While skilled nursing facilities (SNFs) have confronted a nursing shortage for many years, record attrition during the COVID-19 pandemic has intensified the problem. One solution has been to hire newly licensed nurses and quickly assign them responsibility for patient care. However, to retain these nurses, it’s important that SNFs understand reasons newly licensed nurses might hesitate about a career in geriatrics, address the struggles they face as new nurses in a SNF setting, and implement tactics to meet their unique needs.

Attrition of Newly Graduated Nurses from SNFs

The transition from student nurse to newly licensed nurse is a vulnerable time. A study Kovner and colleagues conducted found that more than 17 percent of newly licensed registered nurses (RNs) leave their first nursing job within one year, and 33 percent leave within two years. Furthermore, Press Ganey reports that newly licensed nurses are at highest risk of attrition.

One reason newly licensed nurses are so vulnerable to attrition in the SNF setting is the accelerated transition from student nurse to one who is expected to provide care for multiple residents—and to do so with significant autonomy. In acute care, a newly licensed nurse works closely beside other nurses and often has a dedicated mentor. In the SNF setting, newly licensed RNs might be the only one working at that time of day, or LPNs might find that peers are working in other areas of the SNF and not easily accessible to them.

This sudden shift in expectations, with limited access to experienced nurses, does not provide the support their level of practice necessitates and can reinforce feelings of insecurity and uncertainty. Newly licensed nurses have some clinical knowledge but need guidance to prioritize care effectively and understand what assessment findings mean in relation to potential impact on the resident. Whitmore and colleagues found that when newly licensed nurses feel isolated and struggle to meet the expectations placed on them, a sense of disappointment in self, the SNF, and even in the profession can erase enthusiasm and passion, eventually leading to the decision to quit or to leave nursing altogether.

Furthermore, newly licensed nurses who experience stigma for working in a SNF may second-guess their career choice and seek employment in another setting where they believe they will be perceived more favorably. Manchha and colleagues identified three overarching themes influencing the stigma against nurses and other caregivers specializing in geriatrics:

• Unfavorable characterization of geriatric nurses. Unfounded beliefs posit that geriatric nurses lack the ability to work in other health care settings and that unethical behavior is a common trait (e.g., geriatric nurses are lazy or aren’t smart enough to work in the hospital).
  

• Elder care is of lower societal value. Because society does not value care as highly as a cure and does not believe caring for the geriatric population requires a high level of skill, those engaged in providing care are perceived to have lower professional status (i.e., because geriatric nurses don’t provide a service that results in a cure or other highly valued outcome, their work is perceived as less important). In addition to the faulty assumption that care doesn’t require skill to provide, there is also the belief that the work itself is dirty, with frequent references made to the provision of incontinence care.
  

• Negative emotional connotations associated with elder care. Society negatively perceives that the care environment for elderly people is sad, depressing, and boring.
  

Stigmas against geriatric nurses are perpetuated not only by society in general, but also by other health care professionals who may lack respect for geriatric nursing and undermine the choice to work in a SNF. Newly licensed nurses are often advised to avoid employment in a SNF so they don’t lose skills or to seek employment where they can make a difference and learn more technical nursing skills. This can create serious reservations about continuing SNF employment, especially if they feel insecure or disappointed in their abilities. Other opportunities may entice them if they believe their service will be perceived as important and if they will receive more support to develop their skills.

People typically become nurses because they want to serve others. Some even describe caring for others as a higher calling. A deeply felt drive and passion to help others and provide excellent care is a tremendous motivating factor for a nurse. However, the SNF workload often requires completion of a high volume of tasks in addition to managing certified nurse aides. Because newly licensed nurses are learning how to prioritize care and develop their clinical skills, they may struggle with the demands of the workload, with providing the level of care they want to, and with successfully managing others. Whitmore and colleagues found that when newly licensed nurses perceived misalignment in what they hoped to accomplish and what they spent time doing, discouragement replaced feelings of optimism about making a difference, leading to the decision to quit.

Three Tactics to Retain the Newly Licensed Nurse

To combat these challenges and retain newly licensed nurses, SNFs should implement the following tactics.

1. Implement a formalized orientation and mentorship program tailored to newly licensed nurses and further customized to individuals’ needs and goals. To address needs unique to newly licensed nurses, the program should utilize expert nurses who can help new nurses transition into their roles and expand their abilities as they do so.

The program should include a professional development plan that reflects the importance of a geriatrics specialization. Geriatric nursing is a specialty, just like pediatrics or emergency nursing, and requires a tremendous skillset to care for very vulnerable and medically complex people. A plan that reinforces the specialized geriatric skills the newly licensed nurse will gain, and how the SNF will provide opportunities to develop those skills, combats the stigma that geriatric nursing doesn’t require a high skill level and communicates that SNF leaders value their employees and will invest in their ongoing development.

2. Facilitate collegial relationships between newly licensed and other nurses, encouraging camaraderie but also facilitating knowledge-sharing. This helps newly licensed nurses feel connected to a team, curbs feelings of isolation, and helps them learn from others. It also combats negative perceptions because they are part of a group that has a shared passion for geriatric nursing.

3. Have a plan of support in anticipation that newly licensed nurses will feel overwhelmed and possibly discouraged. Given the shortage, SNF leaders must explore how to best utilize nurses, but when possible, reduce the workload for newly licensed nurses by limiting or assisting with certain tasks. Frequent check-ins to ascertain how new employees are doing and what they need is critical to communicating support and enables management to detect and intervene if the intention to quit emerges.

Alexis Roam, MSN, RN-BC, DNS-CT, QCP, is a curriculum development specialist for the American Association of Post-Acute Care Nursing (AAPACN). Roam can be reached at aroam@aapacn.org.​