Introduction
Nurses are among the most valuable resources for the healthcare sector. They are the largest professional group in healthcare service provision and spend a significant amount of time with patients, which is essential for providing high-quality care. However, nurses’ roles and responsibilities are marked by significant challenges, particularly the growing nursing staff shortage. They struggle with fatigue and health issues, which affect how well they treat patients.
A high nurse turnover rate can result from that level of stress in many healthcare organizations. Nurse turnover is a significant problem that affects the delivery of quality and safe healthcare globally, due to the high costs involved and the time required to hire new nurses. Although nursing turnover is fundamentally a response to every leadership action, managing it is a crucial task for nursing leadership.
Nursing leadership bears the significant responsibility of promoting higher nursing retention. Healthcare organizations are multidisciplinary businesses with a range of clients and staff. Encouraging more outstanding nursing expertise through increased staff stability and reduced turnover is associated with improved patient outcomes. Effective nurse managers significantly influence the quality of patient care and staff nurses’ retention through different strategies.
Problem Statement and Review Outline
Effective leadership indirectly contributes to lower mortality rates by motivating, retaining, and supporting experienced employees. Nurse leaders substantially influence the outcomes of nursing jobs in medical facilities. The rising turnover rate brings numerous problems, including a nurse shortage, increased work, and higher hiring expenses.
The purpose of this literature study is to identify the most critical leadership tactics that are related to nursing retention. The goal is to assist nurse leaders in addressing the issue of excessive nursing staff turnover and retaining vital personnel within a facility. The review will broaden the knowledge of leadership techniques among head nurses, enabling them to promote a higher rate of nursing retention. When formulating strategies to enhance the performance of nurses’ work, this study will also be helpful to hospital administrations and government policymakers. The literature review seeks to answer the following research questions:
- What is the impact of the nursing leader’s behavior on promoting nursing retention?
- How do a nursing leader’s problem-solving abilities impact nursing retention?
- How do the work conditions and environment created by the nurse leader encourage nursing retention?
- How does a transformational role in nursing leadership help to promote nursing retention?
Literature Review
Nursing leadership and retention are crucial factors in promoting better healthcare outcomes. Understanding the correlation between the two nursing components will help uncover their association and ensure that patient needs are adequately satisfied. Nursing leadership involves making decisions that could impact nursing retention.
The desired goal is to have nursing leadership that stimulates higher levels of nursing retention. Different nursing leadership strategies, discussed below, can achieve this. The literature review begins by providing a deeper understanding of the definitions of nursing retention and nursing leadership, as well as their importance in the nursing profession.
Nursing Retention
Nursing retention refers to the percentage of nurses who remain in their current positions and workplaces. It has the potential to enhance their general well-being. Retaining nurses is essential because it fosters a team-oriented environment among hospital employees. Additionally, it can enhance worker effectiveness and satisfaction while helping nurses provide quality patient care (Duru & Hammoud, 2021).
The overall consistency of patient care at hospitals is related to nursing retention. Hospital understaffing impacts patient care and the number of patients seen. More experienced nurses must onboard, train, and teach new nurses how to handle challenging patient situations.
If nurse retention continues to decline, patients may be denied high-quality care by qualified healthcare providers who lack productive staff members. Hospitals’ HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) scores may be impacted if there is a decline in patient satisfaction. The Centers for Medicare and Medicaid Services (CMS) developed a survey comprising 29 questions that make up the HCAHPS scores, and patients are randomly selected to answer questions about their hospital experience (Efobi, 2022). Therefore, the survey helps to evaluate patients’ satisfaction level with the quality of care.
The coronavirus pandemic led to an extraordinary increase in nurse turnover in healthcare settings. The rising demand for nurses increased stress for employed nurses even as the epidemic highlighted the challenge of the growing nursing turnover (Soqair, 2021). Due to the nursing shortage, nurses may be required to work longer hours and perform more tasks than usual. Wang et al. (2022) state that, given that new nurses might not be able to handle the increased workload, experienced nurses are forced to work under greater pressure. As some nurses are already required to work twelve-hour shifts, longer shifts have also been linked to high nurse turnover.
Suliman et al. (2020) state that many nurses frequently work overtime, which is often required under demanding conditions, causing them to end their days exhausted and possibly injured. Forty-three percent of newly licensed registered nurses leave their nursing positions within three years, according to Poon et al. (2022), while 18 percent do so within the first year. Due to the severe nursing shortage, this turnover rate is strongly correlated with high-stress levels.
