The study analyzed responses of nearly 250,000 RNs to identify trends in intent to stay based on age, tenure, and unit type, as well as drivers of intent to stay.
Here are some of the findings:
"Dissatisfaction with the work environment was the most commonly cited reason for leaving," Dempsey says. Nurses across all age groups and experience levels cited this as a reason they planned to leave their job within the next year.
Newly licensed nurses and those who have been in practice for two to four years are at highest risk for attrition. In the next year, 24.5% of NLRNs and just over 27% of those with two to four years' experience reported they planned to change jobs in the next year.
"The predictors of intent to stay for nurses who had been practicing less than two years were things like praise, recognition, nurse manager support, certification, and joy in work," says Dempsey. "Those were not so much the predictors for those who've been practicing for more than 20 years. For them it was about leadership, influence over their schedule, and quality of care."
Nurses in adult step down and med/surg units were more likely to say they were going to leave within one to three years. "These are difficult and demanding units, with sick patients and less staffing than a critical care unit," Dempsey notes. "We need to make sure there is strong managerial support for those units, efficient processes, and that we keep those nurses at the bedside."
Interestingly, while nurses under 30 years old were more likely to say they were going to leave their unit, they still planned to stay within their organizations. "Quite frankly, we're seeing organizations that are more focused on keeping nurses in the organization rather than in the department. I think that is an opportunity to help nurses in professional development while still keeping them in the organization."
Dempsey's advice for other healthcare leaders:
"We interviewed high performers, and in that analysis, we found top-performing nurse managers focused on quality of care, staffing, the professional practice environment, and interpersonal and interprofessional relationships. In other words, top-performing managers spend a large proportion of their time creating foundations for quality of care. That meant that they were visible through rounding. They trained nurses to lead clinical rounds. They developed shared governance structures led by direct care nurses. They use data to support decisions and drive practice. They involve direct care nurses in decisions involving the unit and staffing, and they promoted autonomy. And those are some of the ways that high-performing nurse managers create a positive work environment."
How does an organization recruit and retain registered nurses with the right skills and work experience to deliver high-quality patient care? It's certainly not simple. There's more to building a strong nursing workforce than just filling open positions, and even in organizations with top-notch nurse recruitment programs, research has found there's no guarantee that nurses will stay put.
The 10-year RN Work Projectstudy found 17% of newly licensed RNs leave their first nursing job within the first year, 33% leave within two years, and 60% leave within eight years.
And, according to the recruitment firm NSI Nursing Solutions, Inc., the average national turnover rate for bedside RNs was 16.8% in 2017.
Additionally, Press Ganey's recent analysis of 250,000 RNs who participated in the 2017 National Database of Nursing Quality Indicators RN Surveyfound close to 21% of nurses planned to leave their current jobs within one year, including those retiring. When asked about their job plans over the next three years, 26% said they will pursue other options ranging from new positions in an organization to retirement.
"Recruiting and retaining [nurses] is not an easy task," says Press Ganey's Chief Nursing Officer Christy Dempsey, RN, MSN, CNOR, CENP, FAAN. "It requires that we understand the drivers of job satisfaction across the nursing lifecycle because we're not all motivated by the same thing." (See the sidebar "Why Nurses Stay in Jobs and Why They Go" for more on these key drivers.)
Not to mention that nursing turnover costs healthcare organizations big bucks.
"The average cost of turnover for a bedside nurse is anywhere from $38,000 to $61,000. When you think about that from a per hospital cost, that's between $4.4 million and $7 million a year," says Dempsey. "It boils down to the fact that nurses are arguably the biggest line item in the operating budget, and they spend more time with the patients [than] any other care provider."
So what's a nurse leader to do? Three nurse executives share how they've had success recruiting and retaining nursing staff.
The nurse turnover rate was about 22%, and some departments had vacancy rates as high as 24%, she says.
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.
"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.
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.
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.
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."
Launch a program that entices former RNs back to the bedside
Press Ganey's 2017 National Database of Nursing Quality Indicators RN Survey found that those at highest risk for attrition were newly licensed nurses and those who have been in practice for two to four years.
"We're all feeling the pain of [nurses leaving organizations] within a few years and going to do travel nursing or to insurance companies," she says. "But some are just leaving practice altogether for reasons that we could probably address internally with some creative ideas."
The RetuRN to Practice Program at Allegheny Health is one creative initiative Zangerle is using to address some of these issues.
The program is designed to attract nurses who have stepped away from practice and want to return to bedside care, which helps reduce the workload of current staff and fill staffing gaps.
Flexible scheduling attracts RNs
The RetuRN program offers flexible scheduling opportunities in high-need clinical areas.
Participants must offer managers availability in a minimum of three-hour blocks at any time on a day, evening, or night shift, or on a weekend or holiday.
During their shift, the RetuRN nurses conduct "rover-type" duties, as Zangerle describes it. They cover other nurses' patient assignments during breaks or when staff has to do continuing education off the unit. Or they may come in to do admissions, discharges, or patient education.
"The [RetuRN nurses] know they won't know what they're going to do until they get to the unit," she says. "And they're flexible and they're there on the floor to be able to do that."
Because the RetuRN nurses have been out of practice for various amounts of time—Zangerle says one had not practiced in 20 years—there is an online nurse refresher course through the University of Delaware plus on-the-job clinical shadowing built into the program.
