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Feature: CE Connection

A multifaceted approach to tackling nurse turnover

Kester, Kelly M. MSN, RN, CCRN, NE-BC

Author Information
Nursing Management (Springhouse): June 2020 - Volume 51 - Issue 6 - p 22-28
doi: 10.1097/01.NUMA.0000662652.32499.22
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Nurse managers face many challenging daily responsibilities, including strategic management of staffing, quality improvement, and finances. Clinical nurse retention is a priority for nursing leaders that requires short- and long-term planning. US hospitals experience 17.2% RN turnover on average; overall, 55.3% of hospitals have an RN vacancy rate of over 7.5%.1 In addition to clinical nurse retention, nurse managers must focus on optimizing hiring, training, and onboarding processes because the hiring pool has an average of less than 2 years' experience. Newly created positions are also on the rise, due in large part to the aging population.2

Mitigating staffing challenges requires sustained attention to two primary components: knowing precisely how many clinical nurses you need to adequately staff the unit based on patient census, including anticipating turnover and onboarding competent nurses before a deficit occurs, and knowing how to recruit and retain the needed workforce, including focusing on and fostering a healthy work environment, which is strongly associated with perceived teamwork and patient care outcomes.3 Together, staffing projection and retention skills are the foundation for success in improving clinical nurse retention.

This article provides nurse managers with effective strategies to improve clinical nurse retention by optimizing local RN staffing and healthy work environments.

Honing staffing skills

The technical skills of staffing include the ability to identify the number of clinical nurses needed to care for patients. Simply put, how many nurses do you need on your team to adequately function? Although this may seem like a basic question, it's critical to understand the importance of calculating this number thoughtfully. One crucial part of the decision is knowing if the department will be expected to maintain 100% capacity. If you aren't expected to maintain 100% capacity, you'll need a plan to care for unexpected patient volumes. Using a consistent method each time you review your staffing needs is recommended. Two methods to calculate staffing needs are described here.4

Method 1 provides the calculation to determine the number of clinical nurses needed based on budgeted hours per patient day (HPPD) and census. (See Figure 1.) HPPD includes the hours of care delivered by RNs, LPNs, and unlicensed assistive personnel every 24 hours.5 An organization may define this by level of care, such as intensive care, stepdown, and intermediate, or by workload using an acuity or workload tool. The census used to determine full-time equivalent (FTE) needs may be the average daily census, budgeted census, or 100% capacity. FTE is full-time work, or 8 hours per day, 5 days per week, 52 weeks per year.5 The census used to determine FTE needs is likely determined by hospital leadership and may be based on hospital needs and trends.

Figure 1:
Figure 1::
Method 1

Method 2 is a strategy using the variable staffing plan to determine the number of clinical nurses needed in a department. (See Figure 2.) A variable staffing plan is a guide displaying the number of staff members needed to provide the necessary care hours, which varies based on patient census and types of care that patients require.5 The variable staffing plan provides the number of clinical nurses needed for the specific census, so the total number will be predetermined, similar to method 1. Figure 3 provides an example of method 2 based on a 12-hour shift staffing model, but it can be adapted to meet the needs of 8-hour shifts.

Figure 2:
Figure 2::
Method 2
Figure 3:
Figure 3::
Examples of methods 1 and 2

Once the number of clinical nurses needed is identified, the amount of budgeted indirect time should be added. This budgeted amount should be provided to you. If it isn't predetermined by the hospital, it can be calculated using the previous year's budget. (See Figure 4.) This percent provides a “cushion” that prevents the department from being short-staffed when nonproductive time is needed for projects, education, vacation, leaves of absence, or unscheduled absences.

Figure 4:
Figure 4::
Calculation to determine percentage of nonproductive hours14

The next step is identifying the staffing gap. Using a position control document, calculate the total number of FTEs currently employed, or actual FTEs, by the department. Deduct the actual FTEs from the FTEs needed to determine the staffing gap. For example, the department needs 58.77 FTEs, but actually has 52.9, so the staffing gap is 5.87 FTEs. When a staffing gap exists, you'll need to replenish this gap quickly using a consistent approach to identify the best candidates to interview and hire.

Ideally, hiring practices are driven by use of a predictive rather than a reactive approach.4 To achieve this, nurse managers will require unit-level turnover data from at least the 2 or 3 previous years. We should assess this for turnover trends by time of year and average tenure of RN at departure. Using this information to predict turnover helps justify hiring before having vacant positions. Additionally, the average time to fill a position is needed, which varies depending on hospital location and if the position is for an experienced or new graduate candidate.4 Nurse managers also need to take into account the length of time to train a newly hired nurse. Using this predictive approach is recommended to provide nurse managers with a consistent and objective method of hiring.

