Want to Keep Nurses at the Bedside? Here's How.

Nurse leaders share how they attract RNs to their healthcare organizations and get them to stay for the long haul.

This article appears in the March/April 2019 edition of HealthLeaders magazine.

How does an organization recruit and retain registered nurses with the right skills and work experience to deliver high-quality patient care? It's certainly not simple. There's more to building a strong nursing workforce than just filling open positions, and even in organizations with top-notch nurse recruitment programs, research has found there's no guarantee that nurses will stay put.

The 10-year RN Work Project study found 17% of newly licensed RNs leave their first nursing job within the first year, 33% leave within two years, and 60% leave within eight years.

And, according to the recruitment firm NSI Nursing Solutions, Inc., the average national turnover rate for bedside RNs was 16.8% in 2017.

Additionally, Press Ganey's recent analysis of 250,000 RNs who participated in the 2017 National Database of Nursing Quality Indicators RN Survey found close to 21% of nurses planned to leave their current jobs within one year, including those retiring. When asked about their job plans over the next three years, 26% said they will pursue other options ranging from new positions in an organization to retirement.

"Recruiting and retaining [nurses] is not an easy task," says Press Ganey's Chief Nursing Officer Christy Dempsey, RN, MSN, CNOR, CENP, FAAN. "It requires that we understand the drivers of job satisfaction across the nursing lifecycle because we're not all motivated by the same thing." (See the sidebar "Why Nurses Stay in Jobs and Why They Go" for more on these key drivers.)

Not to mention that nursing turnover costs healthcare organizations big bucks.

"The average cost of turnover for a bedside nurse is anywhere from $38,000 to $61,000. When you think about that from a per hospital cost, that's between $4.4 million and $7 million a year," says Dempsey. "It boils down to the fact that nurses are arguably the biggest line item in the operating budget, and they spend more time with the patients [than] any other care provider."

So what's a nurse leader to do? Three nurse executives share how they've had success recruiting and retaining nursing staff.

Change the organization's reputation

When Karen Mayer, PhD, MHA, RN, NEA-BC, FACHE, chief nursing officer and vice president of patient care services began working at Rush Oak Park Hospital, in Oak Park, Illinois, 13 years ago, nurse recruitment and retention was a struggle.

The nurse turnover rate was about 22%, and some departments had vacancy rates as high as 24%, she says.

With five other hospitals within five miles, there was stiff competition for nurses and patients. Nurse recruitment at Rush Oak Park Hospital was also hindered by a negative reputation because of its poor quality outcomes and a restrictive policy to hire only nurses with experience. In addition, a revolving door of chief nurse executives led to a lack of consistent leadership and vision.

"When you have bad outcomes, and leadership is beating you up and telling you how bad you are, as a staff nurse—even if you are a great nurse—you feel hopeless because nobody wants to work in an environment where they feel like they're providing bad care," Mayer says. "There were excellent, excellent nurses working here, yet the punitive environment resulted in a lack of respect [toward nurses] by physicians [and] administrators, and from nurse to nurse." 

Mayer, however, was up for the challenge of changing the work environment.

"No nurse wants to be a bad nurse," she says. "I had experienced a bad environment where I saw it get totally turned around, and so I felt that I could make a difference in changing the lives of these nurses."

Today, turnover rates are 8.3%, and the only vacant position she has is one in the operating room.

Mayer is the first to say the change didn't happen overnight. The turnaround took many years of hard work, and a combination of solutions and interventions. Still, it can be done when a CNO has a clear vision for nursing and is willing to take risks and build upon successes.

Revamp the hiring process
Mayer's first step to improvement was to focus strictly on recruitment. That meant improving nursing's reputation outside the organization and overturning Rush Oak Park Hospital's previous policy that said it wouldn't hire RNs without experience.

"They had gone for years of just not hiring anyone because no one with experience was applying," Mayer says. "So [we just focused] on recruitment. With the competition of five other [surrounding hospitals] and the poor reputation, we first had to figure out how we could even get people in the door."

