Appendix C

Best Practices for Retention of RNs in U.S. Hospitals
Theresa L. Carroll, Ph.D., R.N.
University of Texas Health Science Center at Houston School of Nursing

Introduction

Retention of the RN workforce is a complex issue associated with a variety of factors that demand attention from many constituents both within and outside the health care delivery system. The nursing shortage has received attention in the popular as well as the professional media. As one solution to the nursing shortage, the importance of retaining RNs in hospitals has attracted additional attention with the publication of a study that linked nurse staffing levels with quality of care in hospitals. This study conducted by Needleman et al. (2002) concluded that "a higher proportion of hours of nursing care provided by registered nurses and a greater number of hours of care by registered nurses per day are associated with better care for hospitalized patients" (p.1715). Stated another way, insufficient numbers of nurses staffing hospitals is related to an increased occurrence of preventable adverse events.

Issues that relate to retaining a qualified and experienced RN staff include both economic and noneconomic factors. Economic factors relate to wages and benefits while noneconomic factors relate to staffing and scheduling, the culture of the professional work environment, job stress, intensity of work, safety, job satisfaction, work-life balance, work redesign, and an institution's location. Rarely, if ever, is retention of an adequate number of qualified nurses attributable to any single factor. Therefore, while the following discussion focuses on the factors as distinct issues, the complex interaction among the factors must not be overlooked.

Economic and Noneconomic Factors that Contribute to Retention

Economic factors include wages and benefits. Citing findings from The National Sample Survey of Registered Nurses (Spratley et al., 2002), Steinbrook (2002) states, "wages for registered nurses have been relatively flat as compared with the rate of inflation. The average annual salary for was $46,784. Between 1980 and 1992, real annual salaries for RNs increased by nearly $6,000. Between 1992 and 2000, however, they increased by only $200 (p.1759)." As the RN workforce ages, health care and retirement benefits have become as important as wages. In a study conducted in 2001, by the American Organization of Nurse Executives and Nurse Week, 79% of RNs stated that improved wages and benefits would help a great deal to solve the nursing shortage. Moreover, the study noted that among those RNs who were planning to leave their present position over the next 3 years, 58% said improved compensation would very likely influence their decision to remain.

But wages and benefits alone will not stabilize the RN workforce. Reviewing the nursing literature as well as interviewing nurse executives and staff nurses helped this author to generate a list of noneconomic factors that have become at least as important as the economic factors of wages and benefits. Most important among the noneconomic factors, staffing and scheduling heads the list of issues necessary for retaining a qualified nursing staff. Hospital nursing is a "24/7" commitment that requires RNs to work less desirable weekend, evening, and night schedules. With a largely female workforce that is committed to child bearing, child rearing, and family care giving, a nurse's work commitments compete with family responsibilities and interfere with perceived quality of life. In relation to staffing, nurses want predictability, fairness, flexibility, and adequate numbers of staff with the correct skill mix. Predictability relates to the decision rules that govern how vacation, holiday, and days off are scheduled. Fairness relates to how these rules are applied. Flexibility reflects the option to request time off to balance multiple commitments to work, school, and family.

Skill mix takes into account not only the number but also the experience and competence of nurses assigned to a shift on a designated unit. The ideal staffing plan adjusts the number, competence, experience, and skill of the staff to meet patient needs based on the patient acuity which reflects severity of illness. The advent of managed care has resulted in a marked increase in the intensity of work related to patient care. Patient acuity has increased and length of stay has decreased, resulting in the same or more work being performed in a much shorter period of time. In addition, shortened length of stay means that the number of admissions and discharges for any given time period has also increased. Work intensity takes on added significance when resources such as adequate staffing are not available and mandatory overtime becomes the staffing modality of choice. While knowledgeable administrators agree that skill mix should match the acuity of patients' illness, at the national level no recent data on staffing exist (including skill mix and competence) that adjusts for the acuity of the patients' illness or the decreased length of stay (Steinbrook, 2002).

Marlene Kramer summarizes the importance of clinical competence as she reflects on findings from over 25 years of her work related to magnet hospitals. Having competent co-workers continued to be one of the most important issues identified by nurses in both magnet and non-magnet hospitals. Competence serves as the basis for autonomy, nurse-physician relationships, and control over nursing practice. Competence is related to attracting and retaining nurses, job satisfaction, and effective nursing practice. "Competence is positively related to self-esteem and locus of control. It is not just that the nurse knows; it's that she knows she knows" (Kramer & Schmallenberg, 2002, p.31).

