Blog July 21, 2009

Best Practices for Retaining Nurses

Providing a rewarding environment in which nurses can work, with opportunities to grow, and a chance to be heard and participate in practice decisions keeps experienced nurses at the bedside and, ultimately, improves patient care.

“Nurses create a history of excellence for you,” said Ann Scanlon McGinity, Ph.D., RN, a chief nursing officer at The Methodist Hospital in Houston, Texas. “When you have people who stay and grow with you, you have better patient care.”

Nursing leaders shared with Healthcare Briefings a variety of retention best-practice suggestions.

Creating the right culture
Nurses want to practice in an environment where they can succeed and provide the type of care they are trained to deliver.

“We have created a culture of safety, quality, and service, and the nurses who work here are very invested in the facility,” said Leah Carpenter, RN, MPA, a chief nursing officer at Memorial Hospital Miramar in Miramar, Fla., who reports a waiting list of nurses who want to work at the hospital.

Keeping experienced nurses is important, she added, because “you want to make sure the legacy of the culture you created is carried on.”

Carpenter hires for attitude. She believes you can train someone in the proper technique to complete a task, but you do not teach someone compassion or a desire to be the best.

“When we hire, we try to hire for life,” Carpenter said. “We spend a lot of resources on reward and recognition. And we pay attention to what our nurses say.”

Self-governance
McGinity credits Magnet practices, such as nurse practice councils, quality improvement efforts, and peer interviewing with enhancing nurse satisfaction and limiting turnover at her facility to less than 10 percent. She said it’s not the gimmicky things that retain people. She hires nurses who share the organization’s values and want a career as opposed to a job.

“Part of how you find those qualities is to have colleagues interview and select who they want to work with them,” McGinity says.

Listening to nurses and acting on it
At Memorial, Carpenter rounds on the units listen to nurses’ ideas and concerns, and ensure nurses have the equipment and supplies needed to practice effectively.

Hospitals frequently measure nurse satisfaction through surveys and the ones that are successful with retention act on nurses’ suggestions for improvement. Scripps Memorial Hospital La Jolla, Calif., implemented a lift team after nurses on its survey requested help with positioning patients.

“It offsets some of the physical demands on our nurses,” said Mary Ellen Doyle, RN, BSN, MBA, chief nurse executive at Scripps, which has a 6.67 percent voluntary turnover rate.

Morristown Memorial Hospital in Morristown, N.J., is installing ceiling lifts in every room and has a physical therapist evaluating ergonomics on each unit. The hospital, which enjoys a 95.5 percent retention rate, also prides itself on changing to address nurses’ concerns and encouraging units to develop and implement their own action plans.

Nurse-physician collaboration
Nurses at The Methodist Hospital participate on clinical quality committees, along with physicians and professionals from other disciplines, which McGinity said nurses really appreciate.

Banner Thunderbird Medical Center in Glendale, Ariz. also promotes collaboration between disciplines.

“Nobody wants to be left out there alone,” said Sally Diamond, RN, MHA, MBA, a chief nursing officer at Banner Thunderbird, which has a 93 percent retention rate for RNs. “It’s nice to know you are there together and can count on one another. When I talk to staff, that team structure makes the days more pleasant.”

Developing leaders
St. John’s Mercy Medical Center in St. Louis, Mo., developed iCare, a formal career development program. Nurses meet with their supervisors to discuss steps toward fulfilling their goals.

“It’s for personal and professional career development,” said Laura Sease, RN, BSN, MBA, recruitment and retention manager at St. John’s Mercy, which has a voluntary turnover rate of less than 1 percent. “It creates relationships, first and foremost, between our nursing staff and their managers.”

Sease added that connecting with co-workers is key to the hospital’s success with retention.

“If nurses feel someone cares about them, they want to come to work every day,” Sease said. “If they feel their opinions count, they want to participate. They don’t just have a job.”

Residency programs
Several hospitals have found that enlisting new graduates in a residency program has improved retention. Not only are the novice nurses less likely to leave, experienced nurses feel less frustration and greater satisfaction with precepting, knowing their efforts are not in vain.

“Preceptors are getting re-energized because people are actually staying,” said Cathy Krsek, RN, MSN, MBA, director of operational benchmarking and nursing leadership for University HealthSystem Consortium (UHC), which offers the UHC/American Association of Colleges of Nursing (AACN) Nurse Residency Program.

Krsek reports a 5.6 percent turnover rate for new graduates completing the UHC/AACN Nurse Residency Program at 29 participating U.S. hospitals, compared with a national average, according to a 2007 PricewaterhouseCoopers report, of 27 percent during the first year of service. Participants complete an evidence-based project as part of their residency, conducting research and providing an opportunity to enhance the nurse work environment and service to patients.

Professional support and development
Phoenix Children’s Hospital developed the paid 14-week Graduate Advancement Program in Pediatrics (GAPP), a didactic and clinical learning program that bridges the gap between academia and pediatric care. Retention of new hires increased from 60 percent to more than 90 percent in the five years since GAPP launched.

“You increase retention by creating an environment that supports professional practice growth and development,” said Deb Wesley, RN, MSN, senior vice president and chief operating officer at Phoenix Children’s. “We’ve focused on professional advancement and development resulting in better patient outcomes.”

Phoenix Children’s also created a clinical scholars program, which teaches nurses how to use evidence to improve the environment or the patient experience.

Scripps places resource nurses on their units. These clinically expert nurses do not receive a patient assignment; they are available to answer newer staff nurses' questions and help them with unfamiliar procedures.

“For the new grad, it’s been extremely valuable,” Doyle said.

Upper Chesapeake Health in Bel Air, Md., also implemented a resource nurse program. The resource nurses work from 5 p.m. until 1 a.m. and respond as needed to other nurses’ clinical questions.

Return to care
VHA Inc., the national health care alliance, has created the Return to Care clinical improvement program to improve quality and retention on medical-surgical units by allowing nurses to spend more time with patients, rather than documenting and hunting for supplies and equipment.

“Our focus on retention has been about the work environment and getting nurses back to the bedside and increasing the satisfaction they have,” says Crystal Mullis, RN, MBA, MHA, director of performance improvement at VHA. “We’re getting back to the basics.”

Suggestions include completing shift reports at the bedside, rounding hourly, placing medications in a locked drawer at the bedside, and moving supplies and linens to the room or nearby alcoves.

Upper Chesapeake Health and Nash General Hospital in Rocky Mount, NC., joined the Return to Care initiative one year ago and have noted anecdotal improvement in nurse satisfaction.

“Overall, the staff is happier,” said Paula Bush, RN, a nurse manager on the medical-surgical unit implementing Return to Care at Nash General.

Joyce Fox, RNC, MS, CNAA, vice president of patient services and chief nursing officer at Upper Chesapeake, added that the program has helped nurses organize their time because they are not dealing with as many interruptions.

Sharing in success
In addition to annual performance reviews, Scripps offers staff “success shares,” a bonus of up to five days' pay if the hospital has met its goals.

“It aligns all of us to work for a common goal and to participate in a reward for that,” Doyle said.

St. John’s Mercy also offers nurses an incentive program. Nurses keep track of their accomplishments, be it presenting at a conference, completing a fellowship program, receiving thank you notes from patients, or achieving something else noteworthy. The nurse and manager meet and review the items, and the nurse can earn as much as $2,000. In addition, nurses with 15 or more years’ tenure with St. John’s Mercy automatically receive an additional five days of vacation time.

“We’ve seen in our workforce that folks want to stay at the bedside,” Sease said. “They can be recognized for being excellent as a clinical nurse.”