NURSING RETENTION AND RECRUITMENT

The reality

Uche Nwabueze, Instructional Professor of Management, Department of Maritime Administration, Texas A&M University

Employment opportunities in the healthcare industry, and in particular in the nursing field, are expected to grow over the next ten years. However, it is no secret that America is experiencing a nursing shortage due to low enrolment in nursing schools and an ageing workforce. In order to bridge the gap, the healthcare industry needs to retain employees from the current workforce, while recruiting new employees. The paper will review current retention techniques and will identify those that are most effective. The subject of recruitment is of equitable importance. The research will review current recruitment techniques and identify what the healthcare industry is doing to entice new prospects to the nursing field. Finally, the paper will examine nursing programmes and the lack of qualified faculty.

As many corporations in this economy are downsizing, the healthcare industry continues to grow. The advancement of technology in the healthcare field sustains patients far past what was expected only a few years ago. This technology also requires more skilled personnel to operate these devices. In addition, the general public is ageing and the longevity of the human race has substantially increased. Therefore, there is an increase in the need for more healthcare employees, due to the increase in the population’s healthcare needs. For instance, the nursing field alone continues to grow in size as the demand for nurses grows by 2-3 per cent a year (Rosseter, 2009).

Currently, the healthcare industry worldwide is unable to keep up with this demand. Further compounding the shortage, the average age of a registered nurse (RN) continues to climb. It is estimated the average age of an RN is 43 years of age (Roman, 2008).This number is projected to climb due to fewer young people entering the field and even fewer students graduating with a nursing degree. This declining statistic is mainly a result of nursing schools that are unable to admit more nursing candidates due to the lack of qualified faculty. In addition, nurses are leaving the industry due to levels of moral distress and decreased job satisfaction. Therefore, employers are experiencing an increase in turnover and lack of qualified candidates from nursing schools. By the year 2025, it is projected that the nursing shortage will reach 500,000 positions (Rosseter, 2009).

This topic of the nursing shortage, and ways to reinstate these positions, is of great importance to society as a whole. It will affect every person due to the ageing population, with an increased need for accessing the healthcare industry. Nurses are continuously at the bedside caring for and becoming more familiar with their particular patients. As a result, nurses have been an important factor in the prevention against potential adverse medical events. Therefore, this nursing shortage and its effects will directly impact the quality of care a patient receives.

Growth of the Healthcare Industry

The healthcare industry continues to grow despite the current economic times. Advances in technology have swept the healthcare field, and in particular the field of nursing. With this technology, patients are surviving illnesses that were previously deemed fatal. This leads to more complicated health issues in patients. As a result, the idea of preventative medicine is a rising trend thus requiring more nursing positions.

Technology continues to advance and be implemented in various aspects of the healthcare field. Patients today receive more radiologic tests, laboratory tests, and surgical interventions than ever before. It is typically the bedside nurse that coordinates and performs these interventions for the patient. As a result of these advanced technologies, tasks that were straightforward only a few years ago have become complex endeavours (Rosenkoetter, Bowcutt, Khasanshina, Chernacky, & Wall, 2008). For example, when a nurse administered an antibiotic fifteen years ago, the bedside nurse would first get the medicines from the patient’s bin, add tubing, and then hang the medicine and count the drips to determine the correct rate. Today, the nurse has to log into a computerised vending machine to obtain the correct medicine. The nurse then logs onto the computer system to verify the medication against the patient’s electronic medication record. Then, the nurse logs into another vending machine to obtain the tubing. Finally, she or he enters the room, scans the patient’s identification band, and then places the medication on a pump. In addition, the pumps now require a nurse to enter the patient’s personal data, select the correct medication to be administered, and verify the correct rate. Meanwhile, she or he might have received three phone calls and two pages from other locations or patients within the hospital that require immediate attention.

