5 Ways to Make Nurses Want to Stay at your Hospital
What makes a nurse want to leave your hospital? Rebecca Hendren outlined five top offenders in the article “5 Reasons Nurses Want to Leave Your Hospital”1 (HealthLeaders Media, August 9, 2011). Without a doubt these broad categories (mandatory overtime, floating nurses to other units, non-nursing tasks, bullying/toxic behavior, and bad managers) are problematic for nurses. It can be argued that nurse recruiting and retention are somewhat less problematic2 now versus several years ago, when financial incentives for nurse hiring and/or retention were frequently found to be budget busters. All the same, poor nurse retention will always have a negative impact on the facility experiencing it and speaks to underlying challenges that must be addressed. Ms. Hendren’s article focuses on outlining the challenges that lead to dissatisfaction for nurses. iVantage’s Nursing Knowledge Communities have discussed these topics in depth. Consider these ideas as you redefine your hospital as an environment where nurses want to STAY.
This material is drawn from more than 500 responses to over 24 surveys, conference calls, and other networking events by members of our Nursing Knowledge Communities. Knowledge Communities are groups of nurses (organized by specialty) and nursing administrators from hospitals throughout the United States who connect with iVantage to peer network through common challenges. Note: You will need your e-mail address and iVantage password to follow most of the links. Clicking an iVantage networking project link brings you to a a log-in page where you can log in, reset your forgotten password, or register as a new user. Don’t hesitate to call us at 262-242-9471 if you need help accessing this information.
Mandatory overtime – Getting Around It
Some nurses are happy to work extra shifts in order to receive overtime dollars, but very few nurses are happy about mandatory overtime. According to recent survey results,3 most members of our Nursing Knowledge Communities are NOT mandating overtime at their facilities. In general, they note that voluntary availability and on call policies have been working. Several facilities also mention good support from the PRN staff and/or the float pool. What else?
One hospital has become aware that the same RNs tend to fill voluntary shifts. To help ensure they have adequate staffing and to avoid burnout, they are educating tele RNs to float to the ICU for certain patient populations.
Another facility notes that nurses would like all “availability” shifts to be on-call paid time. It isn’t economically feasible to always offer on-call paid time. This is their policy: “availability” is paid straight time until >40 hours that week. On-call is $5 per hour and time and a half when an RN is called in. This hospital will offer on-call paid time if census is >15 in a 17 bed NICU.
A few nurse managers have observed that their younger, newer RNs typically prefer to work 12 hour shifts. Older, more established nurses may be happier with 8 hour shifts. If this is the case at your hospital, can you flex your staffing plan with this in mind?
One nursing manager acknowledges that while nurses may be happy with the measures taken to avoid mandatory staffing, these will always be temporary measures until root staffing issues are addressed.
Here’s another related survey: Decreasing Overtime Requirements for RN Staff.4 The majority of the respondents note that overtime is an issue at their facilities. They discuss staffing measures to meet sick calls, vacation coverage, and short staffing.
More about nurse staffing
Theresa Hollinger from OSF St. Anthony Medical Center in Rockford, IL, discusses what is involved in creating a nurse staffing model. Follow the link and click the “Extras” tab to see Theresa’s Arranging All of the Work: Using Evidence Based Practice to Assign Care Load5 presentation.
How do you accommodate the churn of a busy nursing day ” typically admissions, discharges, and transfers? No one we have connected with is using a purely activity-based staffing model, but this is something people are starting to think about. Check out the pre-call survey results and call notes, both at this link: Activity-Based Nurse Staffing Models.6
Does your Charge Nurse carry a patient load? The Nurse Staffing & Charge Nurse Responsibilities7 survey found that about half of the responding facilities have a Charge Nurse in the nursery, and of those, about 60% reported that their Nursery Charge Nurse does provide patient care. Click the link for details on the Charge Nurse’s responsibilities.
Nurse/CNA Teams Increase Staff & Patient Satisfaction.8 Learn how Exempla St. Joseph Hospital in Denver, CO, TM made significant increases in both staff and patient satisfaction through the use of Nurse/CNA teams.
OSF St. Anthony Medical Center successfully switched their OB unit to a Mother/Baby Couplet Care Unit. Nurses and patients are both happier. Click here: Improve Staff & Patient Satisfaction by Switching to Mother/Baby Couplet Care9 to see all the advantages the new model offers.
To float or not to float?
When we last asked, most agreed that at their hospital nurses float off their units. Many will float only within the same service line (i.e. Mother/Child Services, Med/Surg units, etc.). L&D units were listed most frequently as being closed. No one was using a house-wide closed-unit model. Feelings about nurse floating were mixed ” many acknowledged that not floating would be a nurse satisfier and potentially a patient satisfier. At the same time, it was noted that closed units create less flexibility in staffing and ultimately make it harder to cover sick time, vacation time, and other absences. See additional comments in the To Float or Not to Float survey.10
Floating can cause anxiety among nurses who float to areas where they don’t feel they have expertise. Judicious use of floating and well-managed float pools help to keep nurses on “home” units where they often feel they can practice most effectively. While the general idea of floating is a familiar one, nurse “floats” may mean something different at different hospitals. Click here11 to see how peers define, structure, and use their float pools.
Our Nursing Knowledge Communities agree that there are some characteristics of successful float pools.12 Whether a hospital has a registry of 15 or 55 RNs, all agree that flexibility is key. Some float pools are for RNs only, while others include support staff positions. The majority of float pools put nurses on their specialty unit. Nurses, may, however, be moved to the area of greatest need. The use of float pools has positive outcomes with regards to decreased (or no) use of outside agencies, self-scheduling, reduced stress for regular (non-float) staff, and increased flexibility with staffing.
More about floating
Once your float pool is in place, how do you support them? Just under half the responding hospitals in the Float Pool Education & Support13 survey use unit staff to educate the float pool. The majority of units do allow float staff to take the same assignment and acuity as regular floor staff. Critical care may be an exception, where float staff may take a lighter assignment.
How do you schedule your float pool? Survey results14 show that the majority of float pool staff self-schedule. Criteria for self-scheduling greatly varies by facility, from seniority selects first to first come, first select. Peers agree that self-scheduling is a staff satisfier. Caveats to self-scheduling: those who have transitioned from a master schedule or assigned schedule believe that it’s difficult to keep the schedules even. There may be too many staff one day; not enough the rest.
How do you best utilize your float pool?15 Peers agree that limited availability of float staff is their biggest complaint. Many state there are just not enough float staff to fill vacancies. How can you run your float pool to its best advantage? The nurses we asked said to have available workforce to help cover census fluctuations. While this may seem obvious, treat all employees fairly, whether they are floor or float staff. Meet the needs of staff who want to work part-time and enjoy moving to/and from departments.
Non-nursing tasks and nursing interruptions
What do nurses think is the most common interruption to their work? Those that we asked told us that phones most frequently take them away from or interrupt patient care. While there is no easy answer to keep nurses from being interrupted in their work, peers weighed in on this issue. Many liked the idea of a no-interruption zone, though few were using them. Sentara Leigh Hospital in Norfolk, VA started “Quality Time”, uninterrupted time with the patient to review the plan of care. An Administrative Assistant is instrumental in collecting phones during this time and taking messages, allowing for much needed quality time between patients and staff. Nurses offered further ideas for mitigating nursing interruptions, click here16 to view.
Nearly 90% of our survey respondents believe that nurses become distracted at some point while distributing medications. While some believe that distractions are the worst while at the patient’s bedside, others believe that being at the bedside limits distractions. The potential serious implications of distractions while distributing medications need not be listed here; they are obvious. What are hospitals doing to support their nurses while they distribute medications? Measures include use of a “quiet zone” in medication areas, placing signage by the doctors’ charting area requesting that they not distract nurses, creation of a “red zone” around Pyxis stations, and putting the medication room in a remote location. Click here17 for more on how peers limit distractions for nurses while distributing medications.