Further, nursing retention can be influenced by the workload nurses must perform. Prado-Inzerillo et al. (2018) suggest that a higher patient-to-nurse ratio is associated with increased personal achievement, depersonalization, and emotional exhaustion. Duru and Hammoud (2021) claim that the connection between patient safety and nurse-to-patient ratios is mediated by emotional exhaustion. In addition to the high turnover rate, newly qualified RNs are more likely to report emotional exhaustion and cynicism within a year of understaffing. Wang et al. (2022) indicate that nurses in units with high patient-to-nurse ratios are more likely to report job dissatisfaction, emotional exhaustion, and intentions to leave their current employer.
A high patient-to-nurse ratio is also linked to increased adverse events, such as medication errors and patient falls, which can further contribute to nurse job dissatisfaction. Hospitals and healthcare organizations can effectively address these issues by implementing leadership strategies, such as increasing staffing levels and implementing other programs to improve nurse retention and well-being. In addition, when a nurse first enters a hospital or other new healthcare setting, recurring themes of low autonomy are often observed. Poon et al. (2022) suggest that the lack of benefits and autonomy may contribute to a high nurse turnover rate. A lack of autonomy will anger nurses, as they will not receive feedback or mentorship. As a result of the trend, it is more challenging to fully staff healthcare institutions, which has several effects on the standard of patient care (Wang et al., 2022).
Nursing is one of the top three occupations with the highest turnover rates. According to Suliman et al. (2020), research indicates that 43% of newly licensed nurses working in hospitals leave their profession within three years. 17.5 percent of employees work for only one year, while another 33.5 percent leave after two years (Duru & Hammoud, 2021). Low nurse-to-patient ratios result in fewer hours of nursing care per patient, which is associated with higher patient mortality rates (Colwell, 2019). This suggests that healthcare understaffing can compromise patient safety and care quality, as more tasks often remain unfinished at the end of shifts.
Understaffing can then lead to the available nurses being overworked. Alkarabsheh et al. (2022) state that when healthcare professionals are overworked to compensate for limited staffing, they may experience stress and burnout, which limits their capacity to provide effective treatment and increases the risk of medical errors. As a result, healthcare organizations must allocate more resources to managing excessive turnover, which significantly impacts their profit margins. According to Shah et al. (2021), a 1% change in nurse turnover is expected to result in an additional $328,400 in costs (or savings) for the typical hospital.
The average annual turnover costs or losses at hospitals, which range from $4.4 million to $6.9 million, are increasing due to the rising turnover rate among bedside nurses (Webb, 2007; Sfantou et al., 2017). Additionally, according to the author, it typically takes 85 days, or approximately three months, for a specialty nursing role to fill a staff nursing position. The average cost of the hospital recruitment process is $82,000 (Shah et al., 2021). This highlights the need for nursing leadership to support higher retention, thereby saving costs associated with onboarding and training new nurses.
Nursing Leadership
Strengthening the quality and integrating care depend on the leadership of healthcare professionals. According to Kleinman (2004), leadership entails the relationship between the person (s who choose to follow and the one(s) who lead. It also encompasses the behavior of leading and organizing the efforts of a team or group of individuals toward a common objective. In the provision of healthcare services, nursing leadership is ideal. Wang et al. (2022) assert that nurses are just as crucial to providing medical treatment as doctors.
Therefore, effective leadership is highly desirable in defining nurses’ daily work due to the increasing demand for nursing services. One of the many leadership actions nurse managers engage in daily is the natural adoption of a practical leadership approach and the provision of higher leadership roles. Others, however, may find it too challenging to comprehend the concept of leadership or generally feel less competent.
The ability to positively influence others and advance healthcare goals requires nurse leaders to be logical thinkers with excellent communication skills. Ens et al. (2018) indicate that the primary responsibility of nurse managers is to inspire their staff to take the initiative in making decisions regarding patient care and to provide safe patient care in accordance with accepted nursing standards. In healthcare settings, effective leadership is crucial for delivering high-quality care to patients and fostering the professional growth of staff members. Wang et al. (2022) state that increased job satisfaction and decreased nurse turnover are directly impacted by effective leadership.
Alkarabsheh et al. (2022) suggest that a leader should be able to operate effectively under pressure, respond quickly to address issues, and receive training and education in workplace operations. Emotional intelligence is also crucial in management, enabling leaders to effectively manage their own and others’ emotions. Additionally, leaders must play a transformative role to enhance their own performance and that of others, including solving work-related problems.
Today, a nurse’s ability to lead is influenced by several factors. They include the speed of technological development, interpersonal skills, the openness of their information, patient needs and requirements, the standard of their services, and adherence to rules and regulations (Alkarabsheh et al., 2022). The nurse manager should support and coach nurses as they deliver high-quality patient care, control workload and stress, and boost productivity in the workplace. Nurse managers learn to lead by observing and applying competencies in specialized educational activities. However, Sfantou et al. (2017) state that different forces, including social and cultural influences, can influence nursing leadership.
It is essential for practicing nurses who consistently demonstrate exemplary performance in their duties, despite external influences, to be recognized and rewarded, as they can serve as role models to other nurses. According to Colwell (2019), rewarding nurses by assuming leadership roles is essential due to their commitment to improving organizational and patient care services. The sustainability of any healthcare facility should be a goal for nurse managers, underscoring the value and competitiveness of nursing leadership.
Several standards are fundamental to the development of nursing leadership. Alkarabsheh et al. (2022) state that the standards are based on the nursing activities and interventions that a nurse uses to accomplish desired results in a specific hospital setting, as well as the work environment and professional values. For the most part, the size of a hospital determines the nursing leadership abilities needed to create an attractive working environment. Dall’Ora et al. (2020) state that larger hospitals have more nursing leadership responsibilities than smaller ones. In general, a person becomes a leader by exercising leadership, and they become a better leader when they do so, particularly as they navigate various obstacles and conflicts at work.
Although the healthcare industry will continue to evolve, nursing will always require leaders. Alzahrani, S., & Hasan, A. A. (2019) state that leadership will always have a direct impact on an organization’s employees, productivity, and motivation. Hospitals and health systems emphasize adopting characteristics of a highly dependable organization to enhance patient care (Ens et al., 2018). This is a playbook for a business that strives to foster an environment in which potential problems are predicted, identified early, and addressed promptly to prevent adverse outcomes.
Kleinman (2004) indicates that organizations that value trustworthiness encourage leadership skills. Middle-management leaders, such as nurse leaders, are crucial to an organization’s performance, even though it is customary for leaders to focus their leadership efforts at the top of a hospital or health system. They significantly affect a large number of front-line caregivers and healthcare workers.
Most healthcare workers are nurses, who interact with patients more frequently than any other profession. As a result, nurses have a significant impact on patient care, whether that impact is favorable or unfavorable. Nurses will only continue to develop and influence the future of more competent healthcare delivery if there is strong nurse leadership (Webb, 2007; Prado-Inzerillo et al., 2018).
Physicians and healthcare administrators undoubtedly play a significant role in driving the pursuit of high reliability, but nursing leadership is equally important (Casida & Pinto-Zipp, 2008). It is impossible to disregard nurses’ enormous duty to enhance patient care. Given the current situation, strong nurse leadership that is swift, stable, and has a voice at the table is necessary to help improve healthcare.
Effective nursing leadership has been associated with significant contributions to the healthcare sector. In redesigning healthcare in the United States, Niinihuhta et al. (2022) suggest that nurses should be integrated as full partners alongside doctors and other healthcare professionals. Their leadership competence is essential for assessing how patients will ultimately be affected, as nursing leaders significantly impact the teams and units they directly supervise. Ens et al. (2018) continue to show a significant link between good leadership and a productive workplace. This, in turn, fosters a culture of safety that yields successful patient outcomes, further underscoring the importance of nursing leadership.
Hospitals and health systems will be better able to influence patient safety and quality initiatives if they recognize the value of nurse leadership in achieving change. The healthcare industry continually evolves, presenting nurses with new challenges, procedures, and opportunities. The decision of a nurse to remain in an organization or leave frequently depends on a competent nurse leader who can guide them through these changes (Sfantou et al., 2017).
Most new and seasoned nurses are aware of the rapid changes in the healthcare sector (Ens et al., 2018). However, leadership should be able to implement change in a way that enables the unit/team to see the overall benefit of the change in the least disruptive way possible (Niinihuhta et al., 2022). The changes will enhance nurses’ preparedness for success in their responsibilities.