Additionally, there are resources dedicated to helping these nurses through the entire onboarding process, from getting their licenses verified to following up on their satisfaction levels after they've started on the unit.
"We have had a lot that have rushed in and said, ‘OK, I want to do this,' and then when they see all the things they need to do [to onboard] they get scared," Zangerle says. "So we have almost a concierge service–type support. It is worth every single nurse that we bring on board to do this program, to have that for them."
After an initial kick-off event, the organization hired 22 nurses ranging from 0.5 FTE status to 1.0 FTE status.
The retention rate of that group is 100%, Zangerle says.
Creative thinking pays off
For others interested in starting a similar program, Zangerle has suggestions on what nurse executives should consider.
First, nurse managers will have to adjust to scheduling three-hour blocks for the RetuRN nurses instead of the typical eight- or 12-hour shifts.
"We've engaged those nurse managers to say it's really a logistics exercise with scheduling," she says. "We're fortunate that we have electronic scheduling, and that's been helpful."
Once the RetuRN nurses start on a unit, the program easily wins converts among staff nurses and nurse managers.
"Once they get a couple of [the RetuRN] nurses on the unit, they hold onto them and they won't let go," she says. "If you educate the nurses on the unit about why [the RetuRNs] are there and solicit ideas from them on how we can enhance the program, it makes the program robust."
In fact, says Zangerle, current nurses can be a source of referrals to the program.
"They might have friends who left nursing to raise their children and now want to come back, or they left because the hours just weren't there," she says.
Hosting information sessions, connecting with academic partners that run refresher courses, and social media marketing are other ways to get the word out about RetuRN programs. She also recommends having one recruiter dedicated to the program to help it grow.
And, indeed, the program is growing. Between February and May 2019, three more cohorts of 10 RetuRN nurses are slated to begin. The program has also been opened to retired nurses who have been away from the bedside for one year or less.
"A lot of nurses still want to practice but they don't want 12-hour shifts, or they don't want every other weekend," she says. "Then as time goes on, we'll certainly survey our RetuRN nurses to find out what we did right, what we did wrong, and how can we grow this program."
Support nurses' professional development and work environment throughout their career
Kelly Johnson, PhD, RN, NEA-BC, vice president, patient care services and chief nursing officer at Stanford Children's Health and Lucile Packard Children's Hospital Stanford in Palo Alto, California, understands that a healthy work environment and professional development programs are crucial for retaining nurses.
"The work environment, workloads, and the impact of things like technology and new innovations in healthcare—it's really challenging to keep up," Johnson says. "[We need to] provide environments where nurses are supported in professional growth and development and staying abreast of new evidence-based practices [so they can] get to the top of their game regarding professional nursing practice."
Thus, the organization has developed programs to support nurses in the various stages of their careers.
Because pediatrics does garner a great deal of interest among nurses, Johnson says the organization has little difficulty recruiting new graduates. For example, she says, when a new graduate resident opening is posted, they can receive from 400 to 600 applications.
Once a newly licensed RN joins the organization, the nurse is supported by a yearlong new-graduate residency and transition-to-practice program. The program enables the hospital to hire new grads into all specialties, including ones that are more challenging to fill, such as the neonatal ICU or cardiovascular care. The program has shown successful retention outcomes.
"We are close to 100% retention," she says.
Total nurse turnover is around 7%, notes Johnson.
"That is the fact, [considering] that we have some high retirement areas, such as our neonatal intensive care unit and some of our maternity services," she points out.
Nurses are supported in their professional development through personal success plans, a succession planning development program, certification programs, and advanced degree programs.
Johnson says in fiscal year 2019, the organization formalized creation and assessment of personal success plans, which will be reviewed annually with a nurse's manager.
"It is a formal program where part of [the nurse's] evaluation process is developing a personal development plan and making sure that we document it and track progress towards it," she explains.
While all nurses at healthcare organizations are expected to help advance the organization's strategic goals, the personal success plans will help nurses hone their individual personal and professional goals. For example, this could mean working toward a master's degree or achieving specialty certification.
To celebrate nurses' various achievements throughout the year, the organization has an annual awards banquet.
Promote a healthy work environment
The organization also has made a formal commitment to creating a healthy work environment and culture.
"We're looking at lots of initiatives around wellness in the workforce," Johnson says, "and how we promote professional fulfillment and prevent burnout and look at moral resilience and intentional integrity in healthcare."
This includes designing a nursing professional practice model, which addresses the holistic needs of both patients and staff, that includes concepts from Dr. Jean Watson's Caring Science Theory and HeartMath.
According to its website, HeartMath is a "system that empowers people to self-regulate their emotions and behaviors to reduce stress, increase resilience, and unlock their natural intuitive guidance for making more effective choices."
The core concept of the Caring Science Theory, according to The Watson Caring Science Institute's website, is "a relational caring for self and others based on a moral/ethical/philosophical foundation of love and values."
Some principles included in the theory are:
Moral commitment to protect and enhance human dignity
Respect/"love" for the person—honoring his/her needs, wishes, routines, and rituals
Heart-centered/healing caring based on practicing and honoring wholeness of mind-body-spirit in self and each other
Inner harmony (equanimity)—maintaining balance
Watson also outlines 10 Caritas processes that include "creating a healing environment at all levels, whereby wholeness, beauty, comfort, dignity, and peace are potentiated."
