NURSE RECRUITMENT AND RETENTION 15 RUNNING HEAD NURSE RECRUITMENT

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N663: Nurse Recruitment and Retention

Nurse Recruitment and Retention 15

Running Head: NURSE RECRUITMENT AND RETENTION






















Nurse Recruitment and Retention – The Magnet Connection

Taryn A. Higa

University of Hawaii at Manoa










Abstract

With a nursing shortage upon us, hospitals are seeking American Nurses Credentialing Center’s (ANCC) Magnet designation as a way to recruit and retain staff. Magnet Recognition is the highest level of recognition that the ANCC can confer upon organized nursing services. The goals of the Magnet program are to identify excellence in the delivery of nursing services to patients, promote quality in an environment that supports professional practice, and provide a mechanism for the dissemination of "best practices" in nursing services (ANCC, 2002). Achieving this award indicates excellence in nursing services, development of a professional environment, and growth and development of the nursing staff (ANCC, 2002). This paper examines nurse recruitment and retention strategies related to Magnet status. In addition, this paper discusses information technology’s support of nursing excellence.












Background and Significance

The United States is currently experiencing a critical shortage of registered nurses (RNs) (Buerhaus, Staiger, & Auerbach, 2000). Reasons for the shortage are multifold. At present time, approximately one-third of working nurses are over the age of 50. Nurses are expected to be retiring in large numbers over the next decade. As a result, the registered nurse job vacancy rate was 15% in 2003 and expected to be 20% by the year 2020 (Buerhaus, et al., 2000).

Nursing schools are not graduating enough nurses to meet the current demands. Although enrollments in schools of nursing are beginning to increase slightly, there remains a projected shortfall of one million new nurses by the year 2010. It is quite evident that there are also not enough nurse educators to meet the demand. From 1997 to 1998, the number of master’s students in nursing education fell 27.5%. The average age of nurse educators is 49 years (Atencio, Cohen, Gorenberg, 2003). Subsequently, there are serious concerns about expected mass retirements in the next several years. With inadequate new faculty to replace retirees, the country is also facing a nurse educator void. This will directly affect the ability of schools of nursing to admit additional nursing students. Simply stated, the supply of RNs does not meet the demand.

In addition, nurses across the nation are reporting increased stress and dissatisfaction with nursing. One in five nurses plan to leave the profession within the next five years (Atencio, et al., 2003). Considering all these issues, it becomes imperative to search for ways to retain experienced nurses.

With managed care cost initiatives implemented throughout the country, we are seeing a dramatic decrease in patient length of stay. However, as length of stay decreases, the acuity of patients increases. With increased acuity, comes the need for more nursing patient care hours and skilled nurses (Seifert, 2000). Unlike previous shortages, this is not about the sheer numbers of nurses, but about having enough nurses with the needed specialty skills and experience to care for acute patients.

Downsizing has also taken a toll on the health care industry, particularly on hospital nurses. Nurses are required to do more with less. As a result, nurses feel physically exhausted and emotionally drained because of increased patient load and the conditions under which they must work. The present shortage is made even more acute as a result of nurses opting out of the nursing profession all together, due to dissatisfaction with their roles in the clinical setting. The problem therefore, lies not only in recruitment efforts, but equally in the retention of qualified nurses (Sigma Theta Tau International, 1999).

A common belief has been that increasing nurses’ salaries will attract more individuals to the profession. While large starting bonuses and other monetary marketing strategies and means of compensation have been instrumental in alleviating the nursing shortage, they do not address one of the most fundamental underlying causes (Sigma Theta Tau, 1999). Monetary compensation puts a bandaid on a gapping wound.

Higher wages alone is not powerful enough to draw an adequate number of new nurses to the nursing profession, nor is it enough to retain the excellent nurses presently practicing. Nurses want to be appreciated and respected by physicians and the administrative team. They want to be recognized for their expertise and they want to take responsibility and participate in the decision-making process concerning patient care (Johnson, 2000). Nurses want to be valued.

The Magnet Hospital Model

Hospital administrators, including nurse executives, must be proactive in seeking ways to preserve professional staff in the hospital settings. The executive team needs to find ways to make hospital work more appealing to registered nurses. Reorganizing the work setting to bring about increased nursing job satisfaction is a vital solution for today’s critical nursing shortage. Overall, when it comes to job prospects, the majority of nurses select hospitals that offer flexible scheduling, autonomy, and professional growth (Upenieks, 2003).

