Hospitals see empowerment and flexibility as central to nurse retention strategies

As news of a global nursing shortage began to spread, many hospitals set to work, pouring money into global recruitment efforts, hoping to fill their vacancies. Increasingly, however, hospitals are beginning to take the long view and focusing instead on developing and retaining their current nursing staff. In doing so, they are embarking on a complex journey that demands innovation and introspection, as well as a detailed understanding of what motivates nurses to stay.

Several trends have converged to peak interest in retention strategies. The continued growth in the demand for nurses has been exacerbated by the number of nurses retiring or leaving the profession, while fewer nurses enter. At the same time, the aging population has led to a growing number of patients as well as a rise in acuity. These combined forces could lead to an estimated shortage of more than 800,000 nurses by 2020 in the U.S. alone. One recent estimate is that sub-Saharan African countries have a shortfall of 600,000 nurses today.

Simultaneous with demographic shifts, nurses in the U.S. and abroad report stress, burnout, and dissatisfaction with their jobs. Research identifies scheduling, unrealistic workloads, mandatory overtime, low pay, health care opportunities outside of acute care nursing, and hospital administrators’ lack of responsiveness to nurses’ concerns as the chief reasons for nurses to leave their jobs.

Elizabeth Brown: “It is important to be able to give administrators the data that shows why people are leaving, what the impact is, and how we can turn things around.”

Studies also show that “lowering turnover and maintaining the right numbers and skill mix of nurses have a measurable impact on various dimensions,” says Elizabeth Brown, RN, MSN, MBA, Director of Clinical Services at HMI. A stable nurse workforce positively affects safety and patient outcomes, teamwork, and nurse, patient, and physician satisfaction, she explains—all of which add up to better patient care (see sidebar “Staffing and Patient Outcomes”).

While fewer studies have been devoted to longevity than to staffing, anecdotal evidence suggests that maintaining a consistent and stable workforce is equally important. “You may have good people coming and going, but that doesn’t build the competency you develop with an educated and experienced workforce,” explains Joyce C. Clifford, PhD, RN, FAAN, who presides over the Institute for Nursing Healthcare Leadership (INHL). Such competency improves patient care and safety because over time, the workforce learns how to navigate and be creative within the system—making them not only superior clinicians and supervisors but potentially invaluable contributors to system improvement projects and quality initiatives. Further, nurses who have been in an organization for many years develop good working relationships with their colleagues in other disciplines and master the nuances of how to collaborate under their specific circumstances.

Then there’s the economic argument. When you consider the cost of recruiting, interviewing, and orienting a new nurse, and the cost if hiring temporary nurses to fill coverage gaps, turnover can cost between 50 and 200 percent of a nurse’s salary, according to industry estimates. Arguably, that money could be better invested in staff development.

So, how does an organization go about developing this experienced and loyal nurse workforce? HMI World spoke with Brown, Clifford, and nurse leaders and administrators at hospitals with a reputation for nursing excellence about what keeps nurses not just satisfied, but committed.

A Seat at the Table
It’s a misty Wednesday morning in mid-June. More than 15 nurses from throughout the Dana-Farber Cancer Institute (DFCI) sit around a horseshoe arrangement of tables. Members of the DFCI’s Nursing Council, the group comprises directors, program leaders, educators, representatives from pediatric and adult oncology, as well as nurses from the center’s inpatient and outpatient units. As the nurses get down to business—discussing everything from a set of proposed survey questions on administering oral chemotherapy to scheduling a half-day planning retreat to standardizing practices on prescriptions and refills—it becomes clear that this is not your average weekly status meeting. These nurses, from every corner of the institution, represent the foundation of an ambitious shared governance structure implemented by DFCI four years ago to achieve improved clinical outcomes and obtain the coveted Magnet hospital status awarded by the American Nurses Credentialing Center to hospitals that provide nursing excellence.

Shared governance is an organizational model that gives staff nurses control over their practice and can extend their influence not only to decisions about patient care but to administrative areas previously controlled by senior-level clinical and executive managers. For over 20 years, the nursing literature has promoted the idea that this shared (also called collaborative) governance leads to greater job satisfaction. The current nursing shortage has brought the model renewed attention.

