Until the economy imploded a few years ago, every other article on the profession of nursing revolved around the nurse shortage. It was so omnipresent that we became numb to it. Then the economy went south, nurses couldn’t afford to retire or needed to pick up extra shifts to make ends meet, and suddenly it was “what shortage?”

Now, as we knew it would, signs are appearing that the shortage is about to rear its ugly head again. Perhaps now we will face the problem with fresh insight and conviction. At the least, nurse retention is about to become a business imperative again.

I just got back from the annual convention of the National Nursing Staff Development Organization in Chicago and talk of retention was everywhere. Nursing professional development specialists are on the front lines of retention and professional development efforts and they know they have to plan ahead.

It is energizing to hear nursing leaders talk about shared experiences and challenges. This year’s NNSDO conference featured more pep and vigor than any I’ve attended in the last few years of the economic downturn.

This year, the focus was back on nurse retention. Staff development specialists know that a good way to retain nurses—and ensure a competent nursing staff providing quality care —is to offer professional development opportunities. They were also trying to figure out how to implement the recommendations from the IOM’s Future of Nursing report, such as improving the transition experience for new graduate nurses through offering nurse residency programs.

In cost-conscious times, every department must pay attention to the bottom line, which is hard to quantify with something as nebulous as professional development. It may be easy to check off a competency assessment that a nurse can operate an IV pump correctly, but harder to quantify the return on investment provided by in-depth education and development, which is so vital to retention and patient care.

But this is a key skill staff development departments must work on when every department fights for scarce dollars. So, attendees discussed maximizing return on investment of educational, training, and professional development offerings and how to measure outcomes.

Doing so will require the use of evidence to evaluate and improve practice and tie education departments to patient outcomes, as well as finding ways to improve efficiency through new technology.

Jobeth Pilcher, RN-BC, EdD, presented her research on nurses’ preferences for teaching methods and new technology in education. Pilcher cautioned that incorporating technology for its own sake is a waste of time. For example, Twitter is a great medium for keeping in touch with people, but rushing to provide education via Twitter without an obvious strategy is a waste of time. Starting a blog for the CNO can be a great way to communicate and engage with nurses, but not if the CNO has nothing to say.

Useful technology is easy to use, convenient, and has a tangible benefit. Nurses say they prefer to receive education through traditional lecture format, which beat modern options such as videos or podcasts. The top three most popular nurse learning methods are:

1. Lectures
2. Paper and pen self-study
3. Online learning

Learners want interaction with their lectures—indeed any education and training—rather than dry lectures. Putting a class online doesn’t make dry content any more thrilling, so simply going online with education isn’t effective unless the class is redesigned to fit the new format. Savvy staff development specialists will be paying much more attention to collecting such evidence of effectiveness as they prepare for the growing need to fight for nurses.

Hospitals across the country are welcoming recently graduated nurses to their units and hoping to turn them into competent, confident nurses as quickly as possible.

New nurses have a difficult time bridging the gap from nursing school to practice and hospitals must recognize this difficult transition if they hope to keep the nurses for the long term. Here are five strategies that help new graduates through the transition and ensure that they are engaged, long-term employees.

1. Provide a competency-based orientation.

Once new graduates have completed general, organization-wide orientation, they are sent to their units and start learning how to be a nurse in their new world. Making every new nurse go through the same orientation is a bad idea. It's a waste of time to train nurses how to do something that isn't relevant to their specific job and a waste of resources to send nurses to classes they don't need. Yet many organizations do exactly that.

One-size-fits-all nurse orientation takes longer and is less effective at on-boarding new nurses. Effective orientations are based on competency assessment and personalized to nurses' individual training and development needs. Customizing training and development to graduate nurses' needs creates engaged employees and allows managers to allocate financial resources appropriately, rather than sending every employee to every class.

2. Offer a nurse residency program.

If you don't have a nurse residency program, start one. They are much more than orientation. The best programs run throughout new graduates' first year of practice and support them through the difficult transition shock and various phases of competence. The programs give new nurses the tools to become competent practitioners.

Nursing schools advise students to find organizations with nurse residency programs and hospitals that offer them are able to pick from the best new graduates.

Residency programs require investment in time, people, and resources, but research has shown the initial investment is more than made up by increases in competency and retention. Large hospital systems with significant numbers of new graduate hires can find themselves saving $200,000-$400,000 annually by investing in top quality residency programs. Even small organizations can more than repay the expense of a program.

3. Encourage mentoring.

Mentoring can be formal or informal and both are useful. Many nurse residency programs include mentoring from the program coordinator, nursing professional development specialists who teach classes, or simply through nurses in the programs finding buddies amongst their colleagues.

The best mentoring provides more than just emotional support. Effective mentors guide new nurses through career progression and model how to be good nurses. These mentors are well versed on any number of career challenges and opportunities, whether it's discussing coping with nurse-to-nurse hostility or the benefits of specialty certification for long-term career growth.