During the early 1980’s the American Academy of Nurses conducted an extensive research project to identify hospitals across the country that were successful in recruiting and retaining nurses. The objective of the project was to evaluate characteristics of hospital structures that supported professional nursing practice. These hospitals were identified by nursing job satisfaction outcomes, their attractiveness to nurses, and the ability to maintain low rates of nursing turnover, despite the nationwide shortage (Upenieks, 2003). The hospitals surveyed came to be known as “magnet hospitals.”

Organizational characteristics of magnet hospitals consist of professional autonomy and responsibility of staff nurses, an environment that supports professional practice and development, continuing education and research activities, and the supportive leadership attributes of the nurse executive. The turnover rate in magnet hospitals was 9%, whereas the other acute care hospitals were 18% (Upenieks, 2003). Nurses employed at magnet hospitals consistently rated themselves as more satisfied with their jobs than did the comparison group.


Magnet Hospitals

Nurses are at the heart of health care organizations. As the primary coordinators of care - and as the clinicians who spend the most time at the patient's bedside they are an essential part of the delivery of safe, quality care. As many organizations struggling to recruit and retain capable nurses have realized, nursing retention also strongly affects the bottom line. Joint Commission on Accreditation of Healthcare Organizations estimates that turnover of a medical-surgical nurse in U.S. hospitals costs an average of $46,000 (JCAHO, 2001).

Magnet hospitals have found proven solutions to address nursing recruitment and retention and to foster nursing leadership. Recognized as Magnet hospitals by the American Nurses Credentialing Center, a subsidiary of the American Nurses Association, these institutions consistently attract and successfully retain nurses. Magnet hospitals have low turnover (Janzen, 2003; McClure &Hinshaw, 2002) and some even have waiting lists of nurses wanting to join their ranks (Gordon, 2002). Studies illustrate that these institutions are safer workplaces as well, with fewer accidents such as needlestick injuries (Aiken, Sloane, Lake, Sochalski, & Weber, 1999).

While such findings alone are enough to make executive leadership take notice, there are even more important advantages associated with Magnet status. Research shows that Magnet hospitals also have better patient outcomes (Aiken, Havens, & Sloane, 2000), shorter lengths of stay (Aiken et al., 1999), higher patient satisfaction, and lower Medicare patient mortality rates (Aiken, Smith, & Lake, 1994).

Magnet program criteria are based on the American Nurses Association (ANA) Scope and Standards for Nurse Administrators (ANA, 1996). For hospitals to earn Magnet recognition, they must demonstrate excellence in nursing leadership, organization and management structure, evidence of professional practice and nurse autonomy, quality of interdisciplinary relationships, and other metrics. Today, only 101 of the nation's 5,794 registered hospitals (Health Forum, 2002) have received Magnet recognition.

The Chief Nursing Officer at magnet hospitals is usually a well-qualified nurse executive, in a decentralized structure, who is a formal member of the highest decision-making body in the hospital. This nurse leader supports two-way communication with nurses and encompasses organizational structures that emphasize open, participatory management. These hospitals also establish a system of an autonomous, self-managed, self-governed operation at the unit level. The clinical nurses manage hospital-wide governance issues (eg, decisions regarding interdepartmental patient flow, equipment expenditures) (Dwyer-Schull, 1984; Kramer, 1990). Also, the administrative structures support nurses’ decisions about patient care. In all, supportive nursing leadership and commitment to professional qualities of the clinical nurse are reported as the most important and effective traits of a magnet hospital (Sullivan-Havens & Aiken, 1999).

Although magnet hospitals have been operating for nearly 20 years, comparable research on their effectiveness has been limited. Since the early 1980s, when the original magnet research was published, many significant changes have occurred in the U.S. healthcare system. Hospitals are merging with acute care sectors, the focus is on outpatient versus inpatient care, costs are escalating, and length of stay has decreased. Hospitals are changing staffing levels, treating sicker patients for a shorter time, and offering more intense services and care - overall, placing a greater demand on the clinical nurse. The question remains - Do these organizational characteristics still enhance nursing job satisfaction in today’s healthcare setting, as they did 20 years ago?

Clinical Information Technology and Magnet Status

Since the Magnet program originated, another significant development that has shaped nursing practice in leading U.S. hospitals is the growth of clinical information technology (IT) in support of nursing excellence. The Magnet program metrics do not specifically reference clinical IT and many hospitals have achieved magnet recognition without it. However, there are strong parallels between the characteristics that distinguish Magnet-level performance and the successful deployment of clinical IT to support nursing practice (Kirkley, Johnson & Anderson, 2004).