Johnson says these processes are threaded throughout all aspects of the work environment and include self-care activities. For example, the organization is in the process of creating "Caritas carts" filled with healthy snacks that can be delivered during leader rounding. This helps leaders make rounding intentional while supporting staff who may be busy and need a reminder to care for themselves.
"Our practice and practice environment reflects this theoretical foundation and embodies the theory in our practices. SCH is one of the first organizations to implement the integrated model with Caring Science and HeartMath," Johnson explains.
The organization has 23 Caritas coaches and several HeartMath trainers that educate the nurses on these self-care concepts.
"We do a lot of work around self-care and creating a work environment that is caring and healing, not only for the patients and families to receive care, but for our nurses to work in a place where we care about each other and we care about ourselves," Johnson says.
RWJF's Susan Hassmiller shares her perspective on how far the nursing profession has advanced over the past 10 years and what the future holds.
Editor's note: This is the second installment in a two-part series on the Future of Nursing report and Future of Nursing: Campaign for Action. Part one can be read here.
In partnership with AARP, Hassmiller runs the Foundation’s Campaign for Action, which seeks to ensure that everyone in America can live a healthier life, supported by a system in which nurses are essential partners in providing care and promoting health.
Through the Campaign for Action, there has been momentum in all 50-states to achieve the report's recommendations on how nurses' roles, responsibilities, and education must evolve to elevate their contributions to care delivery.
An effort to galvanize stakeholders across the country is essential to successfully creating change, she says.
"I want everybody to feel like they own this. That's why I think the first report was so successful," Hassmiller says. "It has remained the No. 1 report at the National Academy of Medicine, which is amazing. People are owning it. They bring it into the classroom. I know that there are a lot of CNOs that have done their strategic plans around the recommendations."
Hassmiller shares her insights with HealthLeaders on the recommendations' impact, where nurse leaders should focus their efforts running up to 2020, and what's next regarding the Future of Nursing report. Following are the highlights of her recent interview. The transcript has been lightly edited for brevity and clarity.
1. What Members of the C-Suite Should Realize About Nurses
"When I say nurses are a means to an end, I mean nurses are very, very, very important to the health of our country," she says. "[Our foundation] believes nurses have value."
"Often, people in the C-suite don't see nurses as a means to an end. [Nursing is often] the biggest line on the budget. But really, if you had enough of us doing the right things, we could save you a lot of money and make you a lot of money. Not tapping into the full capacity of your nursing workforce is a missed opportunity. Many see nurses as just doing tasks, but there's much more that we can do."
2. Where Progress Has Been Made
"[The NAM] report was about building nursing's capacity—keep going to school, be at the [decision-making] table, and make sure you're practicing at the top of your license. It was all about building the nursing profession."
"[For example], at the time of the report, only 49% of nurses in the U.S. had bachelor's degrees. The evidence the [NAM] committee studied showed that a baccalaureate degree was beneficial [to patient care and outcomes]."
"It's a stretch goal, but here's the important thing about this recommendation—in our country, there's been a cultural shift. If you speak at community college graduation and ask who will go back to school, every single hand will go up. It wasn't like that 10 years ago."
"What we did over all these years was put the infrastructure in place for this cultural shift to move forward. Now, we have memorandums of understanding between community colleges and universities. Will the country reach 80% by 2020? No. But there will be some institutions that will. And in Hawaii, they are at 72% BSN-prepared nurses."
"I want people to look at the Campaign for Action's BSN-prepared nurses map so they can see exactly where they are [in relation to the 80% goal]. We don't want them to forget they still need to work on that."
3. Where Nurse Leaders Should Focus Their Effort
"One recommendation I really would love to meet is having 10,000 nurses on boards by 2020. I really believe we can meet that one. I know we have more than 10,000 nurses on boards. If we could get them to sign-up at the Nurses on Boards Coalition, then I think we could reach that goal."
4. What's Next for the Future of Nursing Report
"Employment, housing, transportation, food access, social isolation—those are the indicators of a person's health and well-being. We know what all the indicators are in this country and they are dismal.
There will be a new report (The Future of Nursing 2020-2030) which aligns with RWJF's mission to ensure everyone in this country has a fair and equitable chance at achieving their highest state of health. This new report is going to be about the role of nurses in addressing social determinants and health inequities in our country. That's a big-ticket item and another way to achieve the goal of reducing high-frequency users."
How much progress has been made in nursing toward the IOM's Future of Nursing recommendations? The Robert Wood Johnson Foundation's Dashboard of indicators reveals where advancement has been accomplished.
The report called for significant changes in nurses' roles, responsibilities, and education to meet the increased demand for care and to make improvements to the healthcare system, and made recommendations in the following categories:
"The important thing to remember about [NAM] reports is the recommendations are generally stretch goals," says Susan Hassmiller, RN, PhD, FAAN, senior adviser for nursing at RWJF and director of the Future of Nursing: Campaign for Action. "We're trying to push the envelope. We were certainly trying to push it on many different fronts."
Some of the recommendations call for achievement by 2020. So just how close is the nursing profession in meeting the improvements outlined in the initial report?
The Campaign for Action's "Dashboard" of seven primary indicators reports how far nursing has come since 2010.
