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Nursing Staff Retention: The New Imperative

Susan Odegaard Turner, RN, MN, MBA, PhD

President/CEO, Turner Healthcare Associates, Inc.

Faculty, University of Phoenix

      Much of the nursing literature over the past few years has focused on the importance of nursing recruitment strategies. Stories about foreign nurse recruitment, sign on bonuses, Hawaiian vacations, and “refer-a-nurse†contests are interspersed with grim statistics about the deepening nursing shortage. There has been limited information about the concept of retaining those nurses already on hospital payrolls. In spite of innovative recruitment strategies, healthcare facilities are now grappling with the evidence that their overall vacancy and turnover rates have not changed. Indeed, over half of Southern California hospitals pay hiring bonuses, which cost an average of $62,000 per facility per year, but their vacancy rates are no different than those who do not pay these bonuses 1.

      The spotlight in many hospitals is still focused on nurse recruitment. The nursing shortage is deepening and there are hundreds of thousands of RN jobs unfilled nationally. Most hospitals are using travelers to fill vacant positions. Staffing with travelers costs two to three times more than staff RNs. Almost two thirds of hospitals are already operating in the red, with labor costs the largest portion of hospital budgets. 2Hospital vacancy rates are between 16-18% throughout the country. 3Most hospitals are using travelers and registry to fill vacant positions with an average annual expenditure of $2 million per facility and an immeasurable impact on employee morale and quality, consistency, and continuity of care. 4 Nationally, 25% of hospitals are recruiting RNs from foreign countries. 5However, foreign nurse recruitment is costly and many of hospitals have considered and have rejected foreign nurse recruitment as a recruitment strategy.

      In healthcare facilities, retention strategies have often taken a back seat to recruitment, although they are closely related. Retention needs to be a key focus because each time a nurse is lost to an institution; it costs at least 150% of that person’s annual compensation to replace him/her. This does not include the cost of advertising, orientation, equipment costs and more 6. One of the critical components of nurse retention is nurses’ perception of their work environment.

      In 2002, Nurseweek and AONE partnered to provide a study on what California nurses say about working in California. This study set out to provide an objective assessment of their view of the work environment and nurses’ career intentions, as well as to educate and inform policy makers and industry leaders on constructive actions toward retaining the current and future RN workforce 7. In short, the study is a blueprint for retaining nurses.

      The study showed that most of the respondents believe that RN stress causes the most significant impact on nursing practice. Other significant impacts on nursing practice include the limited ability of RNs to maintain patient safety, a decrease in both patient care quality and the quality of RN work life. These areas need to be evaluated for enhancing retention strategies. Of those respondents to the survey planning on leaving their positions, strategies that they listed as very likely strategies for their own position retention included: higher salaries and benefits (58%), better staffing (67%), more respect from management (51%), opportunities for professional development (48%), flexible scheduling (35%) and increased autonomy (30%) 8For those California RNs currently not working, possible factors to motivate their return to the workforce include: less stressful work environment (50%), higher wages (38%) better hours (36%), more professionally challenging position (27%). 9 These nurses see the most important solutions to the shortage as: improving the status of RNs within the hospital organization, improving the work environment, improved wages.

      Retention strategies are now being considered as a part of the front line defense for managing the nursing shortage. The data from within California likely demonstrates that retention-focused issues are a major concern for working nurses everywhere. Hospitals in most states are beginning to provide retention bonuses as a way to keep staff over five years 10 . Hospital executives and politicians must embrace and enhance initiatives and funding for retention of nurses-not just recruitment. Retention must be a predominant focal point as work to tackle the shortage continues. Legislative funding must be focused toward institutions that create and implement innovative retention methods. At a facility level, retention must be encouraged and measured as a primary initiative for maintaining care quality, improving the advanced education options for working nurses, as well as meeting staffing ratios. Business development plans must be linked with prospective nursing workforce planning to ensure adequate staff to support new programs.

      Additional research studies identify retention strategies related to the work environment as critical to employee satisfaction.50% of employee satisfaction comes from their relationship with their bosses. 11 Research shows that the quality of the relationship between a boss and subordinate is a primary predictor of intentions to remain in a current workplace. An investment in strengthening an organization’s leaders- from senior executives to middle managers to team leaders-pays off in all sorts of ways, but particularly in attracting and retaining employees.

      Those hospitals that have measures in place to hold managers accountable for retention tended to experience lower turnover rates. Accountability measures can include

Incorporation of retention efforts into the managers' performance appraisal process, bonuses for taking action related to turnover or achieving a qualitative or quantitative change in the turnover rate, and periodic review of employee satisfaction in the manager's specific service area. 12  Additional work environment options implemented by hospitals to retain nurses include  leadership training for nursing managers, voluntary nurse/patient ratios where not mandated, use of RN staff satisfaction surveys, self scheduling for nursing units, shared governance philosophy and nursing organization structure.

      Mentoring programs for new RN hires has been extremely successful across the country with increased retention rates of RNs involved in a formal mentoring program. Retention of RN new graduates is linked to early practice support and guidance, and quality of work environment. New graduate retention rates improved with comprehensive orientation/mentoring/internships. The Nurseweek/AONE study reported average retention rates of new grads to be: 89% at 6 months, 81% at 12 months, and 69% at 2 years. 13 One of the best new grad nurse programs available is the RN Residency offered by Versant/Children’s Hospital Los Angeles. Available at hospitals throughout the country, this six month, in-depth program captures mentoring, precepting, didactic lecture, stress debriefing as well as significant program evaluation research to demonstrate a return on investment for facilities implementing this residency within 18 months. RN Residencies for new grads will become the new standard 14

      With the focus on retention strategies, facilities cannot ignore the effect that leadership style has on retention. Toxic nurse executives and middle managers can sabotage retention efforts by driving away nurses at all levels of the organization. The best retention strategies in the world will not work if retention is inhibited by self-centered, power-hungry leaders. Hospitals best be wary of nurse executives and managers who impede retention by setting up a personal kingdom instead of working as a team, using fear and intimidation to get tasks completed, a “my way or the highway†mentality, making negative comments about staff, or blaming subordinates for decisions that result in poor outcomes.

      Nursing staff who work under retention- inhibiting conditions often complain about their work environment and change positions. Toxic attitudes can spread outward and cause a ripple affect that can damage an entire facility. Positive leadership style is a key retention strategy. Nurse leaders who reward efforts with positive feedback, encouragement and coaching are also retaining staff. Retention-enhancing behaviors are far more positive and include empowerment of staff at all levels, coaching for both positive change and to eliminate negative behaviors, choosing to mentor both new nurses and new managers, investment in training and skill building for all levels of staff, implementing change with a teamwork-based model, encouraging innovation and out-of-the-box thinking for care management and work redesign changes, and proactive planning instead of reactivity.

      Among the newest tools hospitals are using to retain nurses is shift bidding. Hospitals save labor costs by using fewer outside nurses while allowing their own nurses to control when they work and how much they earn by internet online bidding for work shifts. Since 2001, St. Peter’s Hospital in Albany, N.Y. has filled more than 127,000 hours and saved more than $1.7 million through online bidding. Its overall nurse vacancy rate dropped from 11 to 5%. 15

      Nationally, the American Nurses Association (ANA) has structured its initiatives related to the shortages and its resources to focus on retention. According to Mary Foley, past president of ANA, "The targeted subset of work is improving the overall work/care environment, retaining the aging nurse; improving the image….recruitment alone will not assure an adequate nursing supply. It is all about the workplace…" Twenty one states have introduced legislation on staffing ratios and nursing quality indicators believing it will affect nursing retention 16 .

      In addition, ANA recommends these strategies for retention success of both RNs and LVN’s: continue to discuss retention and recruitment issues through marketing, PR and education, build the business case for quality and safety-nurses make the difference, influence policy and align with consumers, build the body of knowledge and evidence of nurses' value in healthcare system, celebrate successful retention strategies and encourage hospitals to journey to magnet status.