Mayer says at that time there was a glut of nurses who could not find jobs after graduation since other organizations also had "you-must-have-experience" policies. Additionally, Rush University School of Nursing graduated its first cohort of clinical nurse leaders, and because Mayer was open to hiring entry-level, master's-prepared nurses, she hired about 25% of the first group of graduates.

After the policy change, she worked with human resources to ensure all nurse applicants were contacted for an interview within 24 hours of application. All applicants, even ones who would likely not make the cut, were scheduled for an interview, and Mayer interviewed each candidate.

"This was our one opportunity to sell ourselves. We wanted to get the message out that we were truly different from what was expected. We decided that the only way to do that was by having the CNO [me] meet with every single one of [the applicants] and identify what [Rush Oak Park Hospital's] vision for the future would be," she says.

"It accomplished sort of a ‘wow effect' because nowhere else did they get to actually meet the CNO. It also made them [think], ‘Whoa, I love that vision. I want to be part of that and I want to help get them there.' We wanted them all walking away saying, ‘I wish they would have offered a job to me. I would have loved to have worked there.' That's what we had for marketing—word of mouth," Mayer says.

The organization also moved to a behavioral interview process.

"We were seeking individuals who had what I call ‘self-efficacy.' People who like a challenge, people who want to be part of fixing things," she says.

Once the stream of applicants and new hires began to flow, it was time to focus on getting nurses to stay with the organization.

"During the first two years [of changing our recruitment strategy], we were still experiencing a lot of turnover … because so much more needed to be put into place so that once [the nurses] got in the door, they would want to stay," she says. "This meant addressing some of the cultural issues related to empowerment."

This included moving to a shared governance structure and coaching managers who weren't familiar with a collaborative leadership style. Additionally, it meant developing a clinical ladder to foster both career development and recognition, both of which are important to retention of
seasoned and newly licensed RNs.

"We were using tons of expensive agency [nurses], so that extra amount of money actually justified us developing a clinical ladder that had criteria tied to increases in salary," she says.

Adopted in 2008, the clinical ladder established three levels of nurses.

• Level 1: Entry-level RN
   
• Level 2: An RN who practices independently and can function as a charge nurse or preceptor to new RNs or students
   
• Level 3: An RN who demonstrates high-level proficiency that is aligned with the organization's professional practice model
   

To achieve level 3 status, an RN must:

• Have a BSN degree and professional certification if eligible
   
• Submit a letter of recommendation
   
• Provide an exemplar of his or her holistic nursing practice
   
• Submit a portfolio highlighting his or her professional development and activities
   

The fact that promotion along the clinical ladder was based on achievement versus tenure did make some experienced nurses uncomfortable at first.

"There are definitely cultural value differences between millennials and boomers. I'm a boomer, and we're about experience," Mayer says. "But as some of the millennials would be reaching one-and-a-half years' experience, they were achieving some of the things that qualified them for level 3 [on the clinical ladder]."

Mayer addressed nurses' concerns by sharing with them that the decision was made based on research that found quality outcomes and mortality rates improved in organizations where the majority of nurses were BSN-prepared and held certifications.

When the clinical ladder structure was implemented, the BSN rate was about 12%, says Mayer. Today 84% of the organization's RNs have a BSN or higher, with 20% of those nurses holding a master's degree in nursing. When Mayer came to Rush Oak Park, only two nurses held specialty certification, whereas today 54% of all bedside nurses hold a certification.

Because of Mayer's changes to nursing recruitment and retention, Rush Oak Park is now known for nursing quality.

For example, hospital-acquired pressure ulcer rates have dropped from 20% to none above stage 2 for the past two years, thanks to improved documentation and screening.

In 2016, Rush Oak Park received the American Nurses Credentialing Center's Magnet® designation, which only 482 hospitals nationwide currently hold.

Plus, the organization has received an "A" grade in patient safety from LeapFrog and a four-star rating from the Centers for Medicare & Medicaid Services. Its ICU was recently recognized with a gold-level Beacon Award for Excellence from the American Association of Critical-Care Nurses.