1. Education
The IOM recommended 80% of nurses be prepared with baccalaureate degrees by 2020. Research by Chenjuan Ma, PhD, associate professor at NYU Rory Meyers College of Nursing, says that goal likely will not be achieved by 2020. However, the number of BSN-prepared nurses has increased according to the Campaign for Action's indicators. In 2010, 49% of employed nurses were BSN-prepared compared to 56% in 2017. Ma projects the 80% goal will likely be attained by 2029.
Some healthcare facilities, particularly those with Magnet designation, may reach the 80% BSN goal says Hassmiller. And some states are closer to the goal than others.
"Hawaii, for example, they're now at 72%," says Hassmiller.
Additionally, in 2018, New York State passed the first-of-its-kind law mandating newly licensed registered nurses obtain a BSN-degree within 10 years of their initial licensure.
2. Doctoral degrees
The IOM recommended that there be double the number of nurses with doctorate degrees by 2020. This goal has already been achieved. In 2010, the total number of employed RNs with doctoral degrees was 10,022. In 2017, it was 28,004.
3. State practice environment
The IOM recommended that APRNs be able to work to the full-extent of their education and training. Since the Campaign for Action began, nine states have removed statutory barriers that prevented nurse practitioners from providing care to their full capacity. That means today, 22 states allow NPs to practice to the fullest extent of their training and education. Additional states have made substantial or incremental improvements toward meeting this goal.
Plus, in 2017, the Department of Veterans Affairs granted APRNs (with the exception of certified registered nurse anesthetists) full practice authority.
4. Interprofessional collaboration
The IOM recommended expansion of opportunities for nurses to lead and disseminate collaborative improvement processes. This can be achieved through a variety of means such as involving nurses in quality improvement initiatives and making interprofessional education more robust.
The Campaign for Action has collected data from nursing schools that outline the number of required clinical courses and/or activities that include RN students and graduate students of other health professions. For example, the University of Pittsburgh went from one required course that allows nurses to collaborate with other health professions in 2011 to four required courses in 2016.
5. Leadership
The IOM recommended that healthcare decision-makers ensure leadership positions are available to nurses. The Nurses on Boards Coalition was created to help meet that goal. The coalition set an objective of having 10,000 nurses serving on corporate, health-related, and other boards, panels, and commissions by 2020. Currently, 5,757 nurses who are serving on boards have registered with the coalition.
Nurses are also increasingly moving into the CEO role at major hospitals and health systems.
6. Workforce Data
The IOM recommended building an infrastructure for collection and analysis of interprofessional workforce data to help nurse leaders make decisions for hiring and to address shortages. Twenty-five states collect data on nurse education programs, supply of nurses, and demand for nurses. The other states collect some but not all of this information. The idea behind this initiative is that more thorough data can assist with improved workforce planning and managing healthcare worker supply and demand.
7. Diversity
The IOM recommended making diversity in the nursing workforce a priority, and there has been some headway made in this area. While the makeup of the U.S. population is about 50.8% female and 49.2% male, in 2017, pre-licensure RN program graduates were 85.6% female and 14.1% male—up from 12.2% in 2010.
According to the American Association of Colleges of Nursing, in 2017, 68.6% of graduates of entry-level baccalaureate nursing programs where white. The number of total minorities in 2017 was 31.4%, up from 24.6% in 2010.
Editor's note: This is the first installment in a two-part series on the Future of Nursing report and Future of Nursing: Campaign for Action. Part two will focus on Hassmiller's insights on the recommendations' impact, where nurse leaders should focus their efforts running up to 2020, and more about the Future of Nursing.
It can be downright exhausting to be a healthcare leader. The healthcare industry continues to be turbulent, and healthcare executives are constantly trying to manage the ramifications of mergers and acquisitions, work with the changing reimbursement models, and implement value-based care requirements for their hospitals and health systems.
But Patricia A. Hickey, PhD, MBA, RN, NEA-BC, FAAN, vice president and associate chief nursing officer, cardiovascular and critical care patient services at Boston Children’s Hospital and assistant professor of pediatrics at Harvard Medical School, thinks about the current healthcare environment as a place of opportunity.
"I think this is an incredibly exciting time for all of us in nursing leadership," she says.
Why does Hickey see it that way?
While she is a pediatric nurse, her career achievements transcend any single specialty. She is internationally known for her research and work in leadership development, care delivery innovation, patient safety, and bridging nursing practice and health policy. Some of her research examines the nursing and organizational factors associated with pediatric patient outcomes and the health of the work environment.
For Hickey, healthy work environments and supporting nurses are foundational to achieving organizational goals and strategy.
In recognition of her body of work, the American Association of Critical-Care Nurses has named Hickey its 2019 Distinguished Research Lecturer.
Hickey shares her perspective about areas in nursing that are vital for nurse leaders to grow into and to move nursing forward. Following are the highlights of Hickey’s recent conversation with HealthLeaders.
"Innovation in healthcare delivery, understanding employee well-being, and taking care of our teams across the continuum of care are key priorities for leaders. [But] as important as healthcare delivery innovation is, a big part of leadership is understanding employee well-being, and taking care of the frontline staff who provide care to patients. Care complexity is increasing, and as leaders, we need to make sure that the health of the work environment is considered in all of our decisions, so we can support nurses and care teams by understanding what’s important [to them]."
"Creating and sustaining healthy work environments is an ongoing goal. We need to ensure the health of the work environment is considered in all our decisions, so that nurses and extended teams are enabled to do their best work, voice their opinions, and know that they are valued."