      Magnet hospital characteristics are named as retention solutions. 17 Magnet hospital status is awarded to facilities that transform the workplace so that nurses find it challenging and satisfying, are empowered to use their professional knowledge and skills in achieving quality patient care outcomes, and not only want to stay in their positions but recruit others to their workplaces and into their profession. The American Nurses Credentialing Center (ANCC) has recognized these types of workplaces as "Magnet" facilities. The Magnet program was formally established in 1993, and recognizes nursing organizations that demonstrate sustained excellence in nursing care and serve as "magnets" in attracting and retaining nurses. These characteristics include flat organizational structures, unit-based decision making processes, influential nurse executives and investments in the education and expertise of nurses. Research has shown that magnet hospitals influence nurse job satisfaction and low turnover rates as well as better patient outcomes than "non-magnet " facilities. Organizations report that prospective employees cite magnet status as a deciding factor in choosing to work at a magnet facility. 18

      Although there is much work to be done to create and enhance retention strategies, there are already organizations and facilities using innovative methods to retain as well as attract nurses. The California Institute for Nursing and Healthcare, as well as other professional organizations including Association for California Nurse Leaders, California Association of Colleges of Nursing and California Association of Associate Degree Nursing  are working together to move retention recommendations into action by creating a collaborative environment with key stakeholders and linking together the multiple projects throughout the state. At a statewide level, there is a master planning process underway to focus on effective nurse retention strategies, as well as on long term solutions for the nursing shortage. Nursing staff retention has become the new workforce imperative.


References

Bradley, Carol (2002, March). The nursing shortage: Facilitating partnerships between service and education. CACN Fall Conference, Garden Grove, CA. Data from Deans and Directors Survey
LA Times "Itinerant Nurses fill Growing Shortages at State’s Hospitals" Sunday, October 27, 2002
California Strategic Planning Committee for Nursing, Phase 3 Final Report, September 2002
Florida Hospital Association Survey, RN Recruitment/Retention, August, 2001.
Lee, B. (2001). Keep your nurses and healthcare plain professionals for life. Calgary, Canada: Mastery Publishing Co.,p.34
AONE. (2002, Sept.). Say what? What California nurses say about working , Nurseweek/AONE Study
Kaye, B.L., Jordan-Evan, S. (2002). Love ‘em or lose ‘em: Getting good people to stay . San Francisco, CA. Benett-Koehler Publishers.
Abrams, M (2002, March). Employee retention and turnover: Holding managers accountable. Trustee. Chicago, 55 (3), T1.
Turner, Susan Odegaard,â€Staying Power†Nurseweek, June 20, 2004
Hill, J, (2003, December 15). System allows nurses to bid for pay, shifts online . Nurseweek, p.3 www.nurseweek.com
ANA Nursing Call to Action presented by Foley, Mary, California Nursing Summit, 9/13/02, Sacramento
McClure and Hinshaw, Magnet hospitals Revisited , American Academy of Nursing, Summer 2002 p.1
Olson, Jan, "A Tool for Attracting Nurses" Contemporary Long Term Care, October, 2002 p 42-44.)

1 Bradley, Carol (2002, March). The nursing shortage: Facilitating partnerships between service and education. CACN Fall Conference, Garden Grove, CA. Data from Deans and Directors Survey

2 LA Times "Itinerant Nurses fill Growing Shortages at State’s Hospitals" Sunday, October 27, 2002

3 California Strategic Planning Committee for Nursing, Phase 3 Final Report, September 2002

4 Bradley, C.

5 Florida Hospital Association Survey, RN Recruitment/Retention, August, 2001.

6 Lee, B. (2001). Keep your nurses and healthcare plain professionals for life. Calgary, Canada: Mastery Publishing Co.,p.34

7 AONE. (2002, Sept.). Say what? What California nurses say about working , Nurseweek/AONE Study

8 Ibid

9 Ibid

10 Florida Hospital Association

11 Kaye, B.L., Jordan-Evan, S. (2002). Love ‘em or lose ‘em: Getting good people to stay . San Francisco, CA. Benett-Koehler Publishers.

12 Abrams, M (2002, March). Employee retention and turnover: Holding managers accountable. Trustee. Chicago, 55 (3), T1.

13 Bradley, C.

14 Turner, Susan Odegaard,â€Staying Power†Nurseweek, June 20, 2004

15 Hill, J, (2003, December 15). System allows nurses to bid for pay, shifts online . Nurseweek, p.3 www.nurseweek.com

16 ANA Nursing Call to Action presented by Foley, Mary, California Nursing Summit, 9/13/02, Sacramento

17 McClure and Hinshaw, Magnet hospitals Revisited , American Academy of Nursing, Summer 2002 p.1

18 Olson, Jan, "A Tool for Attracting Nurses" Contemporary Long Term Care, October, 2002 p 42-44.)




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