Nursing Leadership Strategies to Minimize Nursing Retention
The retention of nurses depends on effective leadership, which should be a vital component of any multifaceted recruitment and retention strategy. Nurse leadership plays a pivotal role in nurse retention and staff satisfaction. To avoid high expenses and an increase in employee loss, nursing administrators must be able to predict nurse turnover.
Various factors can impact nurse turnover rates (Alzahrani & Hasan, 2019). The way nurse managers treat their staff, their leadership style, any possible prejudices they display, or the perks they offer to some employees while excluding others can all contribute to turnover (Ens et al., 2018). In light of the growing nursing shortage, nurse leaders must determine the most effective methods for attracting and retaining employees.
Behavior
Behavior is one of the most critical strategies that can be applied in nursing leadership to increase nursing retention, given the growing demand for healthcare and the declining availability of caregivers. Suliman et al. (2020) argue that, based on the leader-member exchange hypothesis, some researchers contend that a behavioral component has a positive impact on the nurse manager’s job. Nurse managers’ behavior is crucial regarding staff nurse satisfaction and nurses’ engagement in the workplace.
In Soqair’s (2021) opinion, a nurse leadership program develops leadership characteristics by developing managers, clinical nurse specialists, and other team members as role models. According to leadership theories, the fundamental component for leaders is good behavior. Leadership expertise requires acquiring new skills and attitudes through formal education, on-the-job training, and mentoring.
An essential quality of a nurse manager is having supportive interpersonal behavior at work. According to Webb (2007), the mindset and actions of the nurse leaders directly influence managerial support. The study by Poon et al. (2022) suggests that good behavior has a positive impact on leadership and a productive workplace. They conclude that poor behavior increases workload, employee turnover, and a lack of responsibility.
The authors also contend that hospital administration should encourage nurse managers’ autonomy by fostering a work environment where career paths are unambiguously defined in terms of conduct. In practice, nurses exhibit a diverse range of behaviors. The majority need to be more skilled at resolving disputes amicably, exchanging ideas, getting along with one another, or communicating what has to be done for the patient.
Performance
Nursing leadership should focus on enhancing nurses’ performance by promoting interaction among staff members in the medical facility. These relationships help reduce the power disparity between staff members. In particular, the administration of a nursing ward depends heavily on nursing performance, which is also strongly related to job satisfaction and the development of nurse managers’ roles (Naseer et al., 2018).
Improving nurse performance is essential for delivering better quality patient healthcare and excelling in various organizational aspects. High-performing nurse managers in an organization successfully carry out their duties and positively impact nursing leadership (Soqair et al., 2021). Even so, Sfantou et al. (2017) indicate that nurse managers who perform poorly often put considerable effort into highlighting the value of nursing to the company.
Problem-Solving
Nurse leaders can enhance nursing retention by developing improved problem-solving abilities (Wang et al., 2022). Dall’Ora et al. (2020) argue that problem-solving can better address the use of staff because it helps leaders gain new abilities, put them into practice through fostering teamwork, and pass those talents on to others. Nurse leaders with the authority to address organizational issues facilitate timely intervention and effective communication (Ens et al., 2018).
A critical path, clinical road, or care path illustrates how problem-solving is integrated into nursing duties. According to Alzahrani and Hasan (2019), nurse leaders must establish structures to enhance their clinical problem-solving ability. Hospitals do not typically offer problem-solving pedagogy; therefore, nurse managers must develop this skill independently.
Working Conditions and Environment
Nurse managers should cultivate a supportive work environment to promote nursing retention rates. Nurses perform various organizational duties, including disability and palliative care, health promotion, and illness prevention and treatment. The job of a nurse leader is to foster healthy working conditions and a positive work environment. Extra shifts and mandated overtime for nurses are stressing out the workplace (Prado-Inzerillo et al., 2018). Nurse leaders should utilize available resources efficiently and minimize waste to encourage nurses to stay (Zaheer et al., 2021).
Nurse leaders can also help manage the workload to deliver the required services efficiently. According to a study by Alzahrani and Hasan (2019), which explicitly examined nurse staffing levels, nurses are most likely to feel burned out when caring for a large number of patients or when there are concerns about staffing insufficiency. As a result, one retention technique that must be considered is improving the workplace. Finding ways to retain nurses on staff and increase nurse satisfaction while improving the workplace and working conditions is crucial.
