Your nurses have one eye on the door if you do any of the following.
This article was originally published on August 9, 2011.
Are your nurses engaged, committed employees? Or are they biding their time until they can go somewhere better? Job opportunities for RNs and APRNs abound, and even nurses who appear content may be planning their exit strategies.
To predict whether you face an exodus, take a look at the following five reasons why your nurses want out.
1. Mandatory overtime
Nurses work 12-hour shifts that always end up longer than 12 hours due to paperwork and proper handoffs. At the end, they are physically, mentally, and emotionally exhausted. Forcing them to stay longer is as bad for morale as it is for patient safety.
Some overtime is acceptable. People get sick, take vacations, or have unexpected car trouble and holes in the shift must be filled to ensure safe staffing. Nurses are used to picking up the slack, taking overtime, and pitching in. In fact, overtime is an expected and appreciated part of being a nurse. Many use it to help make ends meet. Mandatory overtime, however, is a different matter. Routinely understaffed units that rely on mandatory overtime as the only way to provide safe patient care destroy motivation and morale.
Take a look at the last couple of years' news stories about RN picket lines. Most include complaints about mandatory overtime.
2. Floating nurses to other units
One nurse is not the same as another. Plugging a hole in a geriatric med-surg unit by bringing in a nurse from the pediatric floor results in an experienced, competent nurse suddenly becoming an unskilled newbie. A quick orientation won't solve those problems. Forced floating is usually indicative of larger staffing problems, but even so, its routine use is dissatisfying and compromises patient safety.
Instead, create a dedicated float pool staffed by nurses who volunteer and who can be prepared and cross-trained. Institute float pool guidelines that nurses float to like units. For example, critical care nurses find a step-down unit an easier transition than pediatrics.
Float pool shifts open up options for nurses who need more flexibility and offering a higher rate means you'll never be short of volunteers.
3. Non-nursing tasks
Nurses are already understaffed and overworked. Hospitals with too few assistants rub salt on the wounds. RNs shouldn't have to take time from critical patient care activities to clean a room or collect supplies. Gary Sculli, RN, MSN, ATP, patient safety expert and crew resource management author, offers a vivid analogy. Imagine if half way through a flight you saw the pilot come down the aisle handing out drinks because the plane was short staffed. It just wouldn't happen.
Yes, cleaning a room is important, but don't force nurses' attention away from their patients. Distractions are dangerous and compromise patient safety.
4. Bullying and toxic behavior
Bored of hearing about this topic? So am I. So are nurses. Nothing makes nurses want to walk out the door more than toxic colleagues—whether physicians, nurses, or anyone else—who are allowed to behave badly.
It's not enough to have a zero-tolerance policy. Enforce it. Preach it. Talk about the importance of respectful behavior. Explain expectations, not just at orientation but at multiple times through the year. Send information via emails, hold continuing education classes, and have the topic as a standing item on meeting agendas.
Give managers the tools to confront problem employees and back them up when they do. Have a plan in place to educate offenders. If the behavior continues after that, fire them. Support managers through this work. Nurses would rather work a nurse short than keep a disruptive employee who sabotages the morale and cohesiveness of the others.
5. Bad managers
You've heard it before: People don't leave companies, they leave managers. Yet hospitals still don't pay enough attention to leadership skills for nurse managers. Bad nurse managers who don't know how to lead are retention nightmares. Skilled managers are retention magnets.
Some hospitals have good managers who are stretched so thin they become bad ones. How can anyone focus on the professional development of their staff if they're overseeing several units with umpteen nurses across all shifts? Annual performance reviews shouldn't be the only time the manager and nurse engage in conversation. Nurse managers must help staff reflect on growth and plan for the future.
These five reasons affect every aspect of nursing workload and contribute to fatigue and burnout. Don't forget that nurses always know when their colleagues at the hospital across town are happier.
Nurses made a strong showing in this year's HealthLeaders 20, our annual profile of individuals who are making a difference in healthcare. Four nurses were featured this year, all people who are changing healthcare for the better, and all operating in very different arenas that showcase the many ways nurses make a difference across healthcare.
The public figure AnnMarie Papa, DNP, RN, is president of the Emergency Nurses Association and has achieved national prominence for her efforts to call attention to the prevalence of hospital violence, especially violence in hospital emergency departments.