At Dana-Farber, shared governance is viewed as a communication and decision-making model, explains Anne Gross, RN, MS, Vice president for Adult Ambulatory Services and Director of Adult Ambulatory Nursing at DFCI. The Nursing Council is at the axis of this model, providing a working forum for nurse leaders, educators, and staff to identify priorities and develop recommendations for practice and operational policy changes within nursing. It also integrates the work of all nursing committees (the spokes), monitors ongoing projects, and communicates activities to the frontline staff.

The evolution to this new model has been challenging, Gross acknowledges, mainly because of scheduling difficulties and the fact that shared decision-making can be time consuming. She adds that the communication piece can be particularly demanding, and the nurses are constantly looking for more effective ways to keep everyone informed, involved, and up to date.

Despite these challenges, Gross reports that the impact has been significant and well worth the effort. Not only did DFCI receive Magnet recognition, but, says Gross, “We make much better decisions now that staff, scientists, clinical specialists, and leadership make them together.”

Joanne Ayoub (center) works with HMI partner Acibadem Healthcare Group on organizational development, particularly in the area of nursing.

Similar councils at Massachusetts General Hospital (MGH) and Beth Israel Deaconess Medical Center (BIDMC) are having a similarly positive effect. Joanne Ayoub, Director of Organizational Development at BIDMC, says, “We know now from industry-wide research that people ultimately leave their organization not because of their manager or specialty, but because they feel they are part of an organization that doesn’t embrace their values.” So it stands to reason that people are more likely to stay at an organization that does.

Whether or not a hospital undertakes shared governance or some other model of empowerment, successful retention depends on giving nurses decision-making authority that extends to every domain of their practice. In addition, say nurses and administrators, it is important to develop trained and committed nurse leaders who can serve as role models and mentors for those more recently hired.

Control over Practice
Control over practice is a persistent issue in nursing. Nearly 20 years ago, a sample of 3,500 nurses said that being allowed to exercise nursing judgment for patient care was a top factor in their practice, according to a study published in the American Journal of Nursing in 1998. Today, the degree of control over their practice remains an important research area in hospitals like MGH and DFCI.

At BIDMC, where nurse turnover hovers at just eight percent, nurses consistently report in surveys that they want to be part of an environment that makes quality and safety a top priority, says Ayoub. To that end, BIDMC gives them the tools they need to support those efforts.

One tool, a program called Team Training, gives nurses and physicians a defined way of communicating with one another. Developed for the military and adopted for use in health care settings, Team Training, explains Ayoub, uses a series of checkbacks and cross monitoring to help catch errors. The team structure helps physicians and nurses work together more collaboratively by reducing the reluctance to ask for help.

Another program, called Triggers: Rapid Response, gives nurses unquestioned authority at the bedside. The collaborative program, developed in BIDMC’s departments of medicine, surgery, and patient care services, formalizes the process by which rapid response teams of senior clinicians assess patients who display an acute change in condition. “If a nurse sees any of those triggers, he or she can call for a response team and a physician must respond and be present—without question,” says Ayoub. “In other organizations, the nurse might be asked for additional data or told to try another strategy first.”

Ayoub notes that these programs can be implemented because for over 30 years BIDMC has had a culture that values nurses’ influence in decision-making and has programs aimed at developing physician-nurse relationships. Organizations without such a history may have to build that infrastructure first. In those instances, says Ayoub, “the leadership needs to create a shift in how the organization and physicians look at nurses and the role of nursing.”

Scheduling and Compensation
Employers that are invested in nurse retention recognize that the realities of achieving work-life balance change during the course of a nurse’s lifecycle. Young female nurses may decide that a full-time nursing schedule isn’t conducive to raising a family, while Baby Boomer nurses (which make up an increasing percentage in the U.S.) may need to scale back their hours in order to care for an elderly loved one. On the other end, nurses past retirement age may want to continue working, if given the opportunity to do so at a reduced capacity.

At MGH, a Magnet-recognized facility where nurse turnover rate is just 4 percent, nurses decide how many hours and which shifts they want to work. Although this flexible scheduling practice increases the number of nurses the organization must hire, train, and orient, Human Resources Director Steven Taranto says that’s a small price to pay for having few vacancies and a loyal staff. “I’d rather hire two nurses to fill a single job than have an environment that does not allow for two,” he says.

