Nurse staffing concerns aren't unique to any one hospital or healthcare organization. For example, our Magnet®-recognized community hospital faced a multifaceted challenge that included recruiting and retaining a diverse workforce to provide safe, efficient, high-quality care amidst an imbalance of nursing resources, complex patient care requirements, and growing hospital volume. We highlight our journey to address this challenge through a collaboration between nursing leadership and human resources (HR) to develop a recruitment plan that resulted in major reductions in vacant nursing positions.
The 2019 American Nurses Association's staffing guidelines discuss the complexities of determining nurse staffing and how essential appropriate staffing is to providing quality, comprehensive healthcare.1 Although the guidelines state that the issues surrounding staffing are complicated and ever-evolving, they aren't unsolvable. Nurse leaders should find dynamic solutions to staffing issues that are guided by evidence. This statement is supported by a large body of research that validates the relationship between nurse staffing and patient outcomes.
A nursing shortage is predicted due to an increased demand for nurses coupled with a decreased supply. The shortage is expected to worsen because of the increasing age of the current nurse workforce approaching retirement. Nursing schools' inability to hire nurse faculty and the lack of clinical placement sites to meet nursing education demands will also contribute to the growing shortage. An aging patient population coupled with an increased number of individuals able to access healthcare as a result of the Affordable Care Act will also magnify the nursing shortage. The US Health Resources and Services Administration has predicted a national shortage of 193,000 nurses by 2020. Meanwhile, there are 10 states (Texas, California, Florida, New York, Pennsylvania, Ohio, North Carolina, Illinois, Michigan, and Massachusetts) that are projected to account for half of the nurse job growth.2,3
These statistics are concerning for hospitals across the nation faced with trying to balance patient care needs and nursing resources. Healthcare organizations that are in close proximity to one another often compete for nurses.4 These issues hit home at our 369-bed acute care community hospital located in an urban area of North Carolina with an extremely competitive healthcare market. Our facility was faced with vacant nursing positions, economic pressures, and declining patient and nursing satisfaction scores—all related to inadequate staffing. Retention and recruitment strategies are essential to address supply and demand within geographical regions.5 Magnet-recognized facilities are well positioned to be at the forefront of innovation and evidence-based leadership in the exploration, investigation, planning, implementation, and evaluation of programs to support recruitment and retention.6
Recruitment is everyone's responsibility in an organization despite the presence of nurse recruiters within the HR department.7 Nurse leaders and HR departments must collaborate to create long-term recruitment strategies.4 And recruiters, nurse managers, and nurse administrators must work together to ensure cooperation, collaboration, and understanding of an overall recruitment strategy.7 A formalized recruitment plan should include involvement of key stakeholders, identification of resources, an action plan, and an evaluation method.
At our community hospital, there was no clear plan and no team agreement that a plan was even necessary. The CNO inspired the need for organizational change by communicating a sense of urgency around the shortage of nursing resources to care for patients. We embarked on a process improvement project to increase recruiting, measuring the impact of implemented strategies on time-to-fill positions over a 2-year period. Specific research questions were: 1. Does the mean time to fill a position differ between year one clinical nurses and year two clinical nurses? 2. Does the mean time to fill a position differ between clinical nurse (CN) I and CN II positions? 3. Is there an effect from the interaction between the factors period and job title?
Time to fill is defined as the number of days between when a job was approved and when it was accepted by a candidate. Year one clinical nurses are new graduates within the first year of practice; year two clinical nurses are within the second year of practice. CN I candidates are entry-level and focus on developing basic knowledge and skills. All new graduate nurses enter the clinical ladder at a level I. If requirements are met, they may advance as early as 6 months to level II but are required to advance within 18 months of employment. These nurses are perceived as generally more available for hire. CN II candidates have completed 6 to 18 months of clinical nursing practice. They focus on expanding knowledge and skills, assume increasing levels of leadership, and consistently fully achieve or exceed performance standards. They don't yet meet requirements for higher clinical ladder levels. Job title is defined as whether a nurse is a CN I or II and measures the impact of experience on time to fill.
Our initial aim was to provide an influx of nurse applicants and quickly fill vacant positions. The first step was to examine current recruiting practices through a newly created intervention workgroup. The hiring process group (HPG) was a collaborative partnership of key stakeholders from nursing leadership, HR, and hospital-based nursing school faculty. They were invested in implementing successful strategies and tasked with responding to a competitive market and changing workforce.