Nurses and other healthcare staff are so used to violence from patients and family members that many consider it simply one of the hazards of the job. Healthcare leadership, however, was largely unaware of the scale of the problem until Papa and the ENA shone a light on the statistics and started talking about ways to reduce violence.
ENA published a seminal study in 2009 that revealed one in four nurses in EDs or trauma centers had experienced physical violence more than 20 times in the past three years, and almost one in five had experienced verbal abuse more than 200 times during the same period.
Suddenly the topic was on everyone's lips, The Joint Commission published a sentinel event alert, and healthcare facilities started looking at ways to reduce the risk. Many hospitals now have zero-tolerance policies and the ENA offers a toolkit for hospital administrators to evaluate the safety of their EDs and trauma centers.
The hospital leader Robert Donaldson, NPC, is clinical director of emergency medicine at Ellenville Regional Hospital in Ellenville, NY. He is a nurse practitioner and is also president of the hospital's medical staff, sharing ED leadership responsibilities with a medical director.
Under Donaldson's expert leadership, the 25-bed critical access hospital has gone from 8,000 patients a year to 13,000. And it's done so with a staff made up of nurse practitioners and physician assistants.
"We are admitting patients, making money for the hospital, and the hospital is in the black year after year…The hospital has received an award for its emergency department for patient care. What does that say?" says Donaldson.
In addition to his ED leadership, Donaldson was elected medical staff president and is demonstrating how successful organizations can be when caregivers collaborate and respect is high. The small hospital in the Catskill Mountains is proving to be a model other organizations want to look at more closely.
The care coordinator Jeanne Yeatman, MBA, BSN, CEN, EMT, developed a program to improve care coordination among flight crews, paramedics, and emergency department staff in the Vanderbilt LifeFlight system in Nashville, TN. She launched the iFly program to help paramedics, ED physicians, and ED nurses learn more about care delivery during the "golden hour in trauma." The program brings caregivers along to shadow and learn the process, which ultimately improves patient care.
Yeatman also spends a lot of time talking about compassion fatigue, which plagues healthcare workers and is a major cause of burnout and leaving the healthcare profession. She recognizes the emotional strain on the more than 150 professionals who average more than 3,000 trips annually and to help them cope with the daily rigors of the job, she builds self awareness about the acuity of patients that LifeFlight transports.
The quality improvement specialist Diane Whitworth, RN, CWOCN, is a wound ostomy and continence nurse—and a nurse safety scholar-in-residence—at St. Mary's Hospital in Richmond, VA. She has become a champion in the nationwide effort to prevent hospital-acquired pressure ulcers and has overseen her hospital's dramatic quality improvement efforts.
Pressure ulcers are the second most common patient safety incident, with a development rate of 36.05 incidents out of every 1,000 hospitalizations. In addition, healthcare-acquired pressure ulcer (HAPU) cost the healthcare system roughly $2.6 billion to treat annually, according to HealthGrades Seventh Annual Patient Safety in American Hospitals Study, which was released in March 2010.
Whitworth says over the years she started seeing more and more pressure ulcers in patients, which drove her to work toward reducing the rates. In the back of her mind, she often thought of her grandfather, who in his 80s, fell and fractured his hip and developed a pressure ulcer on his foot. He ended up having to have his foot amputated. "At the time it was an acceptable practice," she says. "Even being in healthcare, I thought, 'Well, that is one of the hazards of falling and breaking a hip.'"
In 2006, some areas of St. Mary's were showing healthcare-acquired pressure ulcer (HAPU) rates of 20%, at a time when the national average was only 5-6%. Whitworth and the hospital realized it had a tremendous opportunity to improve patient care. Now, after a culture changes regarding pressure ulcers, the hospital's rate is around 0.5%.
2011 has been a tumultuous year as healthcare organizations come to grips with value-based purchasing, rules for ACOs, meaningful use, and financial upheaval. Nursing has dealt with continued cost cutting while also being expected to lead care delivery transformation, improve patient satisfaction, and reduce healthcare-associated infections.
Here's a rundown of the most popular nursing stories we covered in 2011 in case you missed them or just want to have another look.
1. Five Reasons Nurses Want to Leave Your Hospital Are your nurses engaged, committed employees? Or are they biding their time until they can go somewhere better? Mandatory overtime and ignored bad behavior are two issues that have nurses eyeing the exits.