As a result of these new technological advances, patients are facing new health issues. Patients are now surviving illnesses that were labeled terminal only a few years ago. This results in new health concerns and conditions for these patients. For example, children who were born with certain congenital heart defects a few years ago were treated with palliative care or kept comfortable until they passed away. Today, the defects are being surgically repaired in these children after only a few days of life. As a result, these children are successfully growing into adulthood. Most of these patients continue to be followed by paediatric cardiologists due to the fact the adult cardiologists have little to no experience with these conditions. Therefore when these patients become ill, either they report to a paediatric hospital, where they will be out of place due to age, or an adult hospital, where the staff may not be experienced with their condition.

The healthcare industry has to learn how to treat these patients long term. In addition, more patients are living longer with multiple chronic illnesses. For instance, these paediatric cardiac patients in adulthood are beginning to experience problems with their respiratory systems due to the demand on their impaired hearts. Therefore, as society continues to age, the demands on the entire healthcare industry will continue to escalate to care for this medically com aged population.

As technology advances and preventative medicine extends the longevity of those in the community, the population will continue to mature. The healthcare industry will face patients with more complex medical conditions. Therefore, the nursing staff will have an increased patient load and more technology with which to master and perform their basic duties.

The healthcare field is also moving more in the direction of preventative medicine and health promotion. If one can prevent the illness from ever occurring or prevent the spread of disease, there would be less crowding in the hospitals. Healthy People 2010 was a governmental funded campaign started to reach a goal of a healthier society by the year 2010 (Martin, 2005). This campaign focused on health promotion and prevention. It targeted a close relationship between the patient and the primary healthcare provider. Therefore, preventative medicine began taking hold within community offices and facilities.

Immunisation campaigns for children have continued, despite the autism versus vaccination debate. In addition, there is a push toward re-immunising adults. This is due to decreased immunity with certain diseases, such as pertussis (Casey &Pichichero, 2005). Other common health campaigns are smoking cessation, asthma education, diabetes education, general health promotion and nutrition, and cardiovascular disease. With these initiatives, there are a lot of additional education and wellness screenings being performed in the communities. Nurses play a vital role in the education and health screening of patients. Many times these clinic visits are to a nurse practitioner or just a simple nurse visit, without physician participation. Therefore, nurses are a key player in the preventive medicine and the health promotion movement.

With all of these new initiatives, the average age of the population continues to climb, which in turn requires more nursing care. It is estimated by 2016, the nursing field will create 587,000 new positions which would be amid the highest for any profession (Bureau of Labor Statistics, 2007). This would, in fact, be an increase of 23 percent from those currently in today’s workforce.

Impact on the Patients

The nursing shortage and increase in workload on the nursing staff directly affects the way in which nurses are able to deliver patient care (Rosseter, 2009). If there are fewer nurses with a higher workload, the quality of care a nurse can deliver will ultimately suffer. The physicians have already become far removed from bedside care, due to their increased patient loads and external demands. For that reason, a patient is dependent on the nurse and the quality and quantity of time that a nurse can spend with them to care for their basic needs and monitor their progress. Yet, the nursing shortage has greatly reduced this bedside time. Their capability to detect complications early has been significantly hindered due to this lack of quality time with the patient (Roman, 2008).This leads to a decrease in the quality of care a patient can and will receive. As a result, this issue of the current nursing shortage will eventually affect everyone in our society.

Moral Distress

Moral distress can be defined as an act of not pursuing what is right due to certain obstacles which make it impossible to do so (Zieber et al., 2008). Moral distress affects a nurse’s interpersonal relationship, mind, and body, which will eventually affect the nurse’s bedside duties and demeanour. When nurses are not able to perform as a nurse patient advocate, they become frustrated and disappointed. This behaviour can slowly increase and eventually cause nursing burnout, especially if there is a lack of administrative or managerial support (Zieber et al.).

A staff nurse’s morale is already experiencing the negative effects of the nursing shortage (Ellenbecker, Samia, Cushman, & Porell, 2007).This can be exhibited by a staff nurse caring for a terminal patient. The nurse wants to spend time with the patient and their family to prepare them for what is to come. She or he wants to educate them on the feelings and emotions they may experience and the physical symptoms that might occur. The nurse wants to help them with the grieving process and dealing with their loss, all the while continuing to administer the patient medications and therapies.

However, one of the other nurse’s patients needs her or him to travel to Diagnostic Imaging (DI) for a test. Meