews. Participant restrictions may have inhibited the amount of time needed to insure complete depth of the research questions.
Implications and directions for further research. The more researchers explore the lived experiences of registered nurses and how communication and leadership can influence retention the better healthcare can understand how to reduce turnover. The themes identified in this study, from the data obtained from the nine participants, can help administrators, managers, directors, supervisors, and cohorts who are committed to reducing turnover.
This study found that registered nurses understand the need for communication and organizational commitment, and that both are necessary for the organization to succeed. The theory of organizational commitment argues that communication, and leadership within the organization are related to organizational commitment, and individuals who display a higher commitment to the organization have higher levels of productivity, and lower absenteeism.
The data has mixed information on generational differences between Baby Boomers, Generation X, and Generation Y (Millennials). There will be differences between the generations, and it is important to retention that these generations work together. The Baby Boomers and Generation X have years of knowledge and real-world experience, and the Millennials bring todays best practices to the unit. Working together registered nurses can share their knowledge to produce a more efficient and better producing unit. The possibilities are high that Baby Boomers, Generation X, and the Millennial Generation will work together in the same workplace, which will increase the possibilities of communication differences between the generations.
The study divulged interesting responses when participants were asked about transformational leadership and Magnet hospitals. The American Nurses Credentialing Center promotes the Magnet Recognition Program, which favors nurse retention by focusing on nurse well-being, and transformational leadership. Transformational leadership is the first of five criteria set forth by the American Nursing Credentialing Center for a hospital to reach Magnet status. However, the registered nurses interviewed for this study do not believe transformational leadership is being promoted within the departments, even though they worked in a Magnet hospital. Transformational leadership is defined as those individuals who create a supportive and positive work environment, and maintains an honest and open relationship to build trust, and increase job satisfaction, and go beyond their immediate self-interest for the sake of the organization [53].
The awareness of leadership and retention divulged data that may be helpful in defining the relationship between leadership and registered nurses, and the influence that relationship had on retention. In the study by Hayward et al. (2016), experienced nurses expressed concern about leadership being unapproachable and lacking support, and less experienced nurses expressed fear of approaching leadership because of the anticipated negative responses. In this study participates also expressed their discontent with leadership. Leadership was either lacking, showing favoritism, or was there to promote themselves, and not the department. Hayward et al. (2016) concluded that workplace environment and leadership support ultimately determined a nurse’s decision to leave the organization.
The topic of passion discovered registered nurses most often know they want to be nurses. Being a registered nurse is sometimes stumbled on by accident, or is a desire starting at a young age. These people have a desire to help others, and to change people’s lives, and to change the world. Their desire to be a registered nurse is so strong that poor leadership will cause nurses to change departments or organizations, but unfortunately will also cause them to leave the profession, which is a loss for the healthcare industry that can be avoided.
Communication and organizational commitment, generational differences, leadership and retention, and transformational leadership and Magnet hospital, and passion for nursing are practical implications for understanding retention of registered nurses. The findings of this study are designed to assist in understanding the daily-lived experiences of registered nurses and how communication and leadership influenced retention. Additionally, with transformational leadership an important factor of Magnet hospital recognition understanding if transformational leadership is being practiced is equally important for influencing retention.
While the results of this research advance scientific knowledge more research on how communication and leadership influence registered nurse retention is necessary. The participants of this study worked in more than one hospital; however, their experiences were not that significantly different. Based on the results of this study future research should investigate further into transformational leadership, and how transformational leadership influences retention of registered nurses.
One of the ways transformational leadership could be studied would be to focus on the people rather than the organizational policies. Hospitals could use the data composed from this study to support transformational leadership and organizational commitment to reinforce registered nurse retention. The researcher is making this recommendation based on the data provided by the participants’ interviews.
Shaping of future generations communication and leadership styles to influence registered nurse retention was not part of this research. However, getting input from all three generations; Baby Boomers, Generation X, and Millennials regarding leadership and communication was important, and future research should be conducted. It would be useful in understanding if these traits are unique to the registered nurses in this research, or to registered nurses in other environments.