3. 5 Ways to Retain New Graduate Nurses
New nurses have a difficult time bridging the gap from nursing school to practice and often don’t stay with their first job for the long term. Hospitals can recognize this transition and help new graduate nurses through the transition with these five strategies that ensure they are engaged, long-term employees.
4. Does Mandating Nurse-Patient Ratios Improve Care?
The debate intensified as more than a dozen states considered laws to establish hospital nurse-to-patient ratios. This article examined whether patients get better care, experience fewer adverse events, and have shorter lengths of stay and lower mortality with ratios.
5. 3 Obstacles to Higher Education Levels in Nursing
Evidence shows that patient outcomes improve when nurses have baccalaureate degrees. But most nurses don't have them, and increasing the numbers with BSNs is tough. Nurse leaders must get fired up and overcome three things that stand in their way.
6. 5 Ways to Reduce Nursing Turnover in Year One
Turnover among first-year nurses remains a huge cost driver and source of frustration for hospital managers. It's hard enough to find these skilled clinicians, and even more annoying that they quit, just when they should be settling into their new careers. That leaves harried HR staff to start the process anew and with no more assurances of retaining the next new recruit.
The average nurse is in cognitive overload, completing about 100 tasks per shift with an interruption every three minutes. At its annual meeting in last spring, the American Organization of Nurse Executives' put the spotlight on the current nature of nursing work to see how care delivery can be reshaped.
8. 10 Ways to Help Nurses Improve Patient Satisfaction
Nurses can make or break the patient experience. So why do we make it so hard for them to have positive interactions with patients? Here are 10 changes to nurse procedures and working conditions that would improve patient experience.
9. Top 5 Challenges Facing Nursing in 2012
The year 2010 may have been when enormous healthcare changes began, but 2011 was the year these changes hit nursing. And in 2012 every nurse leader and manager must be prepared for the full impact.
10. Nurse Staffing Costs Must Be Weighed Against Cost of Errors
When revenues fall, hospitals stop investing in the biggest budget expense: nurses. That's a bad short-term solution to a long-term problem. Executives must acquaint themselves with studies demonstrating how nurse staffing affects a hospital's overall performance and base staffing decisions on evidence.
And one more...
11. Talk to Nurses About Facebook Before They Talk About You
Facebook's ubiquity makes people not think about it very much. It's just part of life. But when one's profession involves interacting in other people's lives, the lines can be blurred. And that's a problem for employers.
A nursing study out this week brings hospitals some welcome good news: The nursing shortage may not be as bad we feared it would be.
Nurse staffing gurus David Auerbach, health economist at RAND Health; Peter Buerhaus from Vanderbilt University; and Douglas Staiger from Dartmouth took a look at 35 years of data and discovered the number of people ages 23-26 entering nursing has increased 62% from 2002 to 2009.
"This is a very welcome and surprising development," says Auerbach, in a media release. "Instead of worrying about a decline, we are now growing the supply of nurses."
The study, published in Health Affairs, shows the nursing workforce is changing and the percentage of younger nurses is higher than in decades, reflecting a dramatic turnaround from the previous two decades. Between 1983 and 1998, the proportion of nurses younger than 30 dropped from 30% to 12%. In turn, this led to an increase in average age from 37.4 to 42. Increasing options for female employment is one of the reasons for fewer younger nurses in these decades.
The workforce stats have been worrying healthcare leaders since the 90s, as experts predicted future shortfalls. Programs have been developed to increase the numbers of college courses and promote nursing as a career. It appears these effort have been working, combined with factors such as the perceived stability of healthcare employment, decline in manufacturing jobs, and growing popularity of nursing for people in their 20s and 30s.
The researchers project the RN workforce will grow at roughly the same rate as the general population through 2030, which is great news for the nursing shortage and should mean its effects are less severe than previously thought. It's giving hospitals hope that the increase of younger nurses will temper some of the effects of baby boomers leaving the profession.
Despite all this good news, it's worth noting we're not completely out of the woods. The highest proportion of nurses in the workforce is still the older generations. According to the 2008 National Sample Survey of RNs, conducted by the U.S. Department of Health and Human Services Health Resources and Services Administration, 44.7% of nurses were older than 50 in 2008. The median age is 46. The influx of younger nurses is helping more than expected, but it won't entirely solve all our problems.
