Staying Power - Strategies for Nurse Retention By Linda Childers
Publication Name: Nurses Week
Published Date: 06/20/2005
The 43-year-old nurse was having a particularly grueling day at work. One of her young patients had died that morning from injuries sustained during a car accident. In the short time he had been in her care, she had grown fond of the 12-year-old boy who reminded her so much of her son. After the boy's death, she found herself feeling emotionally drained and fighting back tears.
Shawna Lobre, RN, BSN, CCRN, a pediatric intensive care nurse at the University of California, San Francisco (UCSF) Children's Hospital, noticed her colleague was overwhelmed with grief. She stopped her in the hallway for a quick hug, some words of encouragement, and a gift card for coffee. Knowing her co-worker had a passion for almond lattes, she invited her to join her for a coffee break, when they could talk about the day's tragic events.
As the official coordinator of her pediatric ICU's retention and recognition committee, Lobre is in charge of ensuring that her nursing peers receive the support, encouragement, and acknowledgement they deserve to be successful in their jobs.
"We're dedicated to making this the best possible working environment for our nursing staff," Lobre says. "During the last several weeks, we lost several young patients, and since most of us have children of our own, these losses really hit home."
Whether it takes the form of a heartfelt token of appreciation, a flexible work schedule, or continuing education classes, hospitals across the country are stepping up their efforts to retain valuable nursing staff. Indeed, sobering statistics released this year by the U.S. Department of Health and Human Services show the need for hospitals to make retention and recruitment a priority. The report indicated that the U.S. has a nurse shortage of nearly 150,000 RNs and that by the year 2020, this number is expected to rise to 800,000 nurses.
At UCSF, Lobre heads a committee that helps nurses through the tough times and makes the unit an environment where nurses enjoy coming to work.
Staff members contribute $30 each year to a "Sunshine Fund," with proceeds used for snacks, coffee, and birthday and anniversary gifts. A raffle is also held at each department staff meeting, with nurses taking home gift baskets of bath products or other goodies.
Because of the intensity of the unit, Lobre and other nurses work hard to keep morale high. Twice a year, nurses find respite at a local spa. Movie nights and waffle days also give staff the opportunity to get to know their co-workers and foster camaraderie.
"If a nurse is having a bad day or needs help at work, they feel much more comfortable approaching someone they know," Lobre says.
The committee also sponsors a "Star on the Spot" program that allows staff members to give instant recognition to a peer who has gone above and beyond the call of duty.
"We have little presents such as gift cards to [coffee shops or video stores] that employees can use to reward peers who have helped them," Lobre says. "Nurses often come to us from other units such as oncology and are amazed when we present them with a gift certificate and thank them for helping us out."
Making retention a priority
"The mantra of hospitals needs to be recruitment and retention," says Suzanne Gordon, author of Nursing Against the Odds (Cornell University Press, 2005). A leading health care journalist, Gordon's research has identified some key areas that hospitals administrators need to address to retain nurses.
"Hospitals need to confront the issue of difficult physician-nurse relationships," Gordon says. "There is conduct tolerated in hospitals that wouldn't be acceptable in any other workplace. Nursing is a stressful job without the criticism and verbal abuse that nurses sometimes receive from physicians." Gordon cites the airline industry, where pilots and flight attendants are mandated to undergo training that addresses how to maintain respectful and collegial working relationships. "Communication should made a mandatory part of the credentialing process," Gordon says.
She also believes that media images of nurses need to change, and she encourages nursing leaders to work with their hospital public relations staff to promote the critical role that nurses play in health care.
"It's important to get the word out to the media on nursing innovations, best practices, and the critical role that nurses play in the daily lives of patients," Gordon says.
Retaining new nurses
Many people think of retention programs as targeting only seasoned nurses, but hospitals are realizing that new graduates also need support and validation.
"Almost 50% of new nurses leave their jobs within their first year," says Susan Odegaard Turner, RN, PhD, CEO of Turner Healthcare Associates.