"The health of the work environment includes authentic leadership, true collaboration, meaningful recognition, and effective decision-making. We all benefit when frontline nurses are involved in decision-making at every level. Nurses really do have the best questions. When leaders are working through problems, the frontline staff need to be involved."
"Our practice environments must be a place where leaders support [one another] and staff are supported in their delivery of the highest quality of care. Today’s practice areas are challenged by a multitude of competing demands and patient care complexities. At Boston Children’s Hospital, we use the AACN Healthy Work Environment Assessment Tool and results as an important measurement to improve and sustain environments that empower staff and optimize experience for patients and families."
"Through serial studies over the last 12 years, we have examined nursing and organizational characteristics and their impact on patient outcomes, including mortality and complications for pediatric patients. The most recent findings show, for the first time in adult or pediatric research, that AACN Specialty Certification is correlated with reduced complications for postoperative surgical patients. Our research findings over the last decade have also revealed that levels of nursing education and experience are significantly associated with improved patient outcomes across critical care units in the United States."
"At Boston Children’s Hospital, we developed a nurse education and support team to empower critical care nurses when they feel challenged with an ethical or complex dilemma. They can receive support, mentorship, and practical tools from an experienced cardiovascular or critical care nurse. The key component of the approach is when a nurse is feeling challenged at the bedside, he or she can call a number, and an experienced critical care nurse will come to the bedside and offer real-time coaching. It is peer-to-peer support. They know the coach has walked in their shoes."
"Leaders should be able to articulate the value of nursing and help nurses articulate professional practice, whether that be with each other or to influence public policy. Nurses are key to helping patients, families, and the general public understand and navigate what is becoming an increasingly complex healthcare system. Sharing and effectively communicating a collective vision for the future and supporting staff in achieving personal and professional goals is always important."
How do you protect employees experiencing domestic violence? One nurse leader shares her first-hand experience.
Sadly, nurses are more than familiar with being hit, kicked, sworn at, or threatened as they try to deliver care. According to a 2014 study in the Journal of Emergency Nursing, three in four nurses experienced verbal or physical abuse from patients and visitors.
But, as Ronell Myburgh, RN, MBA, MHA, manager for certifications and program development at the accrediting organization DNV GL, says, C-suite leaders may be overlooking another type of violence that can affect employees and healthcare organizations—domestic violence.
"Nurses are being exposed to so much violence that we sometimes become so numb to some of these personal things," she says.
Myburgh speaks from her experience in a previous position as a hospital CEO.
"In 2011, my administrative assistant, who was near and dear to my heart, died at the hands of her husband because of domestic violence," she says. "It was devastating to me as her supervisor, but also to our whole organization, to deal with that feeling of guilt about, 'Why did I not know?' "
Myburgh began to engage in self-reflection and encourages other nurse leaders to ask the question:
"How do you protect your employees when they carry that burden [of domestic abuse]?" she says.
Here are five of her insights that could serve as a model to others:
1. Understand the scope of the problem
While the incident involving Myburgh's assistant did not occur on the hospital campus, incidents of domestic violence can, and do, occur in the work environment.
According to numbers from the Bureau of Labor Statistics, 40% of women who died because of workplace violence in 2016 did so at the hands of domestic partners or relatives.
In November 2018, Tamara O’Neal, MD, an emergency department physician at Chicago's Mercy Hospital & Medical Center, was shot and killed by her former fiancé on the organizations' campus. The gunman also killed himself, a pharmacy technician, and a police officer who responded to the incident.
However, incidents like this often are not classified as domestic violence, which may conceal the enormity of the problem.
"Typically, when the police are involved, it's not recorded as a domestic violence event. It was recorded as a homicide," she explains. "So [in our incident] it was one more homicide in the City of Orange instead of adding to the statistic for domestic violence."
2. Reassess your policies and annual training
Myburgh's organization already provided annual training on domestic violence, but after the death of her assistant, they sought out ways to make the training more authentic and applicable to real life.
"A lot of times [training] material is developed by legal organizations and the material is really just to be compliant with your state's requirements on domestic violence," she says. "We revisited the materials and selected some different videos."
Additionally, they added time after the videos for authentic conversations and to discuss what to do if one employee becomes aware that another employee is struggling. They developed processes to handle situations, for example if a spouse were to call to talk with an employee, how to let them know the employee couldn't talk while avoiding triggering an event.
3. Understand the signs
When asked about the signs of domestic abuse, many would say that an employee might come to work with unexplained bruises or injuries. But the signs can be often be less overt.
"What's more prevalent is the psychological abuse," Myburgh says. "When I reflected on what happened…I would hear her talk about her husband and how he was difficult. [She would say] that he was extremely jealous, that she had to tell him she's going to work, that she needs to call him to say she's leaving work."
As Myburgh explains, the victim maintains a pattern of allowing the spouse to be in control most of the time.
"When the victim decides to draw a line in the sand and say, 'I'm no longer going to be controlled by this pattern of behavior,' that's when it can escalate to either physical abuse or something more serious like homicide," she says.
4. Make authentic connections with staff
Myburgh encourages leaders to make authentic connections with staff members.
"Make every effort to get to know employees personally, and know them by name if at all possible," she says, "because, when you do that, you break a barrier and [they might] come to you if they had trouble."
However, Myburgh acknowledges that domestic violence victims may hold back on talking about their situations.
"There's the guilt, there's shame, and sometimes it's they would rather not share because work is their free-zone," she says.