Quality of work life is affected by the professional practice environment. Characteristics of the professional practice environment include the following: respectful, collegial relationships with physicians, administrators, and other members of the interdisciplinary or transdisciplinary team, a well-educated and responsive nursing leadership team, professional autonomy that includes participatory decision making in matters related to patient care and nursing practice, and a culture where continuous improvement is the norm. Hospitals, which have been awarded magnet status by the American Nurses Credentialing Center, traditionally support a professional practice environment.

Professional and collegial interactions founded in trust and respect are the hallmarks of a professional practice environment. One study on nurse physician relationships concluded that daily interactions between nurses and physicians strongly influenced nurses' morale. Yet, of the nearly 1200 nurse, physician, and administrator respondents, 92.5% said that they had witnessed disruptive behavior by physicians that included yelling or raising of the voice, disrespect, condescension, berating colleagues and patients, and use of abusive language (Rosenstein, 2002). Even in the best hospitals, nurses are not immune to this behavior. One senior nurse administrator was dismayed to discover that a long-tenured physician at the hospital had been lashing out at nurses for years. The doctor's outbursts had gone unchallenged because the nursing staff felt that nothing would be done about the behavior (Uhlman, 2002).

Disruptive behavior affects not only nurses but also all members of the health care team. Disruptive behavior can be especially detrimental as teams migrate from an interdisciplinary practice pattern to a transdisciplinary model of delivering care. Whereas interdisciplinary teams are characterized by coordination of patient care by representatives from many disciplines, transdisciplinary teams share knowledge across disciplines and allow members to use skills learned from those other than in their primary discipline. The process of problem solving in a transdisciplinary team strives to avoid traditional power imbalances and competition among professionals (Greco & Anderson, 2002).

A well-educated, responsive nursing leadership is another distinguishing element in the professional practice environment. Senior nursing leadership needs to work at establishing credibility as an effective advocate for nursing to create an environment that supports close mutually productive relationships among nurses, unit managers, medical staff, ancillary departments, and patients (The Advisory Board, 2001). One study of what skills and attributes women (including nurse executives) will need to succeed as leaders in the 21st century identified personal integrity as well as truthfulness, credibility, and ethical standards as the most important characteristics of a successful leader (Carroll & Jowers, 2001). Credibility is characterized by data based decision making, efficient and cost-effective management practice, and strategic collaboration with other department leaders (The Advisory Board, 2001). Within nursing, credibility is about clinical competence, which provides the basis for professional autonomy and decision-making.

Nurses see professional autonomy and participative decision making in matters related to nursing practice and patient care as a major requirement of the professional practice environment. As one nurse executive observes, "we need to find better ways to listen to nurses' concerns, complaints, frustrations, anger and feelings…[because nurse leaders]…recognize that the answers for the tough times ahead will come from the energies of the team…"(Vogtman, 2002, pp.20-21).

One of the attributes of a professional practice environment where nurses can and should have a voice is continuous quality improvement related to clinical care. The overall themes for the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) performance improvement standards include the active involvement of senior hospital leadership and a planned systematic approach to data collection and analysis that is collaborative, interdisciplinary, and organization wide (Kelley, 1999).

Another factor that contributes to retention of RNs in hospitals is physical and psychological job stress "Nurses are exposed daily to significant risks to their personal health and safety" (JCAHO, 2002). According to the American Nurses Association Health and Safety Survey (2001), 70 % of nurses reported that severe stress and overwork were among their top concerns, with 40% reporting that they have been injured on the job. In addition to the fatigue caused by long hours and (in some cases) mandatory overtime, nurses are routinely required to do physically heavy lifting, care for combative patients, and cope with the presence of air and blood borne pathogens. One study of needlestick injuries suggests that they are more common than reported and they do not occur randomly (Aiken, Sloane & Klocinski, 1997). In fact, nurses who work in hospitals with low staffing levels and in a poor work environment are two to three times more likely to sustain a needlestick injury (Clarke, Sloane, & Aiken, 2001).