What does this mean for healthcare? It's not time to abandon retention programs. We know that the aging population will require more and more healthcare services, so we'll need all the help we can get.
In addition, the majority of your nurse leaders and nurse managers are likely from the baby boomer generation. It would be a great folly to wait until they are desperate for retirement before training their replacements.
The need for formal succession planning is clear. The two largest cohorts of nurses are at opposite ends of the spectrum. The younger group needs professional development opportunities and mentoring from their more experienced colleagues. The older group needs creative ways to keep them engaged and able to stay in the workforce as long as they want.
Succession planning programs will provide a roadmap to ensure future nurse staffing needs are met.
This year's search for nurse leaders and staff who have helped elevate the image of nursing is over, and two winners, representing exemplary leadership and clinical skill have been announced.
More about them in a moment, but first you should know that HCPro's 2011 awards honor nurses whose leadership, teamwork, or clinical expertise embodies an image of nursing excellence and contributes to improving patient care, quality outcomes, nurse satisfaction, and the healthcare environment.
Tracy Williams, RN, DNP, is responsible for the nursing care provided in 1,400 beds across the Norton Healthcare system in Louisville, KY, and she oversaw the transformation of this system to a patient- and family-centered care philosophy. The benefits to patients, families, and the system's culture have made Williams the winner of the 2011 HCPro Nursing Image Awards: Image of Nursing in Leadership.
As system chief nursing officer, Williams exemplifies positive leadership by creating a vision and sharing that vision with her colleagues. Her staff report that she inspires and ignites passion to attain goals by developing people as she guides and instructs them in new and innovative ways to care for patients.
"What struck us about Tracy was her action-oriented leadership," said Elizabeth Petersen, associate editorial director, HCPro, Inc., and member of the judging panel. "She's created real, measurable change in her organization and she seems to have found that wonderful balance between practical and visionary management."
The move to patient- and family-centered care increased accountability at all levels: personal, departmental, interdivision, and across the system. It also enhanced transparency, improved outcomes, and created a single standard and language across the system. Since the transformation, feedback from patients, families, and staff has been positive and embracing of the change in practice.
Williams also created the Integration and Alignment agenda for the Norton Healthcare system, which drives quality, safety, and service achievement of goals throughout the system and has resulted in a 1.5 standard deviation improvement in results in fewer than four years.
As a result, Norton Healthcare was recipient of the 2011 National Quality Forum National Quality Healthcare Award for its exceptional leadership and innovation to achieve quality improvement.
Williams inspires nurses in her organization by her commitment to education. She returned to school and successfully obtained her doctorate in nursing practice. Now she guides other senior nursing leaders in appreciating the value of the advanced practice degree and seeking enrollment themselves.
As well as visionary leadership, the awards also recognize clinical excellence. This year's winner of the Image of Nursing in Clinical Practice Award is Cheryl Lillegraven, a clinical nurse specialist with expertise in neuroscience. She is at Iowa Health Des Moines (IH-DM), in Des Moines.
Lillegraven is the first adult clinical nurse specialist to be hired by IH-DM and she has demonstrated how vital the role is to the neuro unit on which she works.
Lillegraven is being recognized for raising the bar for the care of neuro patients, which she does by educating nursing staff and role modeling excellence. She makes a difference in the lives of patients and staff in less visible ways—such as serving on the hospital pain committee, trauma committee, stroke committee, and nursing research—and through being present in patient care—such as rounding with staff, consulting on specific patients, and providing staff education regarding care of stroke patients.
Within the past year, Lillegraven was instrumental in bringing simulation into the training of staff in preparation for IH-DM's certification as a Stroke Center of Excellence. She is currently facilitating the creation of an advanced practice nursing council, overseeing pain management nursing research, and is responsible for the hospital-acquired condition initiative to decrease patient falls.
Lillegraven's ability to inspire others is summed up by a quote from a staff nurse at IH-DM. "Cheryl's strength is that of teaching other nurses and assisting them in using their own critical thinking skills. She is always willing to assist you in looking at the big picture with the patients. She makes the nurses on the floor be better nurses. The care she provides for the patients is nothing short of excellent."
It was the combination of clinical excellence and elevating the profession as a whole that made Lillegraven stand out to the judges.
