05 Mar

Registered Nurse turnover and turnover intention are primarily based on intrinsic motivation factors. Job satisfaction variables are considered by a person before quitting their job. The impact of intrinsic and extrinsic factors on the decision to stay or leave a job is well documented in the literature. The Intention to Leave Scale (TISCALE) by Dr. Dwivedi is a validated instrument (Cronbach Alpha=0.98) to predict an employee's desire to quit. Research proves that a high TISCALE (strong desire to leave) among RNs is unrelated to pay. A study found that despite high pay satisfaction among respondents, nurses still strongly desired to quit the job. The components of the TISCAL help create specific questions that nurse leaders and healthcare executives can use to predict and prevent turnover. Here are the TISCALE questions (modified from the original work by Dwivedi, 2015). The percentage of nurses from recent research indicated agree or strongly agree in parenthesis.

  1. I intend to talk to people about new RN opportunities. (59%)
  2. My current RN job addresses my essential personal needs. (31%)
  3. Opportunities to achieve the most important goals to me are jeopardized. (37%)
  4. I intend to search for a new Nursing position with another employer. (45%)
  5. I occasionally think about leaving the organization. (62%)
  6. I plan to become an entrepreneur. (33%)

The challenge of asking RNs working in your organization the TISCALE question is the awareness these questions raise. It is awkward and uneasy for leaders to ask pointed questions that may create an employee to spin their wheels and think about leaving. Without strong foundational values tying the RN to the organization, they are already doing this regardless of you asking. Reframing the questions can provide insight into the TISCALE-styled questions and provide insight more gently. 

  1. Are there any opportunities for growth and advancement that you would like to explore in the organization?
  2. Can we improve your work-life balance or overall job satisfaction?
  3. What are your career goals, and how can we support you in achieving them in the organization?
  4. What specific factors motivate you to stay in the organization?
  5. Are there challenges and areas that bother you to the point of looking elsewhere to work? Can we explore them?
  6. How do you vision using your skills and talents for the organization other than your current role?

Leaders can reframe questions to gain insight into how their nurses are feeling and concerned about. The questions above can be asked during rounding, annual evaluations, and surveys. The goal is to make more effort to obtain actual data and feedback and work on ways to prevent turnover. Here is an example:

As the nurse manager, you round on a couple nurses as they get ready to leave the night shift. After you talk about the shift and what is new, ask the nurse if you can speak for five minutes to explore their feelings. The nurse makes the statement that there are no opportunities for growth. You dig deeper and share with the council nurse seats, chair of committee X, processes for certification, and advanced education. Leaving this statement as is tells the nurse that he/she is right, and eventually, they would answer TISCALE question #1 as true. Over time this nurse will talk to others about new RN opportunities in and outside their current organization. It is critical to get in front of turnover, not ask why someone is leaving. 

The overarching challenge is the time and ability to ask all the nurses reporting to you. The gold standard is to round on 25% of your staff a quarter so that you round on all your team at the end of the year. The problem with the gold standard is that you ask the above questions annually. This is risky and provides predated information. The new vision and innovative goal constantly offer real-time feedback and support as the manager provided in the scenario. Achieving the vision requires innovation and creativity! More to come...


Dwivedi, S. (2015). Turnover intentions: Scale construction & validation. Indian Journal of Industrial Relations, 50(3), 452-468. http://www.jstor.org/stable/24549107

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