Over 50 nurses used the Nursing Obstacles & Inefficiencies18 survey to tell us about the things that drive them crazy and take them away from the patient bedside. The category that won by a landslide? Charts, documentation, and online documentation. Clearly charting IS a nursing task, but problems associated with charting cause frustration and cut into time spent caring for patients. These problems include missing or incomplete charts, charting excess information or duplicating information, and difficulty finding necessary information. Nurses frequently call out documentation as being excessive; online documentation is the primary inefficiency in the nursing workload as outlined by the nurses we queried. Hybrid (half paper/half electronic systems) are noted as a particular source of frustration. Computer systems that don’t interact with one another create issues; glitchy systems crash and need IT intervention; all this takes time away from direct patient care. Want to know else what nurses identified as other dissatisfiers? Do check out the survey results (link above). We asked not only about nursing dissatisfiers but also asked nurses how they maximize patient care time.
Is the real key to managing nursing interruptions a change in mindset? In response to a related survey, Robin West, Nurse Manager at Sentara Leigh Hospital noted that they have several policies in place designed to decrease interruptions. At the same time, she offers this analogy: “It’s comparable to sleep ” when it’s peaceful and you get 8 hours it’s all good and most things work OK. When sleep is interrupted constantly or is shorter than needed, the end result can be disastrous and cumulatively over time devastating ” the difference between a sentinel event and a minor safety event in our world. Nurse interruptions can have these same consequences, we just have yet to assign them the same level of importance.”19
More about reducing nursing interruptions
See how Fairbanks Memorial Hospital in Fairbanks, AK, implemented20 their red zone.
North Colorado Medical Center in Greeley, CO, TM improved customer satisfaction scores, noticed a reduction in patient falls, and reduced nursing interruptions through a decrease in call lights. They accomplished all of this by developing and implementing an hourly rounds checklist. Click here21 for details.
Does your facility do patient safety rounds as a means of decreasing call lights (among other benefits)? Here’s how Banner Lassen Medical Center in Susanville, CA streamlined22 the process.
Bullying and toxic behavior
At some point everyone will encounter a coworker who makes the workplace a less than ideal work setting. Here are some strategies to reduce their impact:
- Talk with them in a one-on-one setting; they may feel more comfortable speaking in private.
- Allow them to express how they feel and why, without feeling judged by coworkers. Know that if a negative issue is raised in a group setting it can get out of hand.
- Managers with an “open door” policy will help to alleviate some negativity.
- Have you considered documentation for this issue? At LDS Hospital in Salt Lake City, UT, staff sign an accountability document at their yearly evaluation saying they agree to terms of engagement with each other. If people start acting out, a manager may pull them aside to discuss the commitment they have signed and agreed to.
These ideas stem from a related conference call. Here23 are the call notes.
Does your unit do RN peer review? This is one way to get nurses more connected and working well as a team. This process works well on a busy surgical/orthopedic unit at Inova Fair Oaks Hospital in Fairfax, VA. North Colorado Medical Center does peer review too, although it is for all staff, not just RNs. You might wonder if people will give honest feedback ” see these call notes24 to find out how it works at North Colorado Medical Center!
More about bullying and toxic behavior
The article25 “Annoying & Ineffective Nursing Co-workers: Do You Have One in Your Unit?” by Jennifer Ward for NurseTogether (www.nursetogether.com) also addresses this topic. Ms. Ward splits out the types of annoying co-workers and asked nurses what they do to maintain a positive and peaceful work environment. It seems this article struck a chord; there are many and varied comments making for an interesting read.