"Cheryl's work as a clinical nurse specialist at IH-DM is pioneering, but it's her unwavering commitment to her patients, her peers, and the profession that is most impressive," says Petersen.
Please join me in congratulating this year's winners and thank them for the positive image of nursing they portray.
The holiday decorations are going up in my neighborhood, Thanksgiving is next week, and my mind has already turned to end-of-year activities and planning for what's in store in 2012. With these things on my mind, I thought I'd turn in the annual retrospective/prediction column a little early this year.
At last month's Nursing Management Congress I realized that the full ramifications of value-based purchasing have hit home in nursing and have trickled down to the unit level. It's no longer something that is only happening at the administration level and that only concerns nurse executives. Now every nurse leader and manager is actively planning for its impact.
Here's a quick rundown of the most pressing issues right now and into 2012:
1.Advanced degrees are no longer optional
I have been cheered that discussion of the IOM's recommendation for 80% of all RNs to have a baccalaureate degree by 2020 has not veered too intensely into the old ADN vs. BSN quagmire. Instead, the profession is focusing on ways to engage nurses in lifelong learning so that associate degree nurses can find realistic ways to obtain BSN degrees.
In addition, BSN nurses are encouraged to be leaders in evidence-based practice and research and it's becoming more common—and crucially, more expected—for nurses to pursue master's degrees. And the creation of the doctor of nursing practice degree has taken off better than anyone could have expected.
In the last six months, any time I'm in a group of nurse executives, the conversation always turns to who has already entered a program and how long it's going to take the rest of the group to do so.
2.Patient engagement gets real
If you haven't found a way to drive home the importance of patient experience to direct-care nurses, find it now. You know how much reimbursement is at stake, but the rank and file caregivers still don't get it. I've written before that the term "patient experience" has a way of annoying bedside caregivers. '"We're not Disneyworld," is a common refrain; people don't want to be in the hospital. "I'm here to save patients' lives, not entertain them," is another common complaint.
Experience isn't about mollycoddling patients, however, or how flashy the in-room entertainment system is and that's what you need to help nurses understand. In fact, the nurse-patient relationship has always been about patient experience.
Your best nurses instinctively know this. They already create a good patient experience. They help patients understand their care, involve families in decision-making, coordinate multidisciplinary care, sit with patients to explain complex diagnoses, and even, occasionally, have time to offer a quick hug or hand to hold. These are the nurses who get letters from patients and families after discharge and these letters are all about the patient experience.
This is how you need to phrase patient experience with nursing staff so they understand it's not just a program, but a way of life. At the same time, nursing needs to own the cause. They may not be responsible for it in isolation, but they are literally at the center of this issue. They should take the lead and drive the agenda.
Just as nurses should own patient experience, they need to feel ownership for patient safety as well. I wrote last month that "quality improvement becomes one more meaningless directive from 'above' unless nurses feel engaged in the process, involved in the plans, and accountable for the results."
Preventing healthcare-associated infections (HAI) is no longer simply the right thing to do, it's become the only financially viable option. Unless nurses are educated and empowered, real progress cannot be made.
Nursing knows that hiring freezes and layoffs are a constant threat and healthcare organizations are forced to put cost cutting at the top of the agenda in 2012. As the largest budget in the organization, nursing is an easy target.
Organizations can get more agile with staffing and scheduling and find creative ways to reduce cost while maximizing efficiency. Embrace change and flexibility to create the mobile, agile workforce healthcare organizations need to adapt to changing economic realities and increases in patient population.
At the same time, staffing budgets can't be viewed in isolation. There are direct links between nurse staffing and length of stay, patient mortality, readmissions, adverse events, fatigue-related errors, patient satisfaction, employee satisfaction, and turnover. This article examines the danger of considering the cost of nurse staffing without looking at everything else. It's important to understand the relationship between length of stay, unreimbursed never events, and nurse staffing to understand the whole picture.
I've said it before, but ignore retention at your peril. The nursing shortage hasn't gone away simply because the recession has eased its immediate effects. We all know the turnover rate for new graduate nurses is always high, so invest in nurse residency programs that have proven results for retention and for increasing the competency of new nurses.
