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A New Organizational Image Helps Recruit Nurses. A New Culture Retains Them

Analysis  |  By Jennifer Thew RN  
   July 02, 2019

What's the key to successfully recruiting and retaining nurses? Here's how one nurse leader made meaningful changes to attract and retain top-notch RNs.

When Karen Mayer, PhD, MHA, RN, NEA-BC, FACHE, chief nursing officer and vice president of patient care services, began working at Rush Oak Park Hospital in Oak Park, Illinois, 13 years ago, nurse recruitment and retention was a struggle.

The nurse turnover rate was about 22%, and some departments had vacancy rates as high as 24%, she says.

According to the recruitment firm NSI Nursing Solutions, Inc., the average national turnover rate for bedside RNs was 16.8% in 2017.

With five other hospitals within five miles, there was stiff competition for nurses and patients. Nurse recruitment at Rush Oak Park Hospital was also hindered by a negative reputation because of its poor quality outcomes and a restrictive policy to hire only nurses with experience. In addition, a revolving door of chief nurse executives led to a lack of consistent leadership and vision.

"When you have bad outcomes, and leadership is beating you up and telling you how bad you are, as a staff nurse—even if you are a great nurse—you feel hopeless because nobody wants to work in an environment where they feel like they're providing bad care," Mayer says. "There were excellent, excellent nurses working here, yet the punitive environment resulted in a lack of respect [toward nurses] by physicians [and] administrators, and from nurse to nurse." 

Mayer, however, was up for the challenge of changing the work environment. She dug in and through hard work, was able to change nursing's reputation at the organization and in the community. Additionally, she was able to change the culture that lead to huge leaps in recruitment and retention. 

"No nurse wants to be a bad nurse," she says. "I had experienced a bad environment where I saw it get totally turned around, and so I felt that I could make a difference in changing the lives of these nurses."

Today, turnover rates are 8.3%, and the only vacant position she has is one in the operating room.

Mayer is the first to say the change didn't happen overnight. The turnaround took many years of hard work, and a combination of solutions and interventions. Still, it can be done when a CNO has a clear vision for nursing and is willing to take risks and build upon successes.

Revamp the hiring process

Mayer's first step to improvement was to focus strictly on recruitment. That meant improving nursing's reputation outside the organization and overturning Rush Oak Park Hospital's previous policy that said it wouldn't hire RNs without experience.

"They had gone for years of just not hiring anyone because no one with experience was applying," Mayer says. "So [we just focused] on recruitment. With the competition of five other [surrounding hospitals] and the poor reputation, we first had to figure out how we could even get people in the door."

Mayer says at that time there was a glut of nurses who could not find jobs after graduation since other organizations also had "you-must-have-experience" policies. Additionally, Rush University School of Nursing graduated its first cohort of clinical nurse leaders, and because Mayer was open to hiring entry-level, master's-prepared nurses, she hired about 25% of the first group of graduates.

After the policy change, she worked with human resources to ensure all nurse applicants were contacted for an interview within 24 hours of application. All applicants, even ones who would likely not make the cut, were scheduled for an interview, and Mayer interviewed each candidate.

"This was our one opportunity to sell ourselves. We wanted to get the message out that we were truly different from what was expected. We decided that the only way to do that was by having the CNO [me] meet with every single one of [the applicants] and identify what [Rush Oak Park Hospital's] vision for the future would be," she says.

"It accomplished sort of a ‘wow effect' because nowhere else did they get to actually meet the CNO. It also made them [think], ‘Whoa, I love that vision. I want to be part of that and I want to help get them there.' We wanted them all walking away saying, ‘I wish they would have offered a job to me. I would have loved to have worked there.' That's what we had for marketing—word of mouth," Mayer says.

The organization also moved to a behavioral interview process.

"We were seeking individuals who had what I call 'self-efficacy.' People who like a challenge, people who want to be part of fixing things," she says.

A Shift to Nurse Empowerment

Once the stream of applicants and new hires began to flow, it was time to focus on getting nurses to stay with the organization.

"During the first two years [of changing our recruitment strategy], we were still experiencing a lot of turnover … because so much more needed to be put into place so that once [the nurses] got in the door, they would want to stay," she says. "This meant addressing some of the cultural issues related to empowerment."

This included moving to a shared governance structure and coaching managers who weren't familiar with a collaborative leadership style. Additionally, it meant developing a clinical ladder to foster both career development and recognition, both of which are important to retention of
seasoned and newly licensed RNs.

"We were using tons of expensive agency [nurses], so that extra amount of money actually justified us developing a clinical ladder that had criteria tied to increases in salary," she says.

Adopted in 2008, the clinical ladder established three levels of nurses:

  • Level 1: Entry-level RN
  • Level 2: An RN who practices independently and can function as a charge nurse or preceptor to new RNs or students
  • Level 3: An RN who demonstrates high-level proficiency that is aligned with the organization's professional practice model

To achieve level 3 status, an RN must:

  • Have a BSN degree and professional certification if eligible
  • Submit a letter of recommendation
  • Provide an exemplar of his or her holistic nursing practice
  • Submit a portfolio highlighting his or her professional development and activities

The fact that promotion along the clinical ladder was based on achievement versus tenure did make some experienced nurses uncomfortable at first.

"There are definitely cultural value differences between millennials and boomers. I'm a boomer, and we're about experience," Mayer says. "But as some of the millennials would be reaching one-and-a-half years' experience, they were achieving some of the things that qualified them for level 3 [on the clinical ladder]."

Mayer addressed nurses' concerns by sharing with them that the decision was made based on research that found quality outcomes and mortality rates improved in organizations where the majority of nurses were BSN-prepared and held certifications.

When the clinical ladder structure was implemented, the BSN rate was about 12%, says Mayer. Today 84% of the organization's RNs have a BSN or higher, with 20% of those nurses holding a master's degree in nursing. When Mayer came to Rush Oak Park, only two nurses held specialty certification, whereas today 54% of all bedside nurses hold a certification.

Hard Work Yields Positive Outcomes

Because of Mayer's changes to nursing recruitment and retention, Rush Oak Park is now known for nursing quality.

For example, hospital-acquired pressure ulcer rates have dropped from 20% to none above stage 2 for the past two years, thanks to improved documentation and screening.

In 2016, Rush Oak Park received the American Nurses Credentialing Center's Magnet® designation, which only 482 hospitals nationwide currently hold.

Plus, the organization has received an "A" grade in patient safety from LeapFrog and a four-star rating from the Centers for Medicare & Medicaid Services. Its ICU was recently recognized with a gold-level Beacon Award for Excellence from the American Association of Critical-Care Nurses.

Still, Mayer says she has no plans to rest on these laurels.

"When it comes to recruiting and retention, it's an ongoing battle," she says. "Even when you get so good that you have almost no vacancies and you have a waiting list to get into your hospital."

Editor's note: This is a lightly edited excerpt from the HealthLeaders' article Want to Keep Nurses at the Bedside? Here's How. This article appears in the March/April 2019 edition of HealthLeaders magazine.

Jennifer Thew, RN, is the senior nursing editor at HealthLeaders.

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