Nurse retention equals improved productivity
By Bob Chernow, for SBT
Commentary
Several months ago, I began attending meetings of Mayor John Norquist’s "Health Care Cost Containment Commission." The mayor assembled a study group that included business people, union representatives, suburban municipal officials, hospital administrators, and insurance professionals. The intent of the commission was to study and develop solutions to contain upward spiraling health care costs.
As a municipal official and businessman, I found the discussions and recommendations on the topic of cost containment fascinating, especially given my interest in problem-solving strategies. I left the meetings motivated to use my expertise to modestly impact one area of the commission’s work.
The subject I selected was "nurse retention." The reason was because my wife is a retired psychiatric nurse, I know many other nurses, and I am familiar with critical issues facing nurses.
Is nurse retention a problem? The answer is a resounding "Yes!"
A 2001 American Nurses Association study found that nearly 55% of the 7,300 nurses surveyed would not recommend the profession to others. Another 23% said they would actively discourage someone close to them from entering the field.
In addition, nurses display among the lowest "engagement" levels of any category of workers, according to the Gallup Organization. Nearly 24% of the 22,000 nurses surveyed between 1999 and 2001 said they were "disengaged" from their work, defined as physically present but psychologically absent, compared with 18% of workers nationally.
One of every five nurses plans to leave nursing over the next five years. In addition, the 135,696 registered nurses who were employed in non-nursing occupations in March 2000 represented a 15% increase over the 117,820 nurses similarly employed outside of the profession in 1996, and a 36% increase over the approximately 99,955 in 1999. These figures are from the National Sample Survey of Nurses, conducted by the Health Resources & Services Administration.
American Demographic (September 2002) cited Bureau of Labor Statistics that the nursing field will face more staff vacancies by 2010 than other category of professional. The researchers estimate the number of vacancies by the year 2010 at one million due to increased demand and net replacement needs.
There are many causes for the nursing shortage. Central to the problem is the declining enrollment in nursing education programs. This decline has been at an annual rate of 4.2% since 1993. Milwaukee demonstrates an exception to this national statistic, as there is a waiting list for acceptance into the Milwaukee Area Technical College nursing program.
The Robert Wood Johnson Foundation issued a report in April 2002, "Health Care’s Human Crisis: The American Nursing Shortage" that detailed the reasons for the nursing shortage:
1. A relative shortage due to increased health care demands of an aging population
2. Fewer workers
3. An aging workforce
4. A mismatch on diversity
5. More options for women
6. A generation gap (Gen X sees nursing as unappealing)
7. Consumer activism
8. A ballooning health care system, and
9. A poor work environment
From a practical perspective, there are limited solutions to items 1 to 8. The most fruitful area for success rests in improving the work environment. Much of what I will discuss centers on awarding nurses increased respect and greater control in their professional responsibilities. To accomplish that goal several recommendations are central:
1. Recognize that nurses want input into their scheduling. They want to feel as if they are more than just a "cog" in the wheel. They want a say into how schedules are made up, and, importantly, they want to have their requests honored. Two requests a month would be reasonable, but not under the current, inefficient system where nurses need to bargain with fellow nurses for times off.
2. Understand the issues involved when the shortage of nurses makes reassignment to other floors a necessity. Acknowledge that few nurses feel competent functioning on different units, primarily because they are not trained for the technical complexity of today’s modern hospital. It is not that they dislike the work, but because they feel as if they are just "bodies" filling a slot. One solution is not to shift nurses out of their specialties, but have back up staff for each specialty. If this is not possible, and nurses need to be rotated, then they should receive appropriate training on the floors to which they might be assigned. This is not being routinely done.
What will this accomplish? Primarily it will improve productivity, show professional respect, and reduce errors. What occurs currently is that nurses are transferred into areas where they are unprepared to contribute effectively. This system then transfers the work "load" to the understaffed nursing staff that regularly work in that area. This is counterproductive to an efficient work environment or employee morale.
