Why Economic Evidence Matters for Retaining Nurses Across Europe

Europe’s nursing shortage is approaching a point where hospitals may be forced to treat staff retention as an economic emergency, not merely a workplace issue. A new analysis published in The Lancet Regional Health – Europe argues that European health systems still lack the basic financial evidence needed to decide which strategies can keep nurses in clinical care. The authors describe a striking gap: while the continent is confronting rising burnout, ageing workforces and widespread intentions to leave, the most recent European study estimating the cost of nurse turnover dates from 1996 and was conducted in the United Kingdom. Without current, comparable figures, hospital leaders cannot reliably calculate how much money is lost when an experienced nurse resigns, how much a retention programme might cost, or whether improving working conditions would deliver a measurable return on investment.

The scale of the workforce problem is already visible in demographic and occupational data. One recent projection estimated that Europe could face a shortage of approximately 950,000 healthcare workers by 2030, with nurses representing the largest professional group affected. More than one-quarter of European nurses are aged 55 or older and may retire within the next decade, while fewer young people are entering the profession. Burnout is estimated to affect about 30% of nurses across Europe, and the proportion of hospital nurses expressing an intention to leave their current jobs ranges from 12% to 64% across countries and settings. These pressures are not confined to staffing rosters. European evidence has linked nurses’ intention to leave and heavier workloads with increased inpatient mortality, suggesting that turnover and understaffing can translate into direct risks for patients as well as higher costs for institutions.

The authors argue that retention should be prioritised over recruitment because training new nurses takes years, while international recruitment can drain countries with more fragile health systems of their own essential workforce. A third strategy, reactivation, has received far less attention. It involves bringing trained health workers back into care after they have moved into other sectors, taken career breaks or become inactive because their qualifications are not recognised. Germany, for example, estimates that hundreds of thousands of trained health workers are employed outside the health sector. Yet policymakers cannot assess the relative value of retaining current staff, reactivating qualified workers, expanding education or recruiting internationally because workforce data systems rarely capture the information needed for such comparisons. Existing European data are inconsistent between countries and provide little detail about why nurses leave, how long vacancies last or what each departure costs.

Turnover costs begin long before a nurse walks out of a hospital. A nurse may become disengaged during the period before formally giving notice, reducing productivity while still on the payroll. Once the departure occurs, an organisation may face temporary staffing expenses, overtime payments, vacancy-related disruptions and the administrative work of recruitment. Advertising, interviews, background checks, relocation, onboarding and formal orientation add further direct costs. The financial impact can continue for months after a replacement arrives, because a newly hired nurse generally requires supervision and training before reaching the productivity of the experienced worker who left. A comprehensive costing framework therefore combines direct expenses—such as recruitment and temporary cover—with indirect costs, including lost productivity, diminished organisational knowledge and the effects of altered team performance. The latter are harder to measure but may be substantial, particularly in complex hospital environments.

Evidence from the United States illustrates why this accounting can change the political conversation. Annual industry reports have estimated that turnover for a single bedside registered nurse can cost approximately $60,000, with some hospitals losing millions of dollars each year. Such figures give executives a way to translate turnover rates into budgetary consequences. If an intervention reduced departures by a defined percentage, managers could estimate the number of vacancies avoided and compare the resulting savings with the programme’s implementation costs. However, the European authors caution that American estimates cannot simply be imported into European budgets. A cost calculated in dollars within a market characterised by high salaries, expensive temporary labour and substantial administrative spending may bear little resemblance to the cost of replacing a nurse in a tax-funded or social-insurance health system.

This lack of transferability is a technical problem, not a minor statistical inconvenience. Health economists identify at least five sources of variation between countries: how the unit of activity is defined, the quantity and quality of resources used, average price levels, currency exchange rates and the accounting methods used to assign costs. Even the word “turnover” can mean different things. One hospital may count only voluntary resignations, while another includes retirements, dismissals and transfers to different departments. Vacancy periods can be measured from the date a position is posted, the date an offer is accepted or the point at which a new nurse is judged fully operational. These choices produce different estimates before salaries or recruitment expenses enter the calculation. A study comparing four countries with similar income levels found considerable variation in per-nurse turnover costs even when researchers used a standardised methodology, demonstrating how strongly local conditions shape the final result.

Workforce organisation introduces another layer of complexity. European countries differ in the mix of registered nurses, nursing assistants and other professionals, as well as in the tasks assigned to each group. The same patient workload may therefore require different staffing combinations, training pathways and supervisory arrangements. Scope-of-practice regulations determine whether a departing nurse’s duties can legally be redistributed, while task-shifting and changing models of care alter productivity over time. Team composition also matters: replacing one nurse may affect communication, coordination and the workload of colleagues, rather than producing an isolated financial event. Labour-market rules can lengthen or shorten vacancies. Collective bargaining agreements, notice periods, consultation requirements and employment protections influence how quickly a hospital can respond when a post becomes empty. Temporary replacement staff may be widely available in one region but scarce, expensive or restricted by regulation in another.

The analysis proposes that hospitals build formal investment cases for retention, using the same basic logic applied to other major health-system decisions. The first step would be to calculate the organisation’s current turnover costs using local data. Leaders would then estimate the cost of a specific intervention—such as measures to improve scheduling, staffing, professional development or working conditions—and determine whether it changes turnover, absenteeism, productivity, patient safety or other outcomes. The final calculation would compare the programme’s expenses with any savings generated by fewer departures and improved performance. Previous hospital analyses suggest why this approach can be persuasive: in one study of US hospitals pursuing quality designations, reductions in nurse vacancies accounted for most of the quantifiable savings, while nurse-sensitive outcomes such as pressure ulcers and falls contributed additional value. Large net positive returns were reported within the first year, even after programme preparation costs were included.

European decision-makers currently lack the evidence to make similar comparisons. They cannot confidently determine whether a retention programme offers better value than expanding nursing education, increasing salaries, relying on temporary staff or pursuing international recruitment. The absence of cost data also makes it difficult to test whether promised savings actually occur after reforms are funded. The authors call for a coordinated European research agenda based on primary data from multiple health systems. Researchers could adapt existing nurse-turnover frameworks rather than start from scratch, but they would need to collect information on salaries, vacancy durations, orientation time, productivity, administrative overheads, replacement practices and the effects of turnover on patient care. Comparative studies could examine countries grouped by financing model, such as Beveridge or Bismarck systems, and by hospital governance and workforce-planning structures. Standardised definitions would make results more comparable while still allowing researchers to preserve important local differences.

The proposed infrastructure would link routine workforce records with financial and patient-outcome data, creating a basis for repeated economic evaluations rather than one-off studies. Hospitals, ministries, funders and nursing organisations could collaborate with health economists and health-services researchers to identify which retention interventions work best for different hospital types, staff mixes and regional labour markets. The authors stress, however, that better evidence will not automatically determine policy. Budget cycles, institutional inertia, professional interests, leadership priorities and political negotiations all influence whether research is acted upon. Findings must therefore be presented in forms that decision-makers can use, with knowledge brokers and professional organisations helping connect evidence to financing and implementation. Europe’s nursing crisis is already well documented; what remains missing is a credible price tag for losing staff and a reliable calculation of what prevention is worth. Generating that evidence could turn retention from a moral appeal into an investment case capable of competing for scarce public funds.