If your organization doesn't have a formal program for matching nurses with mentors, start one. The process is just as fulfilling for the mentor as for the mentee and it's a good way to help experienced nurses stay engaged and committed.

4. Ensure good managers.

The old refrain says that employees don't leave organizations, they leave managers. This is especially true in nursing where many nurse managers are promoted because they have excellent clinical skills, but are left on their own to figure out everything from how to balance the unit budget to how to manage their staff.

Investing in leadership training benefits the entire organization. New nurses need managers who set clear behavioral and performance expectations, who create a healthy work environment free from bullying, and who pay attention to staff's continuing education and professional development.

The best managers are inspirational leaders who set expectations, coach, inspire, and nurture new graduates to create the best patient care environment possible. The results will be evident both in staff and patient satisfaction scores.

5. Recognize and support.

If you want commitment, you've got to show commitment. New graduates should be shown you value them and are committed to their long-term career progression. Highlight tuition reimbursement and offer praise and support for nurses who return to school. The IOM's Future of Nursing report is pushing for 80% of RNs to have their BSN by 2020. If your new hires don't have a BSN, help them set a timeframe for doing so—and a manageable path for how to get there. And don't stop at BSN.

Many new nurses burn out and leave because of bullying or a hostile workplace. Don't let new graduates be bullied by other nurses, physicians, or anyone. If you don't have a zero tolerance policy, get one now. If you have one, make sure it's being enforced. Is there a rogue cardiologist, for example, who no one wants to work with, but whose bad behavior is tolerated because he brings in so much revenue? Make a stand now. Let the organization know that bad behavior isn't tolerated from anyone.

New nurses get discouraged and burnout when real-world nursing doesn't resemble what they thought it would be. Help them make a difference and effect change. Encourage them to become involved with shared governance councils that directly influence the practice environment. Get them to enroll in quality improvement initiatives. Make sure they are learning about evidence-based practice. If your hospital doesn't have a journal club, suggest the new graduates start one. Invite enthusiastic new graduates to be part of patient satisfaction and patient experience planning.

With these five key themes addressed, your new graduate nurses will be providing excellent patient care for years to come.

Mistakes are a fact of life. As the Institute of Medicine said in 1999, "To err is human." What matters is how we respond to mistakes, which involves putting systems in place to stop errors before they happen and supporting clinicians who make mistakes.

Not long ago, the catch phrase was "no blame" culture, where people talked about non-punitive responses to patient safety incidents. But simply saying "no blame" doesn't take the complexities of medical errors into account. Removing personal accountability from individuals isn't the answer, but neither is a rush to judgment and punishment that we know still occurs too often.

A balanced response that emphasizes individual and organizational accountability is Just Culture, a concept originating in aviation and crew resource management and lately honed by engineer David Marx. The Just Culture process involves purposeful responses to situations that investigate exactly what went wrong and why so as to understand everything, without falling prey to kneejerk emotional reactions that attribute blame.

One organization that has been working on establishing a Just Culture for the last few years is Lutheran Medical Center in Brooklyn. Rosanne Raso, RN, senior vice president, nursing services, says the most important concept of a Just Culture is to remove the emotional response that occurs whenever there is a medical error or a near miss. 

"The old way of doing things was to have a kneejerk reaction and punish people and that doesn't fix anything," says Raso. "You have to investigate and look into why things happened. You can't make any decision or judgment about what happened until you really dig into the whys. You don't know how to fix it until you know what went wrong."

Just Culture emphasizes learning from every event and promoting a culture of shared accountability throughout the entire organization.

"By shared accountability, I mean that the organization is responsible to have good systems that minimize risk," says Raso. "The individual is responsible for their behavior. They are responsible even if they made a mistake."

Raso provides an example. If nurses know the hospital's procedure is to check two patient identifiers before administering medication, then nurses are accountable for doing so. Let's say, however, that an organization uses a flimsy wristband system that is prone to falling off. In addition, there's no way to get another wristband without jumping through five hoops and filling out forms in triplicate. In this case, the organization doesn't have a system to support proper verification of patient ID.

"That's shared accountability," explains Raso. "The staff person is responsible for following safety policies and procedures and for making good judgment. In the end they are responsible for doing the right thing. But the organization is responsible for having systems to support that."

Raso points out that people don't usually break rules intentionally. "So to punish people for breaking rules is not always right because nine times out of 10 everyone is breaking the same rule," she says. "If you have routine violations of a rule, you have to make it part of investigation and have a systemwide corrective action plan. It's usually about systems, not people"

In a Just Culture, organizations perform a thorough investigation following an incident or a near miss, similar to a root cause analysis. It's important that staff are educated about the process or they may fear the investigation is looking for a scapegoat.