The HPG identified several gaps in the recruitment process: 1. recruitment inefficiency due to HR's own departmental vacancies, 2. lack of a clear structured process resulting in delays in processing and hiring of nurses, 3. collaborative relationships between HR and nursing weren't in place to support the development of an efficient recruitment strategy, and 4. lack of interdepartmental cohesiveness with work often performed in silos. Numerous expectations and assumptions existed, leading to conflict between nursing leadership and HR. A clear lack of trust, collaboration, and accountability resulted in disruptive behavior within the group. The common thread that held the group together was a passionate determination to keep working through the differences in the interest of patient care.
The HPG formulated several strategies. The group dismantled the existing processes and had the courage to identify a different approach that didn't reflect the status quo. This required taking calculated risks. A recruitment plan was developed that included service-level agreements, timelines, flow charts, tracking tools, and commitment from all parties. Early in this process, several nurse manager positions were in various stages of hiring, orienting, and onboarding. The directors were included in the individual unit hiring process to facilitate communication and accountability in the absence of or along with the nurse manager. The directors also provided final approval of RN hires to ensure that candidates would promote organizational values and expectations.
The initial focus was on areas of greatest need: aging requisitions and difficult-to-fill positions. The CNO and chief HR officer shared a sense of urgency due to the high number of open positions. Before the formation of the HPG, the organization filled positions based on vacancies and budgeted positions. The HPG shifted the focus from reactive to proactive hiring based on projected volume and needs.
There was a lack of experienced nurses available for hire and an abundance of new graduates. The HPG recognized the advantage of hiring new graduates and worked with the nurse managers to change the culture of resistance to hiring novice nurses in some key areas. The need to fill open nursing positions, administration's strong encouragement of nurse managers to hire more new graduates than previously planned, and the availability of a nurse residency program for entry-level nurses resulted in an increased receptivity toward hiring new graduates.
Timelines and metrics were established to measure success. The first time frame was to hire 100 nurses in 6 months. This goal was met by collaborating with local nursing schools for site visits that included onsite interviews and focused job fairs to fast-track new hires. Information was provided to potential candidates in advance; if all information was in place at the time of interview, an offer was made within 24 hours of the interview. Based on the organization's previous success with onboarding international nurses, this was reintroduced as an additional strategy for bringing in experienced candidates who would be retained for at least 3 years.
To track goals, needs, and successes while implementing the hiring process program, metrics were established and showcased during meetings. A thermometer poster was created and updated every 2 weeks. Spreadsheets tracked the number of positions currently open, newly added, and filled. A spreadsheet was used to track the number of full-time equivalents that were filled, staff away on family medical leaves of absence, staff in orientation, and vacancies as compared with the number of positions needed to staff the unit. The tool also incorporated patient volume and expected turnover. The result clearly identified the gap reflecting the number of nurses that needed to be hired and drove the hiring plan for each unit. The tactics and measures were evaluated after the first 100 hires in the first 6 months and fine-tuned before setting the next target for an additional 100 nurses within the next 6 months. (See Figure 1.)
To evaluate the success of the HPG, pre- and postintervention comparisons of the time to fill a position were performed. The first 12 months of the project—the “storming” and “norming” phases—were compared with the second 12 months, which were considered the “performing” phase.
Job title was included to evaluate interaction effects and adjust for the hiring of a larger proportion of new graduates in year two (P < .01). The data included all RNs in the CN I and II categories posted between January 2015 and December 2016. This inclusion criteria eliminated outliers common with difficult-to-fill positions. Data were collected in May 2017 to ensure that positions posted during the inclusion period were filled.
Tables 1-4 display the mean time-to-fill positions by job title and period. To meet the assumptions required for parametric testing, the dependent variable “time to fill” was transformed to a normal distribution by using its square root. A general linear model employing a univariate analysis was used to compare the means by period and job title and evaluate interaction effects. The results showed that there was a significant 22-day decrease in the mean time to fill in the second 12 months compared with the first 12 months (P = .006) when adjusted for job title. The power for this analysis was .781.
