Nursing Excellence

Leadership development and engagement empower nurses for professional success.

This article first appeared in the March 2017 issue of HealthLeaders magazine.

Nursing is an exceedingly demanding profession, typified by long hours and a high-stress work environment as nurses provide care and respond to a multitude of patient needs. But while their role is mostly clinical, increasingly it is also part care coordinator, social worker, therapist, teacher, customer service professional, and executive.

This tug-of-war between nonclinical and clinical requirements exemplifies one of the core challenges facing the nursing profession—delivering improved outcomes to satisfied patient-consumers. A quick look at nurse performance measurement is revealing. Notably, 76% of respondents in our survey say HCAHPS or other CMS surveys are the top nurse performance measurement tools used at their organizations, measuring mostly nonclinical nursing activities. Given that nurses typically remain dedicated to the clinical side of providing care, it is somewhat surprising that a tool such as the National Database of Nursing Quality Indicators (NDNQI) (42%) finishes in the midtier of responses.

Top nursing challenges
Respondents in our survey say that nurse retention (61%) and nurse recruitment (59%) are the top nursing challenges that their organizations are facing. The next level of responses are nurse engagement (35%) and nurse leadership development (33%). Note that compensation requirements (26%) falls in the middle of the responses, indicating that money is not one of the main drivers in nurse employment, and that factors such as engagement and leadership development play a larger role in nurse retention.

Survey responses reveal the scope of the retention problem—while almost three quarters of respondents (71%) say that their organizations' RN turnover rate over the past 12 months is less than 20%, one-quarter (25%) of respondents indicate that their turnover rate is 20% or more. This type of turnover could create difficulties for provider organizations because of the need to be in training mode, which disrupts productivity.

According to Jennifer Gentry, MSN, RN, NEA-BC, chief nursing officer at CHRISTUS Spohn Hospital Corpus Christi - Memorial and CHRISTUS Spohn Hospital Corpus Christi - Shoreline, part of the Texas–based CHRISTUS Spohn Health System, with six hospitals and more than 15 medical clinics throughout southeast Texas, and the lead advisor for this Intelligence Report, there are two main factors impacting nurse retention rates.

"I think that we, as healthcare organizations, need to better align with our schools of nursing. I don't believe that our nurses today are coming out of schools prepared for what the actual role of a professional nurse is. We see that with our nurses in the first year. They get here, they're overwhelmed, they didn't think it was going to be like this; it's a lot of work. They're just not prepared, and I think that's a big piece of losing the nurse in the first year.

"What I found interesting in the survey results is that nurse leadership development is number four on the list regarding the top three nursing challenges in healthcare organizations. If we don't do strong nurse leadership development, then we're shooting ourselves in the foot when it comes to retention, recruitment, and engagement, because those frontline nurse leaders, they're the key to all these things. They're the ones that are going to create the unit that the nurses want to be on—that strong work environment, those good work relationships, the teamwork, the engagement, the input. And if we're not developing those nurse leaders, then it will be difficult for us to make any improvement in any of those top three challenges."

Tactics to improve nurse retention
The top four tactics with which respondents say their organizations have had success in improving nurse retention are flexible scheduling (53%), communication improvements (51%), orientation programs for new nurses (48%), and salary increases for all nurses (48%). The majority of responses fall in a relatively tight range between 38% and 53%. This is likely because providers may be implementing a broad array of tactics to improve nurse retention in recognition of the fact that successful retention is driven by an assortment of factors.

One of the tactics with the fewest responses is retention bonuses for new nurses (14%). This either indicates that providers may have difficulty funding bonus programs, or that they find retention bonuses ineffective in improving retention over the longer term (or both). Evidence supporting the case for financial resources constraints as a factor can be found in the following data: Based on net patient revenue, a greater share of large (21%) and medium (19%) organizations mention retention bonuses than small (10%) organizations.

"I have to say that this has been my own experience," says Gentry. "I have two emergency departments that report to me. Texas is not a certificate-of-need state, and we had stand-alone, freestanding ERs popping up all over town over the last couple of years. And they can pay more than I can even think about paying. And so we offered retention bonuses as a counter to try to keep those nurses with us, and it came with a two-year commitment.

"What I found ironic is one of my EDs was a very stable ED and had little turnover for years—great teamwork, great work environment, good working relationships with the physicians, good relationships with patients. Everybody took the retention bonus, and the only people who didn't stay for their two years had circumstances that were completely beyond their control. Now, the other ED, which was not mine at the time, had only about half the nurses accept the retention bonus, and out of those that accepted the retention bonus, only about half of those even stayed for the two years. And the reasons they cited for leaving were all of the reasons [cited in the HealthLeaders Media survey] except the retention bonus. So that money made absolutely no difference to them—they wanted other things to be fixed for them to stay."

Tactics to improve shift coverage
It perhaps comes as no surprise that one of the drawbacks of high nurse turnover is shift coverage problems caused by nursing staff shortages. The top tactic that respondents say their organizations use to successfully address shift coverage problems caused by nursing staff shortages is overtime (78%), followed by flexible scheduling (55%) and internal float pools (49%). The use of agency nurses (42%) and travel nurses (32%) round out the list of tactics.

Impact of value-based care
The majority of respondents (54%) expect that the impact from the transition from fee-for-service to value-based care at their organization will either have a major positive impact (18%) or a minor positive impact (36%) on nursing performance. A far more modest number (20%) of respondents expect that this will have a major negative impact (6%) or a minor negative impact (14%). Another 12% say they expect it will have no impact, and 13% don't know.

The importance of organizational culture
Nearly one-third (32%) of respondents say that difficulty changing organizational culture is the biggest stumbling block to creating an effective nursing program at their organization.

To Gentry, creating a good nursing culture begins with providing a professional career path for nurses. "It begins with really working on professional development of the nurses. Our nurses understand their professional responsibility and accept that professional responsibility. It's that the nursing profession is not just about a job; it's not just about coming in and clocking in and out. They have a responsibility to their profession, to their license, to excellent patient care, to improving outcomes, to process improvement, all of those things. And we try to balance that professional expectation and professional development with the limitations of the current financial landscape."