The World Health Professions Alliance (WHPA) published an article outlining elements of positive practice environments for health care professionals. Find it here.26
“Nurses eat their young.” The first time I heard this, as an intern in a children’s hospital, I was surprised. A nurse manager told me this in a very matter of fact manner, and it didn’t fit my image of the compassionate nurse. Since that time, I have heard this frequently, typically in the contexts of improving retention and mentoring/educating new nurses. With this in mind, I read What Makes a Good Nurse Manager.27 In this article, by Kathy Quan for NurseTogether, Ms. Quan compares “the job of being a nurse manager to that of being mom to several children with distinctively different personalities”. She goes on to relate characteristics of nurse managers both good and bad.
A bad manager can be a challenge, certainly, but it’s heartening to know that there are also good managers out there. Lots of them, according to our Nursing Knowledge Communties! We asked about the characteristics of good nurse managers.28 TM Some people believe that the same qualities inherent to being a good nurse create a good nurse manager. Others believe that the skill set required to be a good nurse are not the same as the skill set needed by good nurse managers. The general consensus to date favors nurse managers needing an additional skill set, that of leading people. Comments note that the best nurse managers are good leaders, capable of relating to, leading, and managing staff. The good nurse manager needs to be visionary and able to see “the big picture”. We asked to hear about nurses’ most memorable experiences with their managers, and managers’ experience with their staff. If you guessed that most had good experiences and nice things to say, you were right. The comments were overwhelmingly positive. Most nurses identified a manager who served as a mentor to them, noting that this encouragement was integral to their professional development.
More about nurse managers
Most Clinical Nurse Managers agree that they have 24/7 accountability in their hospital. They have a Mon-Fri work week (which may include night shifts & occasional weekends). They are assigned 40 hours but typically work more than that. They will occassionally spend “off-time” in the hospital. See how they balance a busy work schedule against a full life in the Clinical Nurse Managers – Scheduling & Attaining Work/Life Balance29 survey.
In the nursing world, there are no quick and easy solutions to eliminate common challenges such as mandatory overtime, floating nurses to other units, non-nursing tasks, bullying/toxic behavior, and bad managers. Still, as the surveys, call notes and articles above show, there are steps you can take to improve these situations. These may be facile, such as outlining a red zone with red tape to reduce distractions while nurses distribute medications. They may encourage interaction, as in creating a nurse peer review process. They may challenge the way we think: are nursing interruptions ever OK? As you strive to create an environment where nurses want to stay, remember iVantage’s Nursing Knowledge Communities and the iVantage KnowledgeWeb. Most of the material cited in this paper (complete list below) comes from our KnowledgeWeb, and we are adding new content ” driven by you ” every day. Review our Nursing Knowledge Communities or submit a networking question for peers anytime at www.ivantagehealth.com. You may also call us at 262-242-9471.
- 5 Reasons Nurses Want to Leave Your Hospital. Rebecca Hendren, for HealthLeaders Media, August 9, 2011. http://www.healthleadersmedia.com/page-1/NRS-269561/5-Reasons-Nurses-Want-to-Leave-Your-Hospital
- Nurse Recruiting and Retention ” Still An Issue? iVantage Networking Survey. http://hmc.ivantagehealth.com/client/library/surveys/survey_index.a4d?id=3198;st=1
- How Many Hours Are Too Many for Nurses To Work (2011)? iVantage Networking Survey. http://hmc.ivantagehealth.com/client/library/surveys/survey_index.a4d?id=3448;clear=true;st=2
- Decreasing Overtime Requirements of RN Staff. iVantage Networking Survey. http://hmc.ivantagehealth.com/client/library/surveys/survey_index.a4d?id=3381;st=1
- Arranging All of the Work: Using Evidence Based Practice to Assign Care Load. iVantage Conference Call, Theresa Hollinger, Patient Logistics Manager at OSF St. Anthony Medical Center, Guest Presenter. http://hmc.ivantagehealth.com/client/library/iConferences/iCONF_results.a4d?id=928
- Activity-Based Nurse Staffing Models. iVantage Conference Call.
- Nursery Staffing and Charge Nurse Responsibilities. iVantage Networking Survey.