At the patient’s bedside, IT can help improve nursing productivity and enhance collaboration and communication among caregivers and multidisciplines involved in patient care and discharge planning. Organizationally, the leadership strategies, interdisciplinary committees, and workflow design processes required for successful technology implementation also corresponds with the leadership and cultural initiatives achieved by the Magnet program.

An integrated health care system in Winston-Salem, North Carolina, is notable for its use of technology to support nursing excellence both at the bedside and on the large-scale organization level. The medical center is committed to promoting a professional practice environment, shared governance among nurses, and recognition programs among other initiatives that support the nursing excellence synonymous with the Magnet program (Kirkley, Johnson & Anderson, 2004).

Perhaps the most provocative connection between leadership and IT is that it takes an innovative, risk-taking, and dynamic nurse leader - the type found at Magnet institutions - to undertake the large-scale organizational change needed to successfully implement a clinical information system. At every step of the process, it is critical to gain input and buy-in from the people who will use the CIS (Clinical Information Systems) - and nurses are especially important, given their central role to patient care. Nurses are often referred to as the “front line” of patient care. Nurses are responsible for the online clinical documentation that serves as a foundation for many other clinicians' interaction with the CIS (Kirkley, Johnson & Anderson, 2004).

Organizational Structure

Organizationally, the leadership strategies, interdisciplinary committees, and workflow design processes required for successful technology implementation also corresponds with the leadership and cultural initiatives achieved by the Magnet program. Research has proven a collaborative organizational structure found in Magnet hospitals is consistent with that of the organizational collaboration necessary to successfully select, design, and implement an enterprise-wide CIS (Kirkley, Johnson & Anderson, 2004).

According to ANCC, hospital and nursing administrators should utilize a participative management style, incorporating feedback from staff at all levels of the organization. Relevant feedback is encouraged and valued. In addition, nurses serving in leadership positions should be visible, accessible, and committed to communicating effectively with staff (ANCC, 2003).

To best support the effective implementation of a CIS, an organization greatly benefits from an effective change management program, incorporating input from nurses and other clinicians at all levels in the organization. A strong foundation of shared governance helps to facilitate effective decision-making and communication throughout an organization.

Information systems support more than clinical care delivery. They serve administrative needs as well, including scheduling and financial activities. For example, nurse managers can use a system's reporting capabilities to analyze patient needs and nursing activities to support data-driven staffing models (Kirkley, Johnson & Anderson, 2004). Collaboration of data and patient care information between clinical staff and nurse managers provide the opportunity to maximize patient care and safety.

With built-in decision support and care protocols available at the point of care, a CIS supports nurse autonomy – an essential component of retaining nurses and achieving Magnet status. During the CIS system implementation and planning, nurses and physicians at medical centers may collaborate on care protocols for autonomous nursing intervention for patients experiencing potentially life-threatening situations. CIS systems also offer the ability to store teaching materials online and frees up needed space on the nursing unit. Teaching materials are immediately accessible and permit nurses to customize views to best support patients' individual learning needs.

Current Recruitment Efforts

The impact of the nursing shortage crisis, in combination with the high patient acuity, is a vital concern for any nursing administrative team specifically related to balancing staffing needs with patient needs. Local initiatives to recruit new nurses may consist of offering referral bonuses, working collaboratively with nursing schools as clinical and internship sites, hiring new graduate nurses upon completion of internships, and having clinical nurses visit high schools to increase students’ interest in the health care field.

Retention Efforts

The social climate of the workplace is the primary initiator of a nurse’s intent to stay or leave. Social climate is a determinant of work frustration and work excitement. These factors directly influence job stress, leading to job satisfaction or dissatisfaction. It is the strongest predictor of intent to stay or leave (Atencio, et al., 2003). Burnout is also directly related with job dissatisfaction. Nurses with the highest nurse-to-patient ratio experience burnout and dissatisfaction more than twice as much as those with lower ratios.

The more experienced nurse desires increased autonomy in their work environments. According to Atencio et al. (2003) and Upenieks (2003), autonomy and control over the practice environment had a positive influence on nurses’ job satisfaction, managerial trust, and their assessment of the quality of care delivered to their patients. Management style, perceived as empowering nurses to perform their jobs effectively, was strongly related to job satisfaction.