An estimated 48.2% of RNs leave their job within 2 years of hire, which pushes nurse managers to be more flexible to staff their department's needs.1 You may find that you need to hire large amounts of candidates, so you must be equipped with the skills to hire, train, and develop a diverse team. Consider focusing more heavily on recruiting newly licensed RNs, those who lack related work experience, and recently retired RNs.6 Fostering a well-rounded and consistent onboarding and orientation process will help mitigate the experience gap.2

Promoting a healthy work environment

A second major skill set for achieving workforce stability is retention, specifically retaining clinical nurses who are early and late in their careers as a strategy for maintaining overall staffing and experience levels.2 One way to improve retention is to focus on creating a healthy work environment.7 The American Association of Critical-Care Nurses (AACN) states that a healthy work environment is necessary for nurses' ability to deliver safe and effective care.8 The six standards outlined by the AACN in Standards for Establishing and Sustaining Healthy Work Environments are skilled communication, authentic leadership, meaningful recognition, appropriate staffing, effective decision-making, and true collaboration. (See Table 1.) Nursing departments that have fully implemented the AACN standards can expect to experience improvements in staff perceptions of quality of care, appropriate unit staffing, intent to stay, and moral distress.8

Table 1:
Table 1::
Strategies to achieve the AACN healthy work environment standards

Lasting commitment from the leadership team is an important factor in establishing a healthy work environment. To understand a department's starting point, you can use the AACN's Healthy Work Environment Assessment Tool. Next, engage a diverse team of clinical nurses to be champions and lead the initiative, including newly licensed nurses, experienced nurses, and those who've worked in other departments. This team will require dedicated time and resources to support healthy work environment efforts as it works to improve the following standards.

Skilled communication. The department must have transparent, consistent communication to improve patient outcomes and promote a learning environment for newly hired employees. Systems interventions, such as using Situation-Background-Assessment-Recommendation, the Agency for Healthcare Research and Quality's TeamSTEPPS, communication checklists, and standardized methods for handoff, can be used to optimize communication.9 The use of systems interventions requires multidisciplinary team collaboration.

Authentic leadership. Nursing leaders must be dedicated to the healthy work environment journey, which translates to the team's outlook. Nurse managers are highly influential to the success of gaining buy-in and engagement of local teams. Organizations must provide nurse managers with opportunities to learn how to navigate challenging situations in a consistent manner. Simulation exercises may be a useful method to gain comfort in managing unpredictable or difficult situations. Mentorship is a second strategy that can improve your ability to effectively implement healthy work environment standards and engage nurses in the work. Lastly, having a nurse leader physically present on the unit to build relationships, troubleshoot issues, and deliver recognition is a major component of authentic leadership.10

Meaningful recognition. Nurse engagement is driven by meaningful recognition, which is critical for staff members to feel valued.11 Recognizing staff is a key responsibility of nurse managers, but it must be done in a way that's meaningful to individuals.12 Teams are diverse, and the method in which one individual prefers to be recognized may conflict with another's. Although challenging, particularly in large departments, it's helpful to maintain a log of individual recognition preferences and frequency of recognition to ensure that everyone is being acknowledged. Identifying methods for staff to be recognized by patients and families is also important and may have lasting effects. Having thank-you cards available in patient rooms and waiting areas supports this strategy. Combined with leader recognition, this can generate positive energy and excitement for frontline staff. Lastly, promoting peer-to-peer recognition supports team building and appreciation of others.

Appropriate staffing. The effective match between patient needs and nurse competencies can influence satisfaction, burnout, and retention.7 The first step, as described earlier, is to ensure enough team members so that flexibility is available to meet the needs of patients and staff. Second, nurse managers must have a method to know what patients need and what competencies nurses have. Using competency-based orientation and maintaining consistent records that are easily accessible will make appropriately assigning staff easier. Appropriate staffing is an effort that requires partnership between nurse managers and charge nurses. Making effective patient assignments is a leadership skill that takes practice, evaluation, and balance to meet nurses' needs. To understand patient needs, charge nurses must perform rounding, speaking with patients and families to gain familiarity with unique needs. Staff members must also remain flexible and not be overly focused on nurse-to-patient ratios.7

Effective decision-making. Clinical nurses must be involved and committed partners in progressing patient care and operations.7 Identifying unit- and hospital-based opportunities for clinical nurses to be involved as partners is a responsibility of nurse managers, although the individual nurse is responsible for his or her own engagement in professional growth. Offering specific opportunities for clinical nurses who work nights and weekends is challenging, but particularly important. Empowering nurses at the bedside is critical because they have the best knowledge of patient needs and opportunities for improvement. Including clinical nurses in traditionally leader-only discussions may help gain buy-in, promote positive relationships, and generate innovative ideas and is an opportunity to excite nurses about leadership.