Nurse managers could experience severe psychological stress and a heavy workload, which could limit their ability to create favorable working conditions (Prado-Inzerillo et al., 2018). Sfantou et al. (2017) argue that a supportive leadership position enables nurses in administrative roles to participate in a shared organizational commitment, which in turn improves the working environment. According to Casida and Pinto-Zipp (2008), the organizational culture of the nursing unit, as well as its sensitivity to both internal and external opinions on the hospital’s aims and vision, directly affects the leadership position of nurse managers. Strong nurse leaders may build and nurture a great workplace culture by being visible, approachable, consultative, acknowledged, and supportive.
Transformational Role
One key requirement of nursing leadership is the ability to motivate subordinates to enhance their value within the organization (Duru & Hammoud, 2021). According to Sfantou et al. (2017), transformational leadership is characterized by having clear goals to guide others toward a shared objective. Poon et al. (2022) used the Leadership Practice Inventory approach to compare the outcomes of two forms of nursing leadership.
One group comprises nurse leaders who adopt transformational leadership, while the other comprises nurse leaders who rely on traditional management approaches. Their study aimed to assess the extent to which nurse leaders recognize their ability to lead. The findings by Poon et al. (2022) demonstrate that nurses in transformative roles are more likely to be nurse leaders whom departments and doctors in an institution respect. According to Nasser et al. (2018), nurse leaders require the support of peers who exhibit transformative traits, as they can propose novel ideas to enhance the delivery of nursing services. An individual’s capacity for transformational leadership broadens and inspires both parties to greater performance levels.
Experienced nurses frequently play transformational roles that are highly and moderately relevant. However, Nasser et al. (2018) state that young or less experienced nurses are more likely to decipher roles in common and moderately appropriate ways. According to Zaheer et al. (2020), transformational nursing leadership inspires a sense of empowerment among nurses, which in turn improves their attachment to work and reduces their desire to leave.
Additionally, the study reveals that transformational leaders engage nurses in regular discussions about their values and vision for the future. Nurse managers should play specific transformational roles because they inspire their teams to share the vision of providing safe and quality healthcare. This improves the working environment and may be a valuable technique for making informed decisions.
Conclusion
Nursing leadership plays a significant role in nursing retention. Considering the numerous services nurses provide in the healthcare sector, poor nursing leadership can result in high turnover rates and low retention. Nurses constitute the most prominent professional group within the healthcare staff, who work in a fast-paced environment.
The roles and duties of nurses are increasingly demanding, especially due to the ongoing shortage of nursing staff, and they often face fatigue and health problems that impact the quality of patient care. The challenges cause many nurses to leave their jobs. Still, the findings indicate that effective nursing leadership strategies can enhance nursing retention.
Nursing leadership behavior, performance, problem-solving abilities, work environment, and the transformative role can enhance employee satisfaction, increasing the rate of nursing retention. These strategies are supported by clear and effective communication, which enhances the creation of a positive work environment and fosters trust among nurses. Showing nurses their work is valued and appreciated through behavior, including rewards and recognition, can help them feel more engaged and motivated to stay. Nurses who feel valued and supported by their leaders are more likely to stay in their current positions, which can lead to increased continuity of care and improved patient outcomes.
Empowering nurses with autonomy and decision-making power can support their performance. This approach will help the nurses feel more invested in their work and motivated to stay. In addition, nursing retention can be enhanced by providing nurses with ongoing education and training. This will help them grow professionally in their careers and increase job satisfaction.
Nursing leadership can improve nursing retention by enhancing problem-solving abilities through guidance, mentorship, and constructive feedback. This strategy can help nurses feel more supported and less likely to leave their positions. Teamwork and collaboration enhance performance between the leader and the nurse by encouraging teamwork and idea sharing. This can help nurses feel more connected to their colleagues and invested in their work.
Fair and competitive compensation tied to performance will ensure nurses receive fair and competitive compensation. It will help the nurses feel more valued and reduce the likelihood of leaving their current jobs. Flexibility in leadership fosters a better work environment by offering flexible schedules. Nursing leadership can provide alternatives to help nurses balance their work and personal lives, thereby reducing stress and burnout and enhancing nursing retention.