In Myburgh's case, she did not know her assistant was a victim of domestic violence until she told her at the end of the workday she would be late coming the next morning because she had to let her child's school know she took out a restraining order against her husband. That was the last conversation they had.
5. Create support structures
Myburgh says that during the many conversations that took place after her assistant's death, she learned that other employees were experiencing domestic violence.
The organization created a support group, and participants were encouraged to have a "go bag" they could leave with a friend so if they needed to leave their domestic situation, they would not jeopardize their safety by returning home to get clothes or personal items.
They also provided additional training about the organization's anonymous domestic abuse hotline.
Myburgh would like to leave leaders with one parting piece of wisdom:
"We need to move away from statistics and talk about feelings," she says. "We need to take away the shame of talking with your coworkers about it. If we can transition from the less emotional to the more emotional and talking about emotional issues, the environment will become more transparent."
Editor's Note: If you or someone know needs help or resources regarding domestic violence, call the National Domestic Violence Hotline at 1-800-799-SAFE (7233).
A new Press Ganey report sheds light on a study that was designed to identify trends of why nurses leave or stay in their positions.
"Millennial nurses are so different than other generations of nurses." If you're a nurse leader you've probably heard sentiments like this before, or perhaps even said this. I certainly hear it quite often during my interactions with nurse executives.
But what is meant by "different"? Based on my discussions with a wide array of nurse leaders, here's a few points that are frequently raised.
Millennials want work-life balance. For baby boomers, work was their life.
Younger nurses don't stay in their jobs long. Baby boomers often spent their entire careers on one unit.
Younger nurses are already planning to go on for advanced degrees.
Sure, sometimes it sounds like the typical "Oh, kids these days" talk that has been going on since the beginning of time. But if you dig deeper, nurse leaders are expressing concerns about these differences for good reason.
"We also know there's a strong association between high nurse turnover and problems with safety, quality, and experience," Dempsey says. "We know from previous research that staffing is an issue across the country and when turnover is high, staffing is impacted and the nurses who stay on the unit or in the department are under increased stress, further impacting the work environment. It's just a vicious cycle of turnover and despair."
So, what can nurse leaders do to retain nurses?
"It requires that we understand the drivers of satisfaction and joy across the nursing lifecycle because we're not all motivated by the same thing" Dempsey explains.
"Dissatisfaction with the work environment was the most commonly cited reason for leaving," Dempsey says. "The strongest positive predictors of intent to stay in your job is satisfaction and enjoying work."
According to the analysis, 42% of the 250,000 nurses surveyed said the work environment was the main reason they planned to leave their job within the next year.
Work environment was slightly less important to younger nurses than older nurses. Of respondents under 30 years old, 39.7% said they intended to leave their jobs within the next year due to the work environment compared to 45.4% of nurses aged 40 to 49.
2. Younger Nurses at Highest Risk for Turnover
Newly licensed nurses and those who have been in practice for two-to-four years are at highest risk for attrition. In the next year, 24.5% of NLRNs and just over 27% of the two- to four-year
experience cohort reported they planned to change jobs.
"It was interesting that nurses under 30 were more likely to say they were going to leave their unit, but they were going to stay in the hospital or they were going to leave patient care, but they were going to stay in nursing over the next three years," Dempsey says.
3. Recognition vs. Leadership
"The predictors of intent to stay for nurses who had been practicing less than two years were things like praise, recognition, nurse manager support, certification, and joy in work," says Dempsey. "For those who've been practicing for more than 20 years, [intent to stay] was about leadership, influence over their schedule, and quality of care."
Additionally, the study found "career development, work group cohesion, RN-to-RN consults, and missed care were less influential on intent to stay among the new nurses than on the experienced ones."
4. At Risk Units
Nurses in adult step down and med/surg units were more likely to say they were going to leave within one to three years.
"These are difficult and demanding units, with sick patients and less staffing than a critical care unit," Dempsey points out. "We need to make sure there is strong managerial support for those units, efficient processes, and that we keep those nurses at the bedside."
Advice for Nurse Leaders
The report suggests leaders make the following areas strategic priorities to develop and retain a multigenerational nursing workforce:
Quality of care/joy in work
Manager support
Staff tenure skill mix
Workforce cohesion
Staffing and scheduling
And Dempsey's take:
"I think you need to make sure you are recruiting nurses, not just for their clinical ability, but also for their fit within your organization, and make sure that we [hire someone] who's not only clinically competent but who also espouses the organization's values. We [also need to hold] people accountable for safe, high-quality care. We're not just saying, 'Thou shalt.' They're saying, 'I will.' We [need to] create that positive work environment, and that we're supporting and fostering professional and career goals for nurses. We [need to] make sure we have a good skill mix between newly licensed and tenured nurses so that we have the ability to mentor and welcome new nurses. We [need to] encourage, reward, and recognize [nurses] at all levels, and have safe and appropriate staffing that's not just based on volume but also based on acuity and the nursing skill mix. And, we [need to] offer flexibility so that we can optimize work-life balance, job satisfaction, and, ultimately, joy in work."
Nurses are 'natural innovators', says the American Nurses Association's Bonnie Clipper, but nurses often don't see themselves that way. According to Clipper, there's no one better equipped for innovation than nurses.