"Hospitals need to implement more residency programs that bridge the gap between college and the workforce. Programs that target new graduates need to be the new standard."
Five years ago, Childrens Hospital Los Angeles launched the RN Residency in Pediatrics Program in response to the growing national nursing shortage. The 22-week program provides new nursing school graduates with a comprehensive clinical experience to prepare them for careers in acute care environments. The curriculum was developed with the support of the California Community Colleges Chancellor's Office.
"The major benefit of the RN Residency program is the retention of new nurses," says Mary Dee Hacker, RN, MBA, vice president of patient care services and chief nursing officer at Childrens Hospital Los Angeles. "Prior to implementing this program, turnover for new graduates during the first year of employment was 36%."
Graduates of the RN Residency program have a turnover rate of only 11% for the first year of employment, and the 24-month turnover rate has been reduced from 56% to 22%. The significant reduction in turnover has a direct impact on the budget, reducing costs associated with replacing a single nurse (about $50,000), as well as the need for the use of overtime and registry nurses.
"This program gives new nurses the clinical skills and self-confidence they need to face the emotional challenges of working with children who are often very ill," Hacker says.
The RN Residency program has become a new national model that is being replicated at hospitals across the country.
What nurses want
"One of the top qualities nurses need to be happy is having a good nurse leader," says Quint Studer, president of the Studer Group and author of Hardwiring Excellence (Fire Starter Publishing, 2004). As a health care consultant who works with nurses across the country, Studer sees an increased need for training nurses who are promoted to leadership positions.
"Being a good nurse doesn't automatically make you a good leader," Studer says. "If you're going to promote a nurse to a leadership position, you need to give them the training they need to be successful in their new roles."
Studer is also a big proponent of nurse rounding.
"Once nurse leaders are trained, they need to have a regular presence in their units," Studer says. "Leaders should be approachable and recognize the accomplishments of their staff, both in person and through written thank-you notes."
In addition to recognizing stellar performers, nurse leaders should be cognizant of employees who don't hold their own.
"Low performers can suck the energy out of other staff members," Studer says. "If someone isn't doing their job, these issues need to be immediately addressed."
Nurse leaders need to do more than oversee staff; they also need to build relationships with their direct reports, Studer says.
"Ask your staff what systems need to be improved and what tools and equipment they need to do their jobs better," Studer says. "If they don't feel adequately prepared to do their jobs, they will leave, so make sure they have access to continuing education and professional development programs."
Variety of programs
At UC Davis Medical Center in Sacramento, Calif., nurse retention is a priority.
The medical center offers a variety of programs aimed at both recruiting and retaining nurses.
The "Bridges to Excellence" program offers nurses who are feeling burned out the chance to explore working in other units of the hospital rather than leaving the profession.
"It's based on the 'grass is greener on the other side' theory," says Nikki Smith, RN, a nurse recruiter at UC Davis. "Our nurses get paid to work a shift on another unit to see if it might be a better fit. We have some nurses who welcome the change and others who return to their own unit with renewed appreciation."
Managers at UC Davis have all taken classes on author Deena Ebbert's FISH! philosophy, a unique program that promotes having fun in the workplace.
"We want our nurses to look forward to coming to work rather than thinking of it as drudgery," Smith says. "This program allows nurses more latitude to have fun. One unit has Hawaiian Day each Friday, when they wear Hawaiian-print scrubs. Another has sponsored tea parties in their unit."
UC Davis nurses are also encouraged to spend "therapeutic time" each morning with their patients.
"Nurses are so busy multitasking," Smith says. "We ask them to try and spend at least five minutes daily 'just sitting' with each patient at the bedside to ask about and listen to their concerns."
Nurses use this as a time to check-in with patients and their families and to understand their hopes and expectations for the day.
"Both nurses and patients appreciate this model of care," Smith says. "We're a very family-centered hospital, and this fits in with our philosophy."