Psychological stress often results from a variety of factors inherent in the work of caring for patients with life threatening diagnoses. Understanding psychological stress is further complicated by evidence that suggests that the sources of and solutions for stress are perceived differently by generational cohorts (Santos & Cox, 2000; The Advisory Board Company, 2002). However, there is little disagreement that whatever the generational issues may be, balancing work-life demands, working in a hostile environment, and constantly being required to cope with work demands that outstrip resources also contributes to stress. Any combination of physical and psychological stressors can lead to burnout. While burnout can cause nurses to leave hospital employment, it can also affect the overall quality of care, as burnout can result in nurses distancing themselves from patients and coworkers.

During the 1990s, the health care industry responded to the economic pressures of managed care by mergers, acquisitions, downsizing, and re-engineering that, in retrospect, have been unsuccessful in achieving the targeted productivity and financial goals (Jones & Redman, 2000). These activities caused serious erosion in the nursing work environment, especially at the unit level where management and staff interact most directly to provide patient care. Even the JCAHO (2002) admits that, although unwittingly, the restructuring initiatives of the 1990s had a lasting, negative impact on nursing leadership. This result is no small problem because nurse executives are expected to reconcile the competing business and clinical objectives and build teams that are committed to providing safe, high-quality patient care.

Unlike a majority of hospitals during this period, magnet hospitals were less likely to undergo re-engineering at the unit level (Havens, 2001). A study of the original magnet hospitals, which in 1986 had the most positive nursing work environments, found that by 1998 "these ratings had deteriorated and some of the deterioration was a result of ill informed restructuring" (Aiken, 2002, p.71). Results of another study that compared magnet and nonmagnet hospitals, suggested that there were differences in how the two groups chose to respond to similar political and economic pressures. Nonmagnet hospitals were more likely to implement skill mix changes that resulted in fewer RNs and more LPNs and nurse's aids to care for patients. At the same time, the magnet hospitals implemented significantly more changes to expand the Chief Nurse Executive (CNE) role to oversee multiple non-nursing departments, perhaps suggesting that engineering efforts were more targeted toward administrative and management levels (Havens, 2001).

Any individual or combination of these previously mentioned factors could affect the job satisfaction of nurses. Large-scale surveys of nurses that were initiated to determine their job satisfaction have produced varied and often conflicting results. For example, one study of 43,000 nurses employed in hospitals in five countries, including the U.S., reported high job dissatisfaction while the relationships between nurses and physicians appeared satisfactory (Aiken, Clarke, Sloane, Sochalski, Busse, Clarke, Giovenetti, Hunt, Rafferty, & Shamian, 2001). Another study, which sampled 4100 U.S. nurses working in a variety of settings, found that 87% of the nurses were satisfied with being a nurse and 56% had no plans to leave their present position in the next 3 years (Graham, 2002). Results from a survey of 1200 nurses, physicians, and administrators, who were employed in a west coast community-owned hospital system, reported that 92.5% of the respondents had witnessed disruptive physician behavior and that all groups noted a definite relationship between physician behavior and nurse satisfaction and retention (Rosenstein, 2002).

Whether a hospital is located in a rural or urban area may also contribute to the ultimate success of retention efforts. Urban hospitals have problems related to competition with other facilities, neighborhoods that are unsafe or undesirable, a dwindling referral network for specialty practices, and a landlocked physical facility that makes expansion and construction of facilities like parking garages expensive, if not impossible. While rural facilities may not face landlocked physical plant or competition for staff, oftentimes they are uniquely challenged by a place-bound workforce and limited source of funding for salaries, maintenance, and expansion.

Strategies for Improving Retention

Many strategies have been proposed to improve retention. Some involve system wide interventions while others need to occur at the unit level. In recognition of the diversity of nursing personnel, the American Organization for Nurse Executives (2000) concludes that meeting the needs of nursing professionals in the 21st century will necessitate creating a working model that reflects the needs and desires of individuals at different points in their personal lives and careers. Both immediate and long- term plans need to be developed to address current and future needs of the health care system to insure that sufficient numbers of competent nurses are prepared and willing to work in hospitals. However, with the exception of the work that has been done with the magnet hospitals, little empirical evidence has been published to support the effectiveness of retention strategies.

Economic Factors. At least one major survey of nurses has identified the importance of addressing economic issues in the recruitment and retention of nurses (Graham, 2002). While entry-level salaries have been improved to attract more nurses to hospitals, a salary structure is needed that rewards nurses for increasing competence and experience in order to deal with creeping salary compression. Likewise, benefit plans that are both flexible and competitive with those provided by other industries need to be considered. Health care and retirement benefits are major issues for the aging nursing workforce, while younger nurses may need childcare. Flexible benefit plans allow nurses who are at different stages in their careers balance family needs with retirement planning. Peter Buerhaus (in Graham, 2002) has observed that it is helpful that economic issues are so important to nurses "because in the short run, this may be the easiest change to accomplish, thus, ‘buying' time for responses to be put in place that address the noneconomic actions" (p. 17).