Still, Mayer says she has no plans to rest on these laurels.

"When it comes to recruiting and retention, it's an ongoing battle," she says. "Even when you get so good that you have almost no vacancies and you have a waiting list to get into your hospital."

Launch a program that entices former RNs back to the bedside

Press Ganey's 2017 National Database of Nursing Quality Indicators RN Survey found that those at highest risk for attrition were newly licensed nurses and those who have been in practice for two to four years.

Claire M. Zangerle, DNP, MSN, MBA, RN, NEA-BC, chief nurse executive at Allegheny Health Network in Allegheny, Pennsylvania, says she and other nurse executives have seen similar turnover at their healthcare organizations.

"We're all feeling the pain of [nurses leaving organizations] within a few years and going to do travel nursing or to insurance companies," she says. "But some are just leaving practice altogether for reasons that we could probably address internally with some creative ideas."

The RetuRN to Practice Program at Allegheny Health is one creative initiative Zangerle is using to address some of these issues.

The program is designed to attract nurses who have stepped away from practice and want to return to bedside care, which helps reduce the workload of current staff and fill staffing gaps.

Flexible scheduling attracts RNs
The RetuRN program offers flexible scheduling opportunities in high-need clinical areas.

Participants must offer managers availability in a minimum of three-hour blocks at any time on a day, evening, or night shift, or on a weekend or holiday.

During their shift, the RetuRN nurses conduct "rover-type" duties, as Zangerle describes it. They cover other nurses' patient assignments during breaks or when staff has to do continuing education off the unit. Or they may come in to do admissions, discharges, or patient education.

"The [RetuRN nurses] know they won't know what they're going to do until they get to the unit," she says. "And they're flexible and they're there on the floor to be able to do that."

Because the RetuRN nurses have been out of practice for various amounts of time—Zangerle says one had not practiced in 20 years—there is an online nurse refresher course through the University of Delaware plus on-the-job clinical shadowing built into the program.

Additionally, there are resources dedicated to helping these nurses through the entire onboarding process, from getting their licenses verified to following up on their satisfaction levels after they've started on the unit.

"We have had a lot that have rushed in and said, ‘OK, I want to do this,' and then when they see all the things they need to do [to onboard] they get scared," Zangerle says. "So we have almost a concierge service–type support. It is worth every single nurse that we bring on board to do this program, to have that for them."

After an initial kick-off event, the organization hired 22 nurses ranging from 0.5 FTE status to 1.0 FTE status.

The retention rate of that group is 100%, Zangerle says.

Creative thinking pays off
For others interested in starting a similar program, Zangerle has suggestions on what nurse executives should consider.

First, nurse managers will have to adjust to scheduling three-hour blocks for the RetuRN nurses instead of the typical eight- or 12-hour shifts.

"We've engaged those nurse managers to say it's really a logistics exercise with scheduling," she says. "We're fortunate that we have electronic scheduling, and that's been helpful."

Once the RetuRN nurses start on a unit, the program easily wins converts among staff nurses and nurse managers. 

"Once they get a couple of [the RetuRN] nurses on the unit, they hold onto them and they won't let go," she says. "If you educate the nurses on the unit about why [the RetuRNs] are there and solicit ideas from them on how we can enhance the program, it makes the program robust."

In fact, says Zangerle, current nurses can be a source of referrals to the program.

"They might have friends who left nursing to raise their children and now want to come back, or they left because the hours just weren't there," she says.

Hosting information sessions, connecting with academic partners that run refresher courses, and social media marketing are other ways to get the word out about RetuRN programs. She also recommends having one recruiter dedicated to the program to help it grow.

And, indeed, the program is growing. Between February and May 2019, three more cohorts of 10 RetuRN nurses are slated to begin. The program has also been opened to retired nurses who have been away from the bedside for one year or less.

"A lot of nurses still want to practice but they don't want 12-hour shifts, or they don't want every other weekend," she says. "Then as time goes on, we'll certainly survey our RetuRN nurses to find out what we did right, what we did wrong, and how can we grow this program."