UC Davis also promotes a primary nursing model where each patient is assigned a nurse within 24 hours of being admitted to the unit. The medical center does not employ CNAs and has few LVNs on staff.
"It really allows us to build a rapport with patients and to ensure their continuity of care," says Jackie Rodman, RN, a nurse in the hospital's cardiothorasic unit. "Since we're a teaching hospital and have a lot of doctors who rotate in, this lets them know which nurse they should check in with to get updates on the patient."
Rodman says the primary nursing model and the hospital's Magnet culture allow nurses to make a lot more decisions than her counterparts at other hospitals, as well as enjoy more autonomy. "Every single day that I come to work, it's a new learning experience,' she says. "I work in a high-pressure unit, but I work with a great team, and I have a great nurse manager, so I truly look forward to coming to work."
An SOS "Save our Staff" program recognizes that nurses need regular lunch breaks, so extra nurses are sent in to work three-to-four-hour shifts to cover lunch breaks. If a unit is short on a particular day, the nurse can be asked if she'd like to put in additional hours.
"We don't use any registry or traveling nurses," says Elvie Balinsa, RN, BSN, CRNI, the hospital's nursing skills laboratory coordinator. "We staff these positions with nurses who have young children and want a flexible schedule. It's a win-win situation for all of our nurses."
The hospital also strives to make their nurses' jobs less frenetic by employing nursing students from local colleges who can help with tasks such as dressings and wound care.
"Nursing students are getting paid while obtaining on-the-job experience and offering an extra set of hands to our staff nurses," Balinsa says. "We also use medical assistants from local city colleges to help with jobs such as answering call lights and serving as runners. This gives our nurses more time to do the jobs they were trained to do while also keeping our patients happy."
A good work environment
Rather than luring nurses with hefty sign-on bonuses, hospitals should put the money toward retention programs and ensuring nurses a good working environment, says Susan Odegaard Turner.
"I've seen a lot of nurses save up money to buy a house by cashing in on sign-on bonuses with different employers," she says. "Sign-on bonuses do nothing to promote nurse loyalty and retention."
Turner cites a 2001 Care Force study showing that while 54% of Southern California hospitals paid out $62,000 in sign-on bonuses, the same hospitals showed no improvement in nurse retention.
"Put the money toward programs that better serve nurses, such as flexible staffing, tuition reimbursement, professional development, and training mentors," Turner says.
Jane Cradle, RN, MSM, manager of cardiovascular services at Mercy General Hospital in Sacramento, Calif., says her hospital strives to implement many of the ideas cited by Turner.
"Flexible schedules and self-scheduling are a priority," Cradle says. "We do everything within reason to make sure our nurses obtain the schedules they desire."
Communication is also key. The hospital has held four-hour sessions with physicians and nurses to address dissatisfaction and ways to maintain respectful relationships.
"After the group has met, we check in with them again first at a three-month then at six-month intervals to make sure that everyone feels the relationships are working," Cradle says.
All new nurses are assigned mentors and have evaluations after both 45 and 90 days.
"We want to check in with them on a regular basis to ensure they are getting the training they need and that they feel good about their jobs," she says.
Nurse leaders also make a practice of rounding at the hospital, and staff recognition events are held on a regular basis.
"Our retention efforts are a work in progress," Cradle says. "We are constantly looking for new ways to make our hospital a place where nurses truly enjoy coming to work."
Article in Nurse WeekIdentified Quote:
Nurses at UC Davis Medical Center, Sacramento: Back row: Brandi Cope, RN; Jeniffer Baker, RN; Heather Ciampa, RN; Stephanie Pauley, nursing student; Jackie Rodman, RN; Stephanie Baroni, RN; Tess Lopez, RN; and Eunice Carlson, RN. Front row: Jennifer Aragon, RN; Liwen Mellinger, RN; Teresa Raines, RN; Sara Solomon, RN; and Eloise Navarrete, RN. Photo by Young Kim.