True collaboration. A team that's competent, skilled in communication, respectful of others' thoughts and interests, and invested in sustaining a collaborative culture demonstrates true collaboration.7 By engaging clinical nurses in decision-making and establishing this as a norm, the structures that support this work will be collaborative. Also, providing interprofessional education for all team members to promote the collaborative culture is a meaningful strategy. A truly collaborative culture, nurtured over time, will be rooted and won't change despite personnel turnover. Although nurse engagement is a focus of nursing leaders, identifying opportunities to engage others, such as ancillary teams and physicians, can further promote collaboration that leads to improved communication, patient care, and staff satisfaction.13 Overall, individuals who work in a truly collaborative work environment are appreciative and respectful of others with the shared goal of delivering excellent patient care.

Hiring right

When we combine the technical skills of staffing with a healthy work environment, nursing teams become clinically strong and resilient. Hiring nurses isn't only an opportunity for us to stabilize staffing numbers; it also influences the character and culture of the entire team. Seeking nurses whose values align with the department's mission leads to a supportive environment that further fosters behaviors of a healthy work environment and retention. Partnered with onboarding and orientation that role model these behaviors, this will solidify the newly hired nurses' perspectives and long-term expectations of the team.

When the AACN standards are consistently applied to every aspect of departmental operations, including hiring, training, and clinical care, the team will be successful in delivering high-quality care, retaining staff, and promoting leadership at the bedside. Furthermore, engaging all disciplines within the department's team in these efforts engrains the culture and healthy work environment principles into all aspects of care. Nurse managers are the core influencers of this multifaceted approach to stabilize and improve nursing teams and require ongoing support and education to be successful.

Improvement is possible

Retaining clinical nurses isn't accomplished using one strategy. Nurse managers must be armed with a skill set to understand local turnover trends and hire before vacancies occur. Equally important, nurse managers must choose to initiate the journey toward a healthy work environment using a structured process with measurable goals. By implementing a multifaceted approach, you can drive improvement of clinical nurse retention at the local level.

INSTRUCTIONS A multifaceted approach to tackling nurse turnover

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REFERENCES

1. NSI Nursing Solutions, Inc. 2019 NSI National Health Care Retention & RN Staffing Report. www.nsinursingsolutions.com/Documents/Library/NSI_National_Health_Care_Retention_Report.pdf.
2. Virkstis K, Herleth A, Rewers L. Closing nursing's experience-complexity gap. J Nurs Adm. 2019;49(12):580–582.
3. Price SL, Vine J, Gurnham ME, Paynter M, Leiter M. Experiences with managing the workplace social environment: a qualitative study. J Nurs Adm. 2019;49(11):569–573.
4. Kester KM, Lindsay M, Granger B. Development and evaluation of a prospective staffing model to improve retention. J Nurs Manag. 2020;28(2):425–432.
5. Finkler SA, Jones CB, Kovner CT. Financial Management for Nurse Managers and Executives. St. Louis, MO: Elsevier; 2013.
6. Jones S, Deckers CM, Strand D, Bissmeyer H, Bowman WJW, Mathe DG. Succession planning: creating a case for hiring new graduates. Nurs Econ. 2017;35(2):64–69,87.
7. American Association of Critical-Care Nurses. AACN standards for establishing and sustaining healthy work environments. 2016. www.aacn.org/~/media/aacn-website/nursing-excellence/healthy-work-environment/execsum.pdf.
8. Ulrich B, Barden C, Cassidy L, Varn-Davis N. Critical care nurse work environments 2018: findings and implications. Crit Care Nurse. 2019;39(2):67–84.
9. Grant M. Resolving communication challenges in the intensive care unit. AACN Adv Crit Care. 2015;26(2):123–130.
10. Aboshaiqah AE. Nursing work environment in Saudi Arabia. J Nurs Manag. 2015;23(4):510–520.
11. Zwickel K, Koppel J, Katz M, Virkstis K, Rothenberger S, Boston-Fleischhauer C. Providing professionally meaningful recognition to enhance frontline engagement. J Nurs Adm. 2016;46(7–8):355–356.
12. Doucette JN. Advice on meaningful recognition. Nurs Manage. 2018;49(8):56.
13. Despins LA. Patient safety and collaboration of the intensive care unit team. Crit Care Nurse. 2009;29(2):85–91.
14. Hunt PS, Hartman D. Meeting the measurements of inpatient staffing productivity. Nurs Manage. 2018;49(6):26–33.
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