Initially, strong leaders came together to acknowledge that there were recruitment issues. When reflecting on the journey, we realized that forming a cohesive team between the nursing and HR departments was an essential part of our success. The HPG continued to meet regularly and experienced the dynamic move from territorial to collegial. The group determined which metrics were important to track and developed a simple goal: hire 100 nurses in 6 months.
As the HPG started to evolve, it became obvious that the focus needed to be on staffing, with all energy on hiring and then retaining staff members. This needed to be a daily focus for both nursing and HR. Supporting each other in this process was also a key to success. Biweekly meetings allowed for accountability and kept everyone engaged.
There's strong evidence in the literature that supports the negative impact of prolonged vacancies on nurse turnover due to increased workload.7-9 Vacant nursing positions also impact the healthcare facility's ability to provide quality services to its primary customers. Based on this concern, it was important to understand the hiring process and identify metrics and processes to measure the time to fill vacant positions. According to the 2019 National Health Care Retention & RN Staffing Report, the average time-to-fill rate ranges from 62 to 108 days depending on the specialty.10 Our hospital's time-to-fill rate before the intervention was 86.5 days. We reduced it to 64.1 days after the intervention. The HPG continued to work together to identify additional strategies and address barriers.
Nurses are critical contributors to the delivery of patient care in healthcare facilities and vital to the institution's success. This project shows how effective collaboration between nursing leadership and HR can be used to address the problem of vacant nursing positions. The main influencing factor was the desire to meet current and future patient care demands. As discussed earlier, the nursing shortage will continue to increase based on multiple variables. The number of experienced nurses is decreasing across the US and the applicant pool predominately consists of new graduates. The time to fill a vacant nursing position with a new graduate is significantly shorter than waiting to fill a position with an experienced nurse.11 Nursing leadership must embrace hiring new graduates and support this model with resources.
Jones and colleagues experienced positive outcomes in hiring and retention by taking the approach of identifying new graduates as hires of choice and supporting them with a nurse residency program.9 Nurses in their first year of practice face common challenges transitioning from the role of student to a competent member of the healthcare team. With an evidence-based curriculum focused on leadership, patient outcomes, and professionalism, our year-long nurse residency program provides the tools necessary to build confidence, commitment to excellence, and courage to transform the future of nursing practice. Participants benefit from increased competence and confidence in decision-making, enhanced satisfaction and professional commitment, and the development of strong leadership and critical-thinking skills.
When forming a team between two departments, allow the processes of storming, forming, norming, and performing to evolve. Understand and expect times of disagreement and conflict. Set ground rules and allow each side to present their position, listen to each other, and, most important, keep coming back together. Set one short-term, simple, realistic goal and regularly review progress toward meeting that goal. Implement tools to track the progress of positions filled, as well as positions added. If something doesn't work, go back, reassess why there was a breakdown, and quickly correct the process. Document the journey and communicate success from the highest stakeholder to the frontline clinical staff. Once you meet your goal, be sure to celebrate your achievements!
1. American Nurses Association. Principles for Nurse Staffing
. 3rd ed. Silver Spring, MD: American Nurses Association; 2019:1–8.
2. US Department of Health and Human Services, Health Resources and Services Administration, Bureau of Health Workforce, National Center for Health Workforce Analysis. The Future of the Nursing Workforce: National- and State-Level Projections, 2012-2025
. Rockville, MD: US Department of Health and Human Services; 2014:1–18.
3. American Association of Colleges of Nursing. Fact sheet: nursing shortage. 2019. http://www.aacnnursing.org/News-Information/Fact-Sheets/Nursing-Shortage
4. Drennan VM, Halter M, Gale J, Harris R. Retaining nurses in metropolitan areas: insights from senior nurse and human resource managers. J Nurs Manag
5. Weidner A, Graham C, Smith J, Aitken J, Odell J. Alberta: evaluation of nursing retention and recruitment programs. Nurs Leadersh (Tor Ont)
. 2012;25(Spec No 2012):130–147.
6. Hill KS. Magnet hospitals: recruiting and retaining nurses. Nurs Clin North Am
7. Christmas K. Forging relationships to strengthen recruitment. Nurs Econ
8. Maxwell M. Recruitment realities: building a HR/nursing partnership. Nurs Econ
9. Jones S, Deckers CM, Strand D, Bissmeyer H, Bowman WJW, Mathe DG. Succession planning: creating a case for hiring new graduates. Nurs Econ