References
Alzahrani, S., & Hasan, A. A. (2019). Transformational leadership style on nursing job satisfaction amongst nurses in hospital settings: Findings from systematic review. Global Journal of Health Science, 11(6), 25. Web.
Alkarabsheh, O. H. M., Jaaffar, A. H., Wei Fong, P., Attallah Almaaitah, D. A., & Mohammad Alkharabsheh, Z. H. (2022). The relationship between leadership style and turnover intention of nurses in the public hospitals of Jordan. Cogent Business & Management, 9(1). Web.
Casida, J.J. & Pinto-Zipp, G. (2008). Leadership-organizational culture relationship in nursing units of acute care hospitals. Nursing Economics, 26(1), 7–16.
Colwell, F. J. (2019). Leadership strategies to improve nurse retention. International Journal of Nursing, 6(1). Web.
Dall’Ora, C., Ball, J., Reinius, M., & Griffiths, P. (2020). Burnout in nursing: A theoretical review. Human Resources for Health, 18(1), 1–17. Web.
Duru, D. C., & Hammoud, M. S. (2021). Identifying effective retention strategies for front-line nurses. Nursing Management (Harrow, London, England: 1994), 29(1). Web.
Efobi, C.O. (2022). Poor management skills: A contributing factor to the high turnover rate in nursing homes. Fortune Journal of Health Sciences, 05(02). Web.
Ens, B., Bazylewski, S., & Duchscher, J. B. (2018). Emerging nursing leadership issues. Pressbooks. Web.
Kleinman, C. (2004). The relationship between managerial leadership behaviors and staff nurse retention. Hospital Topics, 82(4), 2–9. Web.
Naseer, A., Perveen, K., Afzal, M., Waqas, A., & Gillani, S. A. (2018). The impact of leadership styles on staff nurses’ turnover intentions. International Journal of Academic Research in Business and Social Sciences, 7(12). Web.
Niinihuhta, M., Terkamo-Moisio, A., Kvist, T., & Häggman-Laitila, A. (2022). A comprehensive evaluation of factors affecting nurse leaders’ work-related well-being. Leadership in Health Services, 35(3), 460–474. Web.
Poon, Y.-S. R., Lin, Y. P., Griffiths, P., Yong, K. K., Seah, B., & Liaw, S. Y. (2022). A global overview of healthcare workers’ turnover intention amid COVID-19 pandemic: a systematic review with future directions. Human Resources for Health, 20(1). Web.
Prado-Inzerillo, M., Clavelle, J. T., & Fitzpatrick, J. J. (2018). Leadership practices and engagement among Magnet Hospital Chief Nursing Officers. JONA: The Journal of Nursing Administration, 48(10), 502–507. Web.
Sfantou, D., Laliotis, A., Patelarou, A., Sifaki- Pistolla, D., Matalliotakis, M., & Patelarou, E. (2017). Importance of leadership style towards quality-of-care measures in healthcare settings: A systematic review. Healthcare, 5(4), 73. NCBI. Web.
Shah, M. K., Gandrakota, N., Cimiotti, J. P., Ghose, N., Moore, M., & Ali, M. K. (2021). Prevalence of and factors associated with nurse burnout in the US. JAMA Network Open, 4(2), 1–11. Web.
Soqair, N. Y. A. (2021). Factors affecting nurses’ turnover in Alhassa governmental hospitals. Open Journal of Nursing, 11(11), 960–980. Web.
Suliman, M., Almansi, S., Mrayyan, M., AlBashtawy, M., & Aljezawi, M. (2020). Effect of nurse managers’ leadership styles on predicted nurse turnover. Nursing Management, 27(5). Web.
Wang, B.-L., Batmunkh, M.-U., Samdandash, O., Divaakhuu, D., & Wong, W.-K. (2022). Sustainability of nursing leadership and its contributing factors in a developing economy: A study in Mongolia. Frontiers in Public Health, 10. Web.
Webb, K. (2007). Motivating peak performance: Leadership behaviors that stimulate employee motivation and performance. Christian Higher Education, 6(1), 53–71. Web.
Zaheer, S., Ginsburg, L., Wong, H. J., Thomson, K., Bain, L., & Wulffhart, Z. (2021). Acute care nurses’ perceptions of leadership, teamwork, turnover intention and patient safety: A mixed methods study. BMC Nursing, 20(1). Web.