Noneconomic Factors. Any comprehensive retention plan must deal with the issue of staffing, including a flexible skill mix to accommodate patient acuity. However, several states have proposed legislation that will dictate mandatory staffing ratios that do not account for patient variables. As of July 1, 2002, the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) began requiring health care organizations to establish staffing plans that the organizations will be required to monitor by using data from "nursing sensitive clinical indicators and human resource indicators such as adverse drug events, patient falls, use of overtime, staff turnover rate, patient and family complaints, and staff injuries on the job" (JCAHO, 2002, p. 15). This requirement includes monitoring the number and mix of all health care practitioners and technical staff to assure the presence of " the right numbers of care givers of the requisite competency and skill mix to provide safe, high-quality care" (JCAHO, 2002, p.15).

In addition, to make the commitment to around the clock, 7-day-hospital work schedule desirable and practical, the issue of flexibility and alternate work schedules must be addressed. In a review of research conducted both within and outside of health care to determine the effects of alternate work schedules, Griffeth and Hom (2001) conclude that flextime helps employees balance home and work duties but does not appear to positively impact retention. However, strategies such as a compressed workweek, which allows for recovery time (a leading cause of turnover in shift workers) and opportunities for job sharing and part-time work, may deter resignations.

While adequate staffing contributes to retention goals, it is also related both to preventing nurse injury and to patient safety. Despite recognition that many workplace injuries are ergonomics-related, nearly 60% of nurses report that patient lifting and transfer devices were not provided by their organizations (American Nurses Association, 2001). Addressing the ergonomics issue, the JCAHO (2002) has noted that, "with an aging nursing workforce and an increasingly corpulent population, health care organizations will find it a basic necessity to acquire ergonomic technologies that reduce the risk of physical strain and injury…" (p.12).

Another strategy that is aimed at enhancing retention of RNs is establishing and maintaining the professional practice environment. The professional practice environment as found within magnet hospitals has been studied extensively by Kramer and Aiken and their colleagues. Their research suggests that this environment is a model for administrative practice and nursing care delivery within an organizational culture that fosters retention. In fact, evidence exists to support the relationship between a positive professional practice environment and shorter lengths of stay and lower patient mortality. Professional practice environments in magnet hospitals are characterized by higher nurse-patient ratios, and clinical autonomy for nurses, including control over nursing practice. This environment is also characterized by better nurse-physician communication and collaboration, educationally prepared nurses and nurse managers, strong organizational support from administration, and a consistently communicated value that the patient is the focus for health care (Aiken, Havens & Sloan, 2000; Havens, 2001; Kramer & Schmallenberg, 2002; Aiken, 2002; Hinshaw, 2002). Both the JCAHO and federal legislation support establishing a magnet hospital certification program as one method of achieving a professional practice environment that will accomplish multiple goals including safe patient care and attracting and retaining nurses.

In addition, within this professional practice environment, nurse-physician-administrator relationships are characterized by mutual respect, open communication and collaboration in the interest of providing safe, quality patient care. Strategies for establishing this culture need to focus both on the institution and, longer term, on the educational system within which all health professionals are educated. Some examples of improvement strategies for health care institutions suggested by Hinshaw, (2002) and Rosenstein, (2002) include the following:

• Create more opportunities for all health care personnel to communicate through such things as open forums, workshops, and educational programs that are aimed at team building and conflict and stress management. Appoint a physician leader who can assist with planning these programs and encourage physician
  participation.
  
• Establish an explicit communication structure for dialogue about patient care issues, such as interdisciplinary performance improvement teams.
  
• Provide a common organization level committee structure for interdisciplinary decision making about such things as patient care policy.
  
• Identify potential sources for conflict, such as scope of practice, competency, staffing, scheduling and equipment, and plan pro-actively to offset and/or avoid these situations.
  
• Establish a zero tolerance code of conduct policy for disruptive behavior, which includes reporting guidelines, and hold all health care personnel accountable for their actions.