Last week I wrote in this space about hot topics at the annual Nursing Management Congress. This week I've had the honor of sifting through the shortlist of nominees for HCPro's 2011 Nursing Image Awards. The two seem unconnected, yet certain recurring themes link the two.
The conference covered the changing face of healthcare and provided a chance to discuss pressing issues affecting nursing's role. Attendees were buzzing about:
The Future of Nursing report: How to implement the Institute of Medicine's recommendations and how they will change the profession.
Patient Engagement: There's more reason than ever before to pay attention to this topic, which nursing can really own
Quality: Preventing HAIs and best practices for any quality improvement initiative
Leadership: Being a better manager, improving communication, and retaining a committed and engaged nursing staff.
These themes were reflected in the nomination essays of the nurses singled out by their peers for recognition. Here are some excerpts:
Education and learning
The essay for this nominee notes the value she places on education and lifelong learning:
"She worked diligently to obtain an increased tuition reimbursement for nursing education, establishing educational relationships with over 10 different accredited nursing programs, yearly certification incentives, a PhD clinical research consultant, and access to an incredible online library with a dedicated medical librarian. Nurses have embraced the many opportunities she has created for them, which is reflected in our strong retention rate and high years of service."
Passion and energy
It's no surprise that among the best leaders are those who have passion for the profession and are able to ignite passion in others with their energy:
"She inspires and ignites passion to attain goals by developing people as she guides and instructs on new and innovative ways to care for patients."
"She exemplifies all that is best about the profession of nursing: clinical excellence, care and compassion, pride and leadership and absolutely lives and embodies the vision of pride, passion and professionalism of nursing practice."
Mentoring the next generation
A common theme among many nominees is their attention to nurturing the next generation of nurse leaders. Many have led the way in understanding the importance of developing new graduates by creating nurse residency programs.
"The residency program enhances the clinical support for these new graduates by providing trained mentors and preceptors while also offering greater understanding of how the organization functions as a whole. Consequently, a mechanism was created for new nurses to assimilate into a fast-paced healthcare environment with the support they need to be successful with their career choice."
The nominations put a spotlight on the pairing of soft skills such as communication with a dispassionate eye for the bottom line. In this era of layoffs, dwindling reimbursements, and shrinking budgets, the nominators recognize leaders who are honest with staff and who have partnered with them to find solutions that work for nurses, patients, and the organization's business goals.
"She is a staff advocate. When administration makes decisions that may have a less than optimal outcome on staff morale, she steps up and doesn't just complain, but offers management ideas for solutions that work in the best interest of the business as well as the staff."
"She is also a business advocate, demonstrating to the staff daily that all resources can be allocated in many different directions as needs arise to meet the needs of the patients but still remain a solvent agency."
These nurse leaders are proactive in helping staff focus on innovation and change rather than resistance.
"She has developed a work session for direct care nurses to promote innovation in nursing."
"She constantly stimulates us to read leadership books and we conduct book reviews as a group on a monthly basis."
"She inspires and ignites passion to attain goals by developing people as she guides and instructs on new and innovative ways to care for patients."
The winners will be announced soon; the nominating stories will inspire me all year.
The three topics on everyone's lips at last week's Nursing Management Congress were: transforming care delivery, the changing role of nursing, and which show to go to that night.
While the Las Vegas setting provided some much-needed fun for the approximately 1,000 nurse managers and leaders who gathered for education and networking, it was the chance to discuss the pressing issues of healthcare reform and nursing's role that truly electrified the audience.
Keynote speaker Tim Porter-O'Grady told attendees that it's time for nursing to unbundle its work and decide what it will no longer do so that nurses are able to focus on what's most important in the changing face of care delivery.
"We've been too addicted to our protocols and our rituals," said Porter-O'Grady. Nursing can't keep doing what it's been doing in the new world of healthcare reform and value-based purchasing. Instead, it's time to embrace meaningful changes.
Here are the key strategies Porter-O'Grady outlined.
1. Change the new graduate nurse experience
"When millennials first graduate and get into preceptorships, we kill them," said Porter-O'Grady. How? Because we ask the oldest and most experienced nurses to serve as preceptors. Too often these preceptors cannot relate to the younger new grads. "We need to stop precepting and start mentoring," said Porter-O'Grady.
Preceptorships should focus around mentoring relationships that recognize new nurses have as much to teach us as we have to teach them.