3. Survey nurses to find out what they want and then implement solutions to satisfy their complaints. Provide feedback to the nursing staff and let them know that you are listening to them.
Interview nurses who have left your employ or have left the profession. Human resources currently conducts exit interviews, but these are ineffective or ignored.
4. Create a positive relationship between doctors and nurses. Develop a team atmosphere, while allowing nurses to practice their profession. Most importantly, train doctors to be sensitive to nursing issues and to utilize nurses’ skills appropriately. With the increased stress and workloads placed upon them, doctors have a self-motivation to maintain optimal working relationships with nurses. This area will present a challenge, as there is a certain "territoriality" among hospital professionals and administrators that needs to be overcome.
5. Consider hiring additional "technicians" (previously termed orderlies) to assume appropriate duties assigned by the nursing staff.
6. Improve communication among the hospital’s support team to maximize the effectiveness of the above steps. Reduce paperwork and increase pharmacy staff to reduce the wasted time nurses wait for a pharmacist.
7. Use more administrative technology, such as transcribers that have the ability to transcribe and verify. This allows for "orders" to immediately enter the system.
8. Commit additional resources through MATC to accommodate the demand for nursing education. Keep in mind that there is a trend toward having educators at MATC earn "higher" degrees. Nursing needs excellent, committed teachers, not a reduction of the pool of teachers due to unnecessary requirements. We need practical "experience" in the teaching staff, not necessarily higher degrees.
We also need to determine if there is an imbalance between what nursing students are taught to aspire to versus the realities of working in the nursing field. It is essential that students learn to think in a specific framework and understand the tasks they will be performing on the job. But will these tasks involve understanding pharmacology or learning organic chemistry? Students need to learn mathematics, but more importantly they need exercises that teach the relationships between mathematics and on the job skills. A further question then becomes, do we need nurses who are specialists or generalists?
9. Reward nurses who remain in areas of nursing where there is a need. Currently the way for advancement and, consequently, "rewards," is to obtain higher degrees or enter into management. We actually need fewer nurse administrators and more coordination among nurses. Fewer managers will improve productivity — assuming that less administration reduces the level of paperwork and puts more nurses to work on the "floors."
10. Provide nurses with the opportunity to see the results of their hard work and achieve closure. Imagination is necessary to accomplish this goal as today’s outpatient settings and short-term stays make this difficult. Nurses care about their patients and need to feel invested in their outcomes.
11. Retain present staff by offering incentives for continued service. Many hospitals are so desperate for nurses that they offer bonuses to new recruits and promise them choice hours and early promotions. Rarely are these types of incentives used to keep staff. When using surveys, as I suggested above, include questions to help determine what makes nurses happy in their ideal employment situation.
It is important to explain to your staff that a primary benefit of aggressive recruitment is the ability to reduce forced overtime and improve service. Rarely (if ever) does management explain their decision-making process. In part this is because management often reacts rather than plans, and because they view nurses as employees, not professionals.
12. Reduce the stress level of nurses by creating realistic expectations. Often expectations are unrealistically high as regards to what nurses can accomplish. The economic realities of health care require higher productivity, but more is not necessarily better. Nurses feel that "better" (doing the job right) is often more beneficial.
13. Lastly, use "incident reports" to formulate positive change for the future, rather than to assign blame. The ideal of "don’t address blame, solve the problem" is central to a constructive work environment. It is often the case that nurses feel singled out for "gotcha" situations when management files incident reports. The reports are frequently viewed as covering the hospital’s backside, and not otherwise productive.
A practical, objective business approach to one aspect of a problem, often effectively contributes to solutions to the larger, encompassing situation. Increased nurse retention can enhance productivity in hospitals and go a long way in containing health care costs.
Bob Chernow is a futurist and Milwaukee businessman. He is also a River Hills village trustee and chairman of the Regional Telecommunications Commission and the North Shore Cable Commission.
Feb. 21, 2003 Small Business Times, Milwaukee