Longer-term strategies involve an overhaul of the educational system in which the values of health care professionals are shaped. Partnerships among providers and educators must be fostered and supported so that education and care delivery systems can be re-conceptualized as interdisciplinary activities. This re-conceptualization should include diminishing the traditional "educational silo" where health profession students have limited opportunities to interact and are taught exclusively by members of there own disciplines in classes open only to students preparing for entry into the same profession. A more interdisciplinary approach should result in a better-balanced perspective of the various contributions that the different disciplines can make to patient care delivery. The goal of such an educational process should result in a system where "no individual or institution dominates deliberations or controls decisions to the detriment of the system" (Conway-Welch, 2000, p. 64).

Finally, establishing the professional practice environment and a high performance culture is the responsibility of the nurse executive, who can delegate the authority for implementation to the nursing management team. The nurse manager is responsible for retaining a high performance workforce. This responsibility includes hiring, identifying turnover risk among employees, coaching the staff nurse, fostering career development that matches the needs of the nurse and the needs of the organization, and building the nursing care team (The Advisory Board, 2001a & 2001b). However, little in basic nursing education programs prepares the nurse for the manager role. Continuing education and in-house staff development can help to fill immediate gaps in specific skills. These are important ways that an institution can foster innovation and creativity, share values, and shape policy. But nurses who aspire to the manager role need support to pursue graduate education in nursing administration.

Unfortunately, over the last decade the surge of support for advanced practice graduate programs has stifled the sustainability and growth of nursing administration graduate programs in most regions. To meet the needs of the health care delivery system for sophisticated nurse managers, graduate nursing programs will need to commit greater resources to revitalize nursing administration programs and post-master's degree certificate options in nursing administration for advanced practice nurses. This commitment will need to include partnerships with health care agencies to plan curricula that are relevant, adapt courses to take advantage of web-based technologies, develop innovative class schedules that are convenient both to the learner and the employer, and recruit new faculty and/or retool existing faculty to teach in nursing administration graduate programs.

One note of caution: The above-mentioned strategies proposed to improve retention of the RN workforce in hospitals should not be implemented without a comprehensive needs assessment of an individual institution or system's RN workforce. Each organization needs to craft a retention plan that is tailored to its specific population and region. While system level strategies are needed to address salary and benefits issues, many of the noneconomic factors can and should be addressed at the nursing department or the individual unit level.

RNs themselves are the best sources of information about the status of care delivery, as well as their own stress and satisfaction levels. When interpreting institution-level data, it is worth noting that nurses' perceptions of their ability to render quality patient care is one of the most significant factors in job satisfaction. This finding was so profound that the definition of a magnet hospital was revised to read, "A magnet hospital is one that attracts and retains nurses who have high job satisfaction because they can give quality care" (Kramer & Schmallenberg, 2002, p. 26). Furthermore, when the quality of nurses' work life is improved and when nurses have high job satisfaction, they become the best recruiters of other nurses.

Conclusions

• Retention is a complex issue that requires
  attention to both economic factors as well as noneconomic factors.
  
• Because of the complexity of the issues related to retention, there are no "quick one size fits all fixes."
  
• The body of published evidence about retention strategies is very thin and consists primarily of descriptions of plans implemented within individual hospitals.
  
• A positive professional practice environment such as that which is found in magnet hospitals is a function of a variety of factors. One of the most important
  factors is the quality of the relationship within and among the disciplines, including but not limited to nurses, physicians, and administrators.
  
• Nurses are the best recruiters of other nurses. When the quality of work life is improved for nurses, the potential for recruiting other nurses is also improved.

Recommendations

• The complexity of retention issues necessitates crafting complex solutions. In order to impact the professional practice environment, new models of delivering care need to be developed and evaluated. A sustained and concerted effort to develop, test, and report successful retention models is also necessary to provide the evidence upon which to base future decisions.
  
• Solutions aimed at improving the professional practice environment need to focus on both
  immediate and long-term strategies.
  
• Immediate strategies need to generate actions that create and communicate expectations that all interactions should be characterized by respectful collegiality in support of safe, high quality patient care.
  
• Strategies aimed at improving the professional practice environments over the longer term need to emphasize changes in the educational systems which foster planned opportunities for students to interdisciplinary educational experiences that are supported through service-education partnerships that include educators and practitioners from all
  disciplines.
  
• Staff nurses need to be actively involved in decision making especially in those issues that affect profes sional nursing practice, patient care, and recruitment, and retention of RNs.

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