This descriptive phenomenological research is limited to the small size of participants. Another way to generalize the results would be to conduct a quantitative or mixed-method study. In addition, conducting the research in different areas of the United States, or on a global scale would add credibility to how communication and leadership can influence registered nurse retention. Using the triangulation method of interviews with registered nurses, their cohorts, supervisors, managers, and directors can confirm or deny that transformational leadership is being practiced and would be helpful in further understanding how transformational leadership can influence retention of registered nurses.
Suggestion for future practice includes transformational leadership as an instrument to encourage organizational commitment, and to transition Millennials and future generations into nursing, by creating a common vision between the generations. Hospital administrators need to acknowledge that Baby Boomers, Generation X, and Generation Y (Millennials) have varying degrees of knowledge that they bring to the workforce.
8. Conclusions
The theoretical foundation of this descriptive phenomenological design research is Burns (1978) theory of transformational leadership. Transformational leadership can influence reservation for the individual through organizational commitment. Burns (1978) leadership theory proposes that transformational leadership influences followers engage the full person and unites the leader and follower for the collective purpose of organizational commitment.
Burns leadership theory focused on the lived experiences of three generations of registered nurses working in hospitals. The research was not focused on any other group of people, which means the finding of this research were based solely on the viewpoint of Baby Boomers, Generation X, and Generation Y (Millennial) registered nurses. Meaningful and detailed data were the basics for the two research questions.
This research explored registered nurses’ lived experiences and the influence communication and leadership have on retention in the Western United States, expanded on the limited amount of literature on the topic, and gained a broader understanding of those lived experiences. Additionally, this study helped fill the gap in the literature on the influence communication and leadership have on the retention of registered nurses to expand the limited body of work on the topic. This section will discuss three categories of implications, theoretical, practical, and future.
The data from the one-on-one semi-structured in-depth interviews developed five themes. These themes included transparency, a cohesive workplace, passion, collaboration, and leadership. Each participant was interviewed one time, and after the data was transcribed, each participant was asked to member check the data for accuracy.
This research has identified a lack of communication or leadership as a factor in retaining nurses, but the research is limited and does not include solutions for increasing retention levels. Communication is important for building organizational commitment and reducing turnover. Organizational commitment is a theory-based concept that may predict turnover more successfully than job satisfaction. Two important organizational commitment factors are attitudinal and behavioral commitment. All the participants in this study spoke of their lived experiences between generations, and the differences that arose between them. Some of the participants experienced positive interactions, and others experienced negative interactions.
The question concerning transformational leadership was designed to discover 1) if transformational leadership was being practiced, 2) if the participants understood the meaning of transformational leadership, and 3) if the participants were working in a Magnet hospital. Understanding the needs and the strengths and weaknesses of registered nurses in the workplace is important for retention. Poor leadership causes burnout, which affects retention and the health of registered nurses. Individual registered nurses may experience burnout because of questionable communication and leadership within the organization [54].
Transformational leadership has been shown to improve communication, inspire, motivate, and increase retention rates of registered nurses; however, with little current literature available, research in this area is important. Seven of the nine participants worked in a magnet hospital, the participants did not have a clear definition of transformational leadership, and none believed it was being practiced in their departments. Utilizing the descriptive phenomenological design aligned the research questions to focus on comprehending human experience as it exists in the daily lives of registered nurses and how communication and leadership developed a working environment that improved the retention of registered nurses.
Communication and organizational commitment, generational differences, leadership and retention, transformational leadership and Magnet hospital, and passion for nursing are practical implications for understanding the retention of registered nurses. The findings of this study are designed to assist in understanding the daily-lived experiences of registered nurses and how communication and leadership influence retention. Additionally, with transformational leadership, an important factor of Magnet hospital recognition is understood if transformational leadership is being practiced which is equally important for influencing retention.