Appendix H

Improving our Practice Environments: A Key Strategy to Nurse Retention and Recruitment of Ethnically and Racially Diverse Nursing Personnel

Linda Burnes Bolton, Dr.P.H., R.N., F.A.A.N.
Vice President and Chief Nursing Officer
Director of Nursing Research and Development
Cedars-Sinai Health System and Research Institute
Los Angeles, California

The number of nurses working in acute care settings has not diminished significantly over the last four years (Spetz, O"Neill, National Nursing Sample 2000). However, the retention and turnover rates have continued to rise over the same time period (American Hospital Association, VHA). Improving the practice environment is a key strategy to achieving the following strategic goals:

1. Improve the quality of the work life for all nursing professionals
2. Attracting and retaining a diverse nursing populace.
3. Improve nursing and other health professional's productivity through enhancement of interdisciplinary communication and practice.
4. Redesign systems and environments to achieve safety and quality goals.
5. Promoting career ladder, mentorship and community and consumer connectedness as tactical imperatives to achieving strategic goals.

Background

The current and future shortage of registered nurses across the United States has significant implications for the American public. Most initiatives including proposals from local, state and federal governmental agencies focus on gradually increasing the supply of registered nurses through improving the production capacity of America's nursing schools. In addition, there are attempts to increase the number of foreign trained nurses in the American workforce. Finally, there are efforts underway to extend the amount of worked hours any one RN performs in her/his career. In a recent study sponsored by the Robert Wood Johnson Foundation Ed O'Neill and colleagues present data suggesting that focusing solely on increasing supply will not resolve the nursing shortage crisis. In fact, if we fail to address the demand side of the equation the public's health will be adversely affected by the year 2005. The Division of Nursing Health Resources Service Administration, American Organization of Nurse Executives, National Black Nurses Association, National Black Nurses Foundation, Coalition of Ethnic Minority Nursing Associations, American Nurses Association and the American Hospital Association agree that we must design a practice environment that decreases the burden of providing nursing care to improve nursing retention and patient care outcomes.

Improving the quality work life of all nursing personnel

The number of individuals in healthcare performing a nurse function continues to grow. The fastest growing group of individuals is technical and unlicensed assistive personnel. Many of these individuals are from diverse ethnic populations, including foreign born and trained registered nurses. Registered nurses, licensed vocational nurses, nurse aides and home health workers are all victims of a system that has failed to recognize the value of the humans providing care to humans. As a result the environments in which they work have been characterized as cesspools, slave centers and unfriendly and discriminating places to work. The organization without regard of the conditions in which they work is viewed as important. The importance of caring for employees and achieving positive work-life balances a key strategy to improving retention. Ethnic people of color continue to experience discrimination in the workplace. This factor alone has deterred health care workers in general and registered nurses from encouraging their sons, daughters, nieces, nephews grandchildren, godchildren or the neighbors across the way from entering the nursing profession.

The continued shortage of nurse professionals from ethnically and racially diverse background in leadership contributes to the inability to attract and retain nurses or to support the career advancement of entry level workers. The health personnel shortages in the nursing field are a product of a system that has failed to value the work provided by the nursing population. As a result members of the nursing workforce are reluctant to promote the profession as a career that will be of social benefit to the individual, their family and cultural group and the communities they wish to serve.

Attracting and retaining a diverse workforce across practice settings

The best recruitment strategy is the retention and professional development of nursing personnel in all healthcare settings. Providing career development opportunities from patient care sitters to the chief executive officer role has increased the number of individuals from diverse ethnic and racial backgrounds. Examples include Shands Regional Medical Center in Florida. The leadership of the center established goals to promote a culturally competent and satisfying work environment. The institution has been recognized for its outstanding results in attracting and retaining a diverse workforce to meet the health needs of a diverse community.

Robert Wood Johnson University Medical Center is another example of outstanding efforts to attract and retain a diverse workforce. Since 19xx the medical center has worked with a coalition of primary and secondary schools, business community and employees of the organization to promote nursing and other health professions as valuable careers.

East Alabama Medical Center was identified as one of the top Fortune 100 best places to work in the United States. The center deploys a variety of strategies to promote a positive working environment connected with the community through its employees.

The Minnesota Hospital and Healthcare Partners launched a project with the Minnesota Organization of Nurse Leaders to strengthen practice environments. Their goals are to create environments that demonstrate respect and recognition for a diverse nursing workforce that meets the needs of urban and rural communities.

Southern University School of Nursing in Baton Rouge, Louisiana used a "community needs" as rallying vehicle to increase the number of ethnic and racially diverse nurses. The school successfully increased the number of nurses prepared to shape the practice environment in acute and community settings. The nurse managed clinics provide primary care services and serve as culturally appropriate practice settings for all students and faculty.

Northwestern Memorial Hospital in Chicago has an academy staffed by advanced practice nurses, educators and administrators to improve the cultural competence, clinical skills, literacy and service skills of its employees. The center has led to improved retention and promotion of ethnically and racially diverse personnel.

Cedars-Sinai Medical Center in Los Angeles, California created an Institute for Professional Nursing to assure the availability of a qualified nursing workforce. The Institute has six programmatic thrusts including the development and testing of innovative practice.

Developing new practice models to retain and attract a diverse nursing populace. Implement Culturally and Linguistic standards in to clinical practice programs.

The United States population will continue to expand its racial and ethnic groups over the next twenty years. The population will also continue to age and live longer with disease and illness. The current preparation programs must be changed to provide health professionals with the knowledge and skills to care for a chronically ill populace across settings. Nurses in the role of educators in acute and primary care settings to assist, coach and mentor individuals and populations in the management of their disease and illness are needed.