Support nurses' professional development and work environment throughout their career

Kelly Johnson, PhD, RN, NEA-BC, vice president, patient care services and chief nursing officer at Stanford Children's Health and Lucile Packard Children's Hospital Stanford in Palo Alto, California, understands that a healthy work environment and professional development programs are crucial for retaining nurses.

"The work environment, workloads, and the impact of things like technology and new innovations in healthcare—it's really challenging to keep up," Johnson says. "[We need to] provide environments where nurses are supported in professional growth and development and staying abreast of new evidence-based practices [so they can] get to the top of their game regarding professional nursing practice."

Thus, the organization has developed programs to support nurses in the various stages of their careers.

Because pediatrics does garner a great deal of interest among nurses, Johnson says the organization has little difficulty recruiting new graduates. For example, she says, when a new graduate resident opening is posted, they can receive from 400 to 600 applications.

Once a newly licensed RN joins the organization, the nurse is supported by a yearlong new-graduate residency and transition-to-practice program. The program enables the hospital to hire new grads into all specialties, including ones that are more challenging to fill, such as the neonatal ICU or cardiovascular care. The program has shown successful retention outcomes.

"We are close to 100% retention," she says.

Total nurse turnover is around 7%, notes Johnson.

"That is the fact, [considering] that we have some high retirement areas, such as our neonatal intensive care unit and some of our maternity services," she points out.

Nurses are supported in their professional development through personal success plans, a succession planning development program, certification programs, and advanced degree programs.

Johnson says in fiscal year 2019, the organization formalized creation and assessment of personal success plans, which will be reviewed annually with a nurse's manager.

"It is a formal program where part of [the nurse's] evaluation process is developing a personal development plan and making sure that we document it and track progress towards it," she explains.

While all nurses at healthcare organizations are expected to help advance the organization's strategic goals, the personal success plans will help nurses hone their individual personal and professional goals. For example, this could mean working toward a master's degree or achieving specialty certification.

To celebrate nurses' various achievements throughout the year, the organization has an annual awards banquet.

Promote a healthy work environment
The organization also has made a formal commitment to creating a healthy work environment and culture.

"We're looking at lots of initiatives around wellness in the workforce," Johnson says, "and how we promote professional fulfillment and prevent burnout and look at moral resilience and intentional integrity in healthcare."

This includes designing a nursing professional practice model, which addresses the holistic needs of both patients and staff, that includes concepts from Dr. Jean Watson's Caring Science Theory and HeartMath.

According to its website, HeartMath is a "system that empowers people to self-regulate their emotions and behaviors to reduce stress, increase resilience, and unlock their natural intuitive guidance for making more effective choices."

The core concept of the Caring Science Theory, according to The Watson Caring Science Institute's website, is "a relational caring for self and others based on a moral/ethical/philosophical foundation of love and values."

Some principles included in the theory are:

• Moral commitment to protect and enhance human dignity
   
• Respect/"love" for the person—honoring his/her needs, wishes, routines, and rituals
   
• Heart-centered/healing caring based on practicing and honoring wholeness of mind-body-spirit in self and each other
   
• Inner harmony (equanimity)—maintaining balance

Watson also outlines 10 Caritas processes that include "creating a healing environment at all levels, whereby wholeness, beauty, comfort, dignity, and peace are potentiated."

Johnson says these processes are threaded throughout all aspects of the work environment and include self-care activities. For example, the organization is in the process of creating "Caritas carts" filled with healthy snacks that can be delivered during leader rounding. This helps leaders make rounding intentional while supporting staff who may be busy and need a reminder to care for themselves.

"Our practice and practice environment reflects this theoretical foundation and embodies the theory in our practices. SCH is one of the first organizations to implement the integrated model with Caring Science and HeartMath," Johnson explains.

The organization has 23 Caritas coaches and several HeartMath trainers that educate the nurses on these self-care concepts.

"We do a lot of work around self-care and creating a work environment that is caring and healing, not only for the patients and families to receive care, but for our nurses to work in a place where we care about each other and we care about ourselves," Johnson says.