2. Lead the next generation of nurses
The current crop of nurse leaders is tasked with leading the next generation into a future we don't understand and that we will never fully occupy, said Porter-O'Grady. By holding onto the past, it becomes an impediment to occupying the future.
Nurse leaders should embrace technology and its ability to revolutionize healthcare, rather than viewing it as something foisted on nursing by others.
3. Measure value not volume
"We are moving out of an age of volume into an age of value," said Porter-O'Grady. Nursing needs to stop measuring itself in terms of volume and start looking at the value it provides. Nurses are not valuable to their organizations simply because of all the many tasks they do. They are valuable because of the outcomes they produce and this is what needs to be emphasized.
Nurse leaders' role is to identify the parts of the job nurses do that have value and make a difference and the parts that don't belong in the role of RN. Do this by asking what impact the work has or whether it changed something, he said.
We will no longer be paid for volume of work. "Work is not valuable because you do it. It has to have meaning," he said. We all know healthcare is getting more complicated—the only way to maximize the value of what nurses do is to do less of the work that doesn't add value so there is more time to devote to the increasingly complex work that does.
The frontline nursing leaders attending last week's conference are the ones who can help organizations make this crucial distinction.
Who owns the quality measure and patient outcome scores in your hospital? Most hospitals have quality, safety, and infection prevention professionals devoted solely to these statistics and ways to improve them.
All their efforts are meaningless unless nurses and other clinical staff are engaged in the process. Too often, they are not. Most staff nurses don't know what value-based purchasing is or why they should care about it. All they know is that when Administration or "Quality" has a new scheme it will take nurses more time to do their jobs.
Nurses may fully support the changes because they will benefit patients, but they don't own them and they don't own those scores.
As the people who actually touch patients, all members of the nursing staff need to feel directly responsible for patient safety. Quality improvement becomes one more meaningless directive from "above" unless nurses feel engaged in the process, involved in the plans, and accountable for the results.
"Culture eats strategy for lunch," says Mary J. Voutt-Goos, MSN, RN, CCRN, director, Patient Safety Initiatives and Clinical Care Design at Henry Ford Health System in Detroit. "If frontline staff aren't in agreement and actively engaged in the process, it won't happen. Top-down approaches to culture change are typically unsuccessful."
This is one reason why scores can start creeping downward after a successful quality improvement effort has come and gone. If nurses aren't engaged in the process, they have less inclination to remain on a directed path.
"All frontline staff, not just nurses, should be engaged, as well as empowered to act, if we really want to see a change in our culture of safety," says Voutt-Goos.
One way to build a feeling of accountability in nurses is to empower them to solve the problems themselves—in conjunction with quality and patient safety professionals, of course. New procedures or processes are more likely to be met with acceptance and to become part of everyday practice when the caregivers themselves are involved in the design.
At Henry Ford Health System, the organization reviewed a synthesis of safety culture and safety climate research conducted by the Aviation Institute that identified global indicators of safety culture.
"We use these global indicators as a guiding framework for our culture of safety efforts," said Voutt-Goos. "One of the global indicators is employee empowerment."
Empowering employees involves giving them a level of responsibility and knowledge, which sometimes they may not want, but is vital to achieving an end result of quality patient care in a financially healthy organization.
One common practice to reduce outcomes-related to issues such as patient falls or CAUTIs is to pit units against each other in competition and reward the winner with a pizza or ice cream. While it's appropriate to celebrate success and recognize hard work, I think it's a mistake to rely too heavily on competition.
Rewarding the unit that most improves its customer satisfaction scores or reduces patient falls by the greatest percentage is great at building enthusiasm and recognizing hard work, but it's not an effective long-term strategy. Nurses should be treated like adults and involved in the imperatives behind process improvement, both those related to patient care and those related to the organization's bottom line.
Just as the hospital should treat nurses as adults, nursing staff should be more interested in quality outcomes. They must seek out and embrace their level of ownership in these metrics. In today's financial reality, it is no longer acceptable to not take an active role in quality improvement efforts. Organizations should engage nurses in frank and honest communication.
The financial imperative is such that hospitals can't afford for nurses to not be wholly engaged. Back in June, Lillee Gelinas, MSN, RN, FAAN, vice president and chief nursing officer at VHA Inc., explained how "value-based purchasing is a game changer." She said hospitals can't afford to focus only on incremental improvements. They must focus on wholesale transformation, which requires a shift in nurses' thinking.