Positive perceptions related to autonomy, work place morale, managerial trust, and job satisfaction are crucial in retaining experienced nurses and decreasing turnover. By addressing the needs and desires of the experienced nurse, we will increase nurse retention, reduce turnover, and ultimately improve patient outcomes. While recruiting new nurses is important in regulating nurse to patient ratios, schools of nursing have limited capacities to admit and graduate new nurses. Therefore, it is essential to develop strategies that will retain existing nurses.

Implementation of shared governance, participative scheduling, continuing education opportunities, paid professional leave, sabbaticals, and opportunities to travel offer new and exciting avenues for the experienced nurse to pursue. These are all common attributes associated with Magnet Hospitals. In addition, hospitals may create an employee recognition program for each unit as well as hospital wide recognition. Acknowledgment for one’s efforts is quite valuable and shows that you are truly making a difference. This form of recognition is also inexpensive to maintain. Hospitals can also offer a “day away” for clinical staff. This day serves as a retreat from the hospital environment to attend “Team” workshops. These workshops will promote team unity and create a team mentality, which fosters a trusting, supportive environment.

Conclusion

The nursing shortage is real, and likely to grow worse. No single strategy will cure the crisis. Both recruitment and retention efforts must be put into action, specifically related to respecting and recognizing nurses for their expertise and providing them with responsibility to participate in the decision making process concerning patient care. Achieving Magnet recognition and implementing clinical information systems support professional autonomy and responsibility, thereby contributing to nursing satisfaction. If we do not take an active approach, we run the risk of experiencing a major shortage in the acute care setting, which will ultimately lead to deterioration in patient care.









References

Aiken, L.H., Havens, D.S., & Sloane, D.M. (2000). The magnet nursing services recognition program: A comparison of two groups of magnet hospitals. American Journal of Nursing, 100(3), 26-36.

Aiken, L.H., Sloane, D.M., Lake, E.T., Sochalski, J., & Weber, A.L., (1999). Organization and outcomes of inpatient AIDS care. Medical Care, 37(8), 760-772.

Aiken, L.H., Smith, H.L., & Lake, E.T. (1994). Lower Medicare mortality among a set of hospitals known for good nursing care. Medical Care, 32(8), 771-787.

American Nurses Association. (1996). Scope and standards for nurse administrators. Washington, DC: Author.

American Nurses Credentialing Center. (2002). Health care organization instructions and application process manual. Washington, DC: Author.

Atencio, B.L., Cohen, J., & Gorrenberg, B. (2003). Nurse retention: Is it worth it? Nursing Economics, 21(6), 262-268, 299. Jannetti Publications, Inc.

Buerhaus, P.I., Staiger, D.O., & Auerbach, D.I. (2000). Implications of an aging registered nurse workforce. Journal of the American Medical Association, 283, 2948-2954.

Dwyer-Schull, P. (1984). Magnet hospitals: Why they attract nurses. Nursing. 50–53.

Gordon, H.B. (2002). Success story: No nursing shortage here. Continuous Improvement [online journal]. Retrieved from: www.ihi.org/resources/continuousimprovement/ index.asp

Health Forum. (2002). Hospital statistics. Chicago: American Hospital Association.

Janzen, S.K. (2003). Testimony before the House of Representatives Committee on Veterans'Affairs, Subcommittee on Oversight and Investigation.

Johnson, E.J. (2000). The nursing shortage: From warning to watershed. Applied Nursing Reaserch, 13(3), 162-163.

Joint Commission on Accreditation of Healthcare Organizations. (2001). Health care at the crossroads: Strategies for addressing the evolving nursing crisis (white paper). Oakbrook Terrace, IL: Author.

Kirkley, D., Johnson, P., and Anderson, M. (2004). Technology support of nursing excellence: The magnet connection. Nursing Economics, 22(2), 94-98. Jannetti Publications, Inc.

Kramer, M. (1990). The magnet hospitals: Excellence revisited. Journal of Nursing Administration, 20(9), 35–44.

McClure, M.L., & Hinshaw, A.S. (2002). Magnet hospitals revisited : Attraction and retention of professional nurses .Washington,DC: American Nurses Publishing.

Seifert, P.C. (2000). The shortage. AORN Journal, 71(2), 310-312.

Sigma Theta Tau International. (1999, July). Facts of the nursing shortage. Indianapolis, IN: Author.

Sullivan-Havens, D., Aiken, L.H. (1999). Shaping systems to promote desired outcomes: The magnet hospital. Journal of Nursing Administration, 29(2), 14–19.

Upenieks, V. (2003). Recruitment and retention strategies: A magnet hospital prevention model. Nursing Economics, 21(7), 7-13, 23. Jannetti Publications, Inc.






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