Similarly, no two nurses’ schedules are exactly the same at BIDMC, which recently instituted an online scheduling system called ishift that lets nurses see what shifts are available at all times and sign up for as many or as few as they choose.

This creativity and autonomy extends beyond scheduling to compensation. At MGH, for example, the Staff Nurse Advisory Committee (the equivalent of DFCI’s Nursing Council) decided that they wanted more aggressive differential rates. In other words, says Taranto, they proposed a higher pay structure for nurses who work nights and weekends, rather than implementing usual across-the-board market-driven salary increases. The hospital administration listened to the nurses and tried the new approach. The result? “It was a double satisfier,” reports Taranto. Now, people who choose to work off shift are more generously financially compensated for it, and people who don’t are no longer required to. In fact, not only are all the shifts covered, but there is a waiting list among nurses who want to work “special weekends,” which involves working two weekends out of four, Taranto says.

MGH also allows nurses to increase their salaries by voluntarily enrolling in a Clinical Recognition Program. The interdisciplinary program allows nurses and other health care professionals to achieve up to four levels of clinical practice and earn up to two five percent salary increases—while continuing to provide direct patient care rather than moving away from the bedside. Taranto says this program helps with employee satisfaction because “people enjoy knowing they have greater control over their destiny. They can work with their manager and matriculate through the program’s levels at their own discretion.”

Professional Development Opportunities
Another important way these hospitals keep nurses interested and committed is by supporting their desire for professional development. In regions of the world where nursing advocacy is not as strong, financial constraints and long work hours often leave nurses with few or no options for professional development. Hospitals that invest in professional development have a leg up on those that don’t with regard to keeping nurses committed and growing in their profession.

At BIDMC, nurses are able to choose a specialty area after their first year at the hospital. Because some areas, such as critical care, require extensive training and coaching to get new nurses up to speed, senior nurses in the department design and run a program to give them this additional education.

To help nurses maintain and develop their expertise without leaving the campus, MGH just opened a new center for clinical and professional development. The Norman Knight Nursing Center offers programs that integrate innovations in clinical practice, research, continuing education, and training into patient care delivery.

The payoff for these kinds of initiatives can be enormous, says INHL’s Clifford. “Nurses want to continue to improve their practice and the care that is given to patients. So when organizations invest in that, they are more likely to have higher satisfaction and therefore higher retention rates.” She adds that this satisfaction is felt by patients, who ultimately are cared for by nurses who are happier, more pleasant, and more competent.

Nurse Leadership
Many hospitals in the U.S. and globally are focusing on nurse leadership development as a way to build retention, says Brown. “They are recognizing that the role of nurse leader is crucial to staff development, patient safety, and fiduciary responsibility. And that by putting more emphasis on how people are identified for that role, and how they are mentored and developed, everyone wins.” Nurse leaders control the flow of information vertically and horizontally and are the cornerstone of a successful transition to a shared governance model.

Nurse leaders understand the big picture, says Clifford. And they can help people in and out of their discipline to see it too. “They play a large role in helping novice and expert nurses to navigate and understand priorities and politics. And they make sure people have the ability and resources to provide quality care in a collaborative interdisciplinary fashion.” Not surprisingly, she adds, turnover in nurse leadership often leads to turnover among the supporting staff.

With regard to all of these efforts—whether it is shared governance, practice development, or nurse leadership—“a lot of what we are talking about is basic good management and good leadership,” concludes Clifford. In other words, the CEO and CNO need to be closely involved. “You can’t just do this for nurses. It has to be about the culture of the organization.” And that, she says “starts at the top.”

Still, may be possible for a chief nursing officer and human resources manager get executive attention with a well-defined strategic plan around retention, says Brown. “Such a plan should lay out the vision and compare it with the current state of affairs, identifying not only what the nurses in the hospital identify as areas for improvement, but also what the research is telling us about hospitals with high retention rates. It is important to be able to give administrators the data that shows why people are leaving, what the impact is, and how we can turn things around.”

--Written by Natalie Engler for Harvard Medical International

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