That means an end to thinking "patient safety" and "quality" belong to a department and a realization that it belongs to nurses and to every person employed in the organization.
Nurses are feeling the pinch from the economy as much as anyone else and a new study reveals that many plan to continue working well into traditional retirement age. That's bad news for nurses and their plans to say sayonara to difficult patients and endless documentation, but it's good news for hospitals.
Almost 45% of RNs are older than 50, meaning they are due to hit retirement right as their fellow Baby Boomers start deluging the healthcare system. By some estimates the country will be short 260,000 RNs by 2025, but we'll start feeling the effects as early as 2018. Decreased readmissions and the poor economy have eased nursing shortages around the country and fooled many into thinking the shortage has gone away, but it hasn't.
Retention efforts may be at the bottom of a very long priority list, considering most organizations are currently engaged in cost-cutting efforts, and 2018 seems like the distant future, but it will be here before we know it. Savvy hospitals can prepare for the future and decrease costs now by planning for the retention and effective utilization of the older RN workforce.
The study, released last month by Fidelity Investments, revealed that 71% of nurses have not saved enough money for retirement and that almost half have changed their retirement plans because of the economy.
More than a quarter of nurses surveyed believe they will never fully retire. Twenty-six percent expect to retire later than originally planned, and 22% say they will change their plans and work in retirement.
Of the nurses who plan keep working past traditional retirement age, 79% said they will need to work to meet basic living expenses and 28% expect to struggle to make ends meet in retirement. These numbers show a significant change from the last time the survey was conducted in 2007 when nurses were more confident about their financial health in retirement.
The study was not all bad news for nurses, however. Fifty-four percent responded that they loved their jobs and didn't want to give them up even in retirement. Whether they continue working because they want to or they need to, the numbers of older nurses in your organization will force changes to the way nursing care is provided.
1.Offer Shorter Shifts
Serious attention will have to be given to the over-reliance on 12-hour shifts. These shifts contribute to cognitive overload and nurse fatigue and have been shown to result in more errors, but nurses love them and fight any suggestion to do away with them. Older nurses, however, will be less wedded to 12-hour shifts and many will need options that either include less direct patient care time or shorter shifts.
As part of your cost cutting efforts now, investigate ways to improve staffing and scheduling and develop different shift options that meet the needs of all your staff. Offering 4, 8, or 12-hour shifts provides flexibility for both staff and the hospital. For example, four-hour shifts can be scheduled around busy times during high patient census.
2.Invest in Staffing Software
Reduce your need for agency nurses by investing in staffing software that makes it easy for nurses to view and pick up open shifts. These programs can be implemented across multiple sites, making it easier for hospitals in a system to share resources and solve staffing issues together. The initial investment is more than offset by the reduction in agency staff as well as increases in staff satisfaction. Opening the system to older nurses who work per diem or part time gives them opportunities to pick up work when they want it.
3.Be Mindful of Physical Limitations
Retention efforts must also pay attention to the physical needs of an older workforce. Safe lifting programs become paramount to retain older nurses, but also reap benefits for all staff. As the obesity epidemic continues, all caregivers need education about safe patient handling and lifting as well as the availability of assistance when needed.
Another effort that is essential for older nurses but that also benefits everyone is reducing the number of steps nurses take each day. Studies with nurses wearing pedometers show that many staff walk miles each day doing tasks such as hunting supplies or retrieving wheelchairs that needless take them away from patients' bedsides. Locating supplies closer to where nurses work, educating pharmacy staff about the effects on patient care when nurses have to chase down medication, and equipping nurses with cell phones can all reduce unnecessary walking and increase the time nurses spend with patients.
4.Reap the Benefits of Experience
Having older nurses remain in the workforce means you can continue to benefit from their years of experience and wisdom. Use it wisely and you provide them with new challenges for their professional development. Create shift options that include project work or quality improvement efforts. Pair them with new graduate nurses in buddy programs.
Preceptors have to focus on the checking off competencies and ensuring new nurses are clinically competent. Buddy nurses can spend more time on sharing experiences and can just mentor, encourage, commiserate, and inspire.
With a little advance planning, these easy-to-implement programs make continuing working into retirement years a more attractive prospect.