- Nurse/CNA Teams Increase Patient & Staff Satisfaction. iVantage Successes & Good Ideas, submitted by Exempla St. Joseph Hospital.. http://hmc.ivantagehealth.com/client/library/sgis/sgi.a4d?id=409
- Improve Patient Satisfaction & Staffing By Switching to Mother/Baby Couplet Care. iVantage Successes & Good Ideas, submitted by OSF St. Anthony Medical Center. http://hmc.ivantagehealth.com/client/library/sgis/sgi.a4d?id=407
- To Float or Not to Float? iVantage Networking Survey. http://hmc.ivantagehealth.com/client/library/surveys/survey_index.a4d?id=2495;st=1
- iVantage Nursing Administration Profile. http://hmc.ivantagehealth.com/client/library/surveys/survey_result.a4d?id=128;st=3;qid=1355;s=floating%20nurses
- Float Pool Usage ” Roundtable Discussion. iVantage Conference Call. http://hmc.ivantagehealth.com/client/library/iConferences/iCONF_results.a4d?id=601
- Float Pool Education & Support. iVantage Networking Survey.
- Scheduling of Float Pools. iVantage Networking Survey. http://hmc.ivantagehealth.com/client/library/surveys/survey_index.a4d?id=2908;st=1
- Float Pool Utilization. iVantage Networking Survey. http://hmc.ivantagehealth.com/client/library/surveys/survey_index.a4d?id=2881;st=1
- Managing Nursing Interruptions. iVantage Networking Survey. http://hmc.ivantagehealth.com/client/library/surveys/survey_index.a4d?id=3339;st=1
- Distractions While Distributing Medications. iVantage Networking Survey.
- Nursing Obstacles & Inefficiencies. iVantage Networking Survey.
- Comment by Robin West, Nurse Manager at Sentara Leigh Hospital in response to the survey “Managing Nursing Interruptions“. Posted to iVantage’s General Nursing Knowledge Community Wall. http://hmc.ivantagehealth.com/client/?kc=333
- Red Zone Reduces Medication Errors Due to Distractions. iVantage Successes & Good Ideas, submitted by Fairbanks Memorial Hospital. http://hmc.ivantagehealth.com/client/library/sgis/sgi.a4d?id=417
- Checklist for Hourly Rounds Improves Satisfaction & Safety. iVantage Successes & Good Ideas, submitted by North Colorado Medical Center. http://hmc.ivantagehealth.com/client/library/sgis/sgi.a4d?id=435
- Winning White Boards ” Less Writing, More Checking! iVantage Successes & Good Ideas, submitted by Banner Lassen Medical Center. http://hmc.ivantagehealth.com/client/library/sgis/sgi.a4d?id=445
- Nurse Job Satisfaction ” Toxic Coworkers, Floating, and Other Morale Busters. iVantage Conference Call. http://hmc.ivantagehealth.com/client/library/iConferences/iCONF_results.a4d?id=974
- RN Peer Review To Increase Nursing Satisfaction & Teamwork. iVantage Conference Call. http://hmc.ivantagehealth.com/client/library/iConferences/iCONF_results.a4d?id=560
- Annoying and Ineffective Nursing Co-workers: Do You Have One in Your Unit? Jennifer Ward, for NurseTogether. http://www.nursetogether.com/Career/Career-Article/itemid/2471.aspx
- Positive practice environments for health care professionals. Published by the World Health Professions Alliance (WHPA). http://www.ppecampaign.org/content/key-characteristics
- What Makes a Good Nurse Manager. Kathy Quan, for NurseTogether. http://www.nursetogether.com/Career/Career-Article/itemid/1469/What-Makes-a-Good-Nurse-Manager.aspx
- What Makes a Great Nurse Manager? iVantage Networking Survey. http://hmc.ivantagehealth.com/client/library/surveys/survey_index.a4d?id=3452;clear=true;st=2
- Clinical Nurse Managers ” Scheduling & Attaining Work/Life Balance. iVantage Networking Survey. http://hmc.ivantagehealth.com/client/library/surveys/survey_index.a4d?id=2086;st=1