The opportunity to provide care that is meaningful for ones family and community will attract and retain nurses. However the practice environment must enable the nurses to provide that type of care. Individuals must be supported to advance their knowledge of motivational theory, self care theory and evidenced based nursing practice. Simultaneously, individuals must be developed to provide technical care in a satisfying and culturally relevant manner. Differentiated practice models that reward and recognize each practice level can assist in promoting nursing as a career vs. job. The University of Iowa Medical Center has developed a collaborative differentiated practice model with the school of nursing The model has enabled nurses at the baccalaureate and master level to implement initiatives to improve nursing retention and patient care outcomes.

Career clinical ladders that enable nurses to advance without leaving their direct patient care roles have proven efficacy and attracting and retaining nurses according to McClure and Hinshaw (2002). Providing incentives to promote the mentoring of new nurses is the cornerstone of retention. The University of California San Diego Medical Center Preceptor Incentive Program is an example. The program has decreased the turnover of Hispanic and African-American nurses from their outreach efforts.Their outreach program include a coalition to support increased enrollment and graduation of ethnic and racially diverse nurses into associate and baccalaureate nursing programs.

National forum to develop solutions to retain and develop the workforce

The American Nurses Association, American Hospital Association, Institute of Medicine, American Academy of Nursing and others have identified the need for a national forum to improve the practice environment. The Division of Nursing should assume a key leader role in the organization and launching of such a forum. This forum would represent the cornerstone of a major change in the deployment and utilization of nurses to meet the needs of a chronically ill, aging, multigenerational and ethnic and racially diverse American public.

The Division should seek to partner with professional nursing associations, employers of nursing personnel, funding agencies and other federal agencies to promote and support the development of innovative models that result in the achievement of goals identified in the NACNEP Action Agenda in 2000. The Division should use its existing and new funding sources to stimulate local and regional efforts to achieve ethnic and racial diversity in practice settings and improvement in the ability of all nurses to provide culturally relevant care. The following strategic initiatives are recommended for the Councils consideration.

Strategic Initiatives

1. Launch a national forum on improving the practice environment and nursing's ability to provide culturally relevant care.
2. Issue a request for proposals to support the creation of innovative practice models.
3. Promote applications under advance nursing practice and diversity to on practice enrichment to retain and develop ethnic and racially diverse nurses.
4. Partner with ethnic nursing organizations and others to promote a national agenda on improving the practice environments across settings and communities.
5. Encourage the provision of full living stipends to support career advancement for entry, mid and advanced career level nursing personnel.
6. Expand the National Nursing Sample Survey to include questions on diversity in the workplace and effective models of nursing practice.

Summary

The data on ethnic and racial diversity in nursing indicates no significant improvement over the last decade. To stimulate growth and development of diverse nurses across practice settings requires the initiation of new practice models, development and deployment of nurse leaders from diverse backgrounds, launching of new roles that support the career advancement and mentorship of nurses and collaboration of federal, public and private institutions. The Division of Nursing has a rich history of launching initiatives through its funding priorities that have improved the preparation and utilization of nurses to meet the health care needs of the American public. The funding of advance nurse practice programs increased access to primary care. The nurse managed clinic initiative enabled advanced practice nurses to work in primary care, provided clinical practicums for students and provided quality health care for diverse populations. The traineeships help to expand the basic nursing workforce and stimulated interest of nursing as a career. The launching of a practice environment improvement initiative that focuses on enabling all nurses to provide culturally relevant and appropriate care, attracting and retaining ethnic and racially diverse nurses, linking nursing diversity with the ability of practice settings to achieve quality goals will help the Division of Nursing and the US Public Health Service to achieve its goals of closing the health disparity gap.

References

Kimball, Bobbi and O¹Neil Edward. 2002. Health Care¹s Human Crisis: The American Nursing Shortage. Robert Wood Johnson Foundation.

United States General Accounting Office. 2001. Nursing Workforce: Emerging Nurse Shortages Due to Multiple Factors. Washington, DC.

Villarosa, L. 2001. Working to Burnish Nursing¹s Image. New York Times, May 22, 2001.

Yasin, S. and Albert. 1999. Minority Teacher Recruitment and Retention: A National Imperative. American Association of Colleges for Teacher Education.

AHA Commission on Workforce for Hospitals and Health Systems. 2002. In Our Hands. American Hospital Association, April 2002.

AHA Division of Nursing.1987. Surving the Nursing Shortage: Strategies for Recruitment and Retention of Hospital Nurses. American Hospital Association.

American Organization of Nurses Executives Institute for Patient Care Research and Education. 2000. Nurse Recruitment and Retention Study. AONE.

McClure,M and Hinshaw,AS. 2002. Magnet Hospitals Revisited. American Academy of Nursing.

McClure, M., Poulin, M., Sovie, and Mandelt, M. 1983. Magnet Hospitals Attraction and Retention of Professional Nurses. American Academy of Nurses.

Aiken, L 2001. "Evidenced based management: Key to workforce stability." Journal of Health Administration Education. 19 (4), 117-24.

Aiken, L.and Patrician, P. 2000. "Measuring Organizational traits of hospitals: The revised nursing work index." Nursing Research, 49 (3), 146-53.

Mitiguy, J. 2002. "Shining a light on solutions: The Institute for Professional Nursing Development- Cedars-Sinai Medical Center." Nursing Spectrum September 2002.