For many people, including those in healthcare, innovation is just another word for technology. But, says Bonnie Clipper, DNP, RN, MA, MBA, CENP, FACHE, vice president of innovation at the American Nurses Association, there is more to innovation than just smartphones and software.
"There isn't just one definition," she says. "Generally, [innovation is] doing things differently and creating value."
Clipper says she fell in love with the concept of innovation after her experience in the Robert Wood Johnson Foundation Executive Nurse Fellows program, a three-year advanced leadership program that was created to address the needs, opportunities, and challenges of nurses in senior leadership roles.
"[There I] began to learn about what innovation is, how it works, and how it benefits organizations," she says.
"I learned even more about design thinking and innovation, and learned that there is a tremendous opportunity in healthcare to use more human-centered design to build the systems and processes that provide care for patients," she says.
And, if you ask Clipper, there's no one better equipped to do this than nurses.
"It is interesting to me that nurses don't really understand what innovation is and don't see themselves as innovators, yet they're absolutely natural innovators," she says.
While Clipper's passion for innovation was perhaps cultivated from participating in the fellowships and from her 30 years of nursing experience—20 of those have been in the nurse executive realm—she may have already been heading down the path to innovation when she decided to be a nurse at age six.
"When I was a child, the only experience I had with [healthcare] personnel was when I went for checkups [at the pediatrician's office]. I remember that my nurse there was smart and seemed to have a good grasp on everything going on," she says. "That always stuck with me. I was very impressed by all of the things she was able to do."
Today, Clipper is encouraging nurses at all levels and settings to embrace a can-do spirit and make a difference in healthcare through innovation.
In fact, the ANA has recently formed a collaborative partnership with HIMSS to drive nurse-led innovation through co-branded initiatives such as NursePitch, NurseJam, and other Innovation Lab events.
Following are the highlights of Clipper's recent conversation with HealthLeaders about nursing and innovation.
"The common response when I ask a room full of nurses—nurse leaders, outpatient nurses, inpatient nurses—'Is anyone here an innovator?' a couple of hands go up. Then I ask them, 'Have you ever had to do a work-around to provide care for a patient?' Well, then a lot more hands go up. Then I say, 'Have you ever macgyvered anything to take care of a patient?' By the end of that [question], every hand is up."
"The point is, [nurses] are all innovators. We just don't see ourselves that way. We don't use that word [innovation] because [we are just doing] what we do to take care of the patient. So that's a really powerful thing for me—helping nurses understand that innovation is not about rocket science and crazy-unique artificial intelligence or gizmos and gadgets and devices. It's really about doing things differently and bringing value."
"There's research that [suggests] nurses typically have one work-around per hour. Now, you might say that's not always good, and perhaps it isn't, but it just demonstrates all the roadblocks and the system failures that nurses have to work around to care for patients."
"Nurses impact change through innovation every day. Part of what [the ANA] wants to do is to help [nurses] understand how [they] can contribute to innovation. It doesn't all have to be the hard stuff. It can be through their own ways that they contribute to innovation."
"[The ANA conducts] nurse pitch events, which are kind of like a version of Shark Tank. We have hosted innovation labs, and we've been at hackathons where we are starting to bring nurses and say, 'We want you to experience this so you understand how you [can] contribute and get involved to transform care.' So we're really trying to bring nurses into this conversation. What's fascinating is there are four times as many nurses as physicians and there are eight times as many nurses as pharmacists, yet tech companies go to physicians and pharmacists. But it's nurses that know the workflows the best."
"Nurses are always going to find ways to take care of their patients because they're huge patient advocates. They're always going to find ways to [give patients the care they need to receive], and I think that demonstrates a lot of creativity and ingenuity and perseverance. To me, that exemplifies being a natural innovator."
"Would you consider healthcare fixed? Why not? That's one of my questions, "Why not?" Nurses are closest to the patients. They spend more time with patients and families than anyone else. There are more of them than there are of any other discipline. So why not engage them in transforming health? We believe that we're going to transform health through nurse-led innovation. [Nurses] are visible and they're present with the patient due to their scope and numbers. We absolutely should be involved in transforming health."
The nursing group at HealthLeaders and HCPro is asking for your candid feedback regarding your experiences as a nursing professional for our Salary Survey benchmarking report.
The nursing group at HealthLeaders and HCPro is asking for your candid feedback regarding your experiences as a nursing professional for our Salary Survey benchmarking report. The information you share about your wages and career growth will help others in the field identify ways to advance their own careers. Please take a few minutes to complete this brief survey. The results are confidential; they will be analyzed by members of the nursing community and compiled in a special report to be published later this year.
As always, by sharing your voices and experiences you help us all grow! Thanks for your time and assistance.
Nurse leaders connect with their peers at HealthLeaders CNO Exchange to discuss solutions to transform patient care.
Editor's note: The following is an excerpt from HealthLeaders CNO Exchange Insights Report: Transforming Patient Care and Experience. Download the full report.
As the healthcare landscape changes, nurse leaders are being asked to forge new paths to achieve high-quality, cost-effective patient-centered care.
For example, patient care is growing beyond acute care. Nurses are connecting with patients in more settings than ever before through new and changing roles in areas like care coordination or outpatient clinics. These new roles demand that nurses have different knowledge, skills, and competencies than in the past. Additionally, patients expect care to be delivered in a seamless, timely, and efficient manner that takes into account their personal needs and preferences. How do nurse leaders meet the challenge of the transformation of patient care?
The changing role of nursing may sound daunting, but nurse leaders don't have to go it alone. They can rely on their peers to learn best practices in redesigning care delivery.
Learning from peers is exactly what took place at the 2018 HealthLeaders CNO Exchange in Charleston, South Carolina, where 35 nursing and patient experience executives gathered in roundtable sessions that addressed transforming patient care and experience.
Here are five insights on care transformation from the event's attendees.
1. Care Must Extend Across the Continuum
Population health and value-based care initiatives help push for preventive care in non-acute settings, and outcomes-based reimbursement is requiring better care coordination across all settings and levels of care. Nurses have an opportunity to drive patient care across the continuum, but healthcare organization leaders need to support them in developing the necessary skills to provide optimal patient care in these settings.
"We're trying to integrate nurse practitioners to assist with care coordination and reduce some of the frontline staff nurse's workload. Also, the NP and clinical nurse leader can support less experienced nurses and act as a resource," says Jennifer O'Neill, DNP, APN, NEA-BC, CNO, vice president of patient care services at Saint Barnabas Medical Center in Livingston, New Jersey. "We've also added nurse educators to the off-shifts and weekends to act as a resource to the novice nurses on the night shift. That's been a big help for us. And we have transitions-of-care nurse practitioners. They work with a pharmacist and perform inpatient care coordination and follow a subgroup of high-risk patients from discharge to home."
2. Patient Care Technology Should Work Smarter Not Harder
In healthcare, the word technology is often synonymous with electronic health records. And in the minds of frontline caregivers, EHRs are often synonymous with increased workload. But there is much more to technology, which can decrease workload and improve patient care by providing nurses with decision support.
"We need to look at where we have opportunities for integration with IV pumps, beds, and other areas where nurses would typically be required to document themselves. And, also, where can nurses lead the design of some predictive analytics that we have in the EHR? We'll be implementing a predictive model for sepsis and a falls predictive model. This will help with that decision support for our nurses, and we'll have some protocol development associated with it. Then by the time they contact the physician, we have additional information for them to make good decisions," says Erin LaCross, DNP, RN, CMSRN, CENP, CNO, Parkview Regional Medical Center and Affiliates in Fort Wayne, Indiana.
3. Shared Goals Promote Patient Flow
When multiple departments and disciplines plus patients and their family members have clear and agreed-upon goals for care plans, improved patient flow can be attained.
"The patient hears the term discharge at 6:30 in the morning, but it's always 'pending clinicals.' That could be five consultants weighing in on the plan or trying to get medical equipment, or something like that. Then the family can't come get them until 6 p.m. So, here you have this absolutely frustrated patient sitting there. Standardizing language across the team—so that when you say 'discharge,' everyone knows what it means—that helps. We have a discharge lounge, and nurses from there can go up to the floor and discharge the patient for the staff nurse. We have three nurses that staff it, and it's made a huge difference with our patients," says Karen Grimley, PhD, RN, NEA-BC, FACHE, chief nursing executive at UCLA Health, and vice dean at UCLA School of Nursing in Los Angeles. "The discharge nurse who goes to the bedside and did all the paperwork physically escorts the patient to the lounge. We have recliners there, and a nurse is there so someone can help the patient if they need anything. Then when the ride pulls up, that nurse will take them out. The success for us was when we left the discharge lounge open all the time. We have a core group of nurses from our float pool who are deployed there on a regular basis, and we've actually opened it to Saturdays now because we have that much volume."
"We're in the process of implementing our Care Delivery Integration System (CDIS), and this is a model that's being championed by our system chief medical officer. The model involves bringing together the medical directors of all our units—nine inpatient ICUs and 23 inpatient medical and surgical units—in a dyad model, which pairs the medical director with each unit's nurse manager. We meet regularly and identify issues and discuss any quality or safety concerns. For instance, we recently focused on reducing CAUTI and CLABSI in the ICUs," says Beverly Bokovitz, DNP, RN, NEA-BC, CNO & vice president, patient care services at the University of Cincinnati Medical Center in Cincinnati. "Each dyad is joined into a larger group (i.e., ICU grouping) and includes representation from other team members such as performance improvement, supply chain, infection control, IS & T, etc. You're bringing together all the key players in the organization to focus on a specific improvement and reduce barriers, but the major change is a more robust involvement from our physicians. It's been a spectacular success based on our recent outcomes. We've gone 120 days in our neuroscience ICU with no instances of CAUTI. It's been a physician champion model, and it's coming together to partner with nursing and with all the other disciplines."
5. Boost Patient Experience With Personal Connections
Patients want to be seen as whole people, not just a disease or a room number. By paying attention to what many consider to be small things, nurses can improve the patient experience.
"We started changing the way we talk to people in the ED, and it seems to be helping. When the leaders round and the nurses round, they'll [ask the patients], 'Do you know what you're waiting for?' If the patients say no, then they'll say, 'OK, here's what we're waiting for.' If patients say, 'Yes, I know what I'm waiting for,' then they'll say, 'Do you know how much longer you're going to have to wait?' Again, if patients say no, then they'll fill them in. The physicians have started saying, 'What questions can I answer?' It's made a big difference. It's more welcoming. It makes patients feel like we have time for questions. It makes people feel like they're being treated in a more special way. It's the little things," says Shawnna Cunning, MSN, RN, FNP-C, CNS, NEA-BC.