"Make it very clear that it's not a witch hunt," says Raso. "Say, this is not about punishing you. We are here to learn what happens so we can fix systems that support you to give best care possible to our patients.'"

The investigation should focus on what happened and why. Was there a system problem, does a process need to be redesigned? Was it a competence issue and does the individual need education or a focused performance review?

If organizations decide a caregiver made a mistake due to risky behavior and needs coaching, care should be taken to make it relevant. Simply admonishing caregivers to "be more careful" is a waste of time. To effect change, coaching should focus on behaviors. For example, coaching a nurse through the process of medication administration and the steps the organization expects nurses to complete each and every time.

"The other thing is that competence is not optional," says Raso. "If you are in unit where you cannot demonstrate competent behaviors for that patient population despite education and coaching, then you can't continue to work there."

It's hard to separate emotions when something goes wrong, but "in a true Just Culture, it's not about the outcome at all," says Raso. "Whether the patient was harmed or whether the error never reached the patient at all, you still use the same principles."

Everyone is responsible for their own actions and behavior. So if the investigation discovers a nurse was reckless or intentionally disregarded important safety safeguards, then the person receives punishment, such as suspensions or termination. However, incidents of intentionally reckless or criminal behavior are rare. Most incidents are completely unintentional and clinicians are devastated after making a mistake.

"You can't punish the person more than they punish themselves," says Raso. "There is nothing worse than the punishment that someone who makes a mistake inflicts on themselves."

See Also:
HHS Unveils $1B Program to Reduce Medical Errors
Time to focus on medical errors outside the hospital
Linking Medical Errors, Nurses' 12-Hour Shifts

Top 10 Most Costly, Frequent Medical Errors

7 Medical Error Disclosure Deterrents

Nurses are rallying in Washington, DC, Tuesday to bring attention to average Americans' healthcare hardships, saying the economic downturn has resulted in a healthcare emergency for many in this country.

The event has been organized by National Nurses United, the country's largest nursing union, which represents 170,000 nurses. NNU expects nurses to be joined by labor and community allies and will rally in front of the White House, Congress, and the Chamber of Commerce.

The NNU is proposing a "Main Street Contract for the American People," which, according to a press release, is "a program for rebuilding American communities with jobs, healthcare, education, and other urgent needs, funded through a fair tax policy targeted at those on Wall Street who created the economic crisis."

The event puts nurses at the forefront of healthcare reform discussions and positions them as advocates for patients. The presentations will link the recession and everyday Americans' economic woes to a myriad of problems, including poor health outcomes.

"We're here to talk about reinvesting in America in turns of investing in our communities," says  DeAnn McEwen, RN, co-president of the California Nurses Association. "We believe it has to change. People are suffering. We see them every day. They have lost their jobs, they are suffering illnesses, hospitals are closing beds. There's a whole population of people who have lost their healthcare coverage."

In an article in NNU's magazine for its members, the organization posited that healthcare legislation missed its chance to reform the industry and instead served to further entrench an insurance system that leaves too many Americans uninsured or underinsured. It states that too many are either without care or shoulder so much of the economic responsibility for healthcare that it leaves them financially strapped or forced to choose between medical care and essential household payments.

"We see something wrong and we have credibility with the public," says McEwen. "As the public's advocates, they trust and depend on us to run interference. It's our duty and right to stand up and say this is wrong. We see tremendous disparity between rich and poor."

U.S. Senators Bernie Sanders and Barbara Boxer (authors of two NNU-sponsored bills), AFL-CIO President Richard Trumka, and other legislators and community leaders will be speaking at the event. Boxer has introduced a patient safety bill that would establish minimum RN-to-patient ratios at all acute care hospitals across all shifts, as well as patient classification systems to ensure appropriate staffing.

"Numerous studies have been released saying patients suffer from preventable complications when there are not sufficient numbers of RNs at the bedside to meet their needs," says McEwen. "That's what breaks our hearts. We see people being harmed by this system when there aren't sufficient numbers of people there."

This event will likely garner coverage from mainstream media and serve to reinforce the public's impression that nurses are true patient advocates. Year after year, nurses are voted the most trusted professionals in the country in a national Gallup survey, and this type of event further solidifies in the public's mind that nurses have their best interest at heart.

It's a savvy move by NNU. Nurses are uniquely positioned to understand the way healthcare is delivered and experienced in this country and they see all too often the realities of how that care is delivered and the hardships often faced. As such, their voice is crucial in discussions about reform and provision of care.

NNU has found a large soapbox to ensure its voice is heard. And in doing so, it has served to solidify the impression of nurses as patient advocates. The next time contract discussions at a hospital represented by NNU heat up, this campaign will be included in the media coverage. If nurses are calling for patient ratios or more staff from a big business healthcare system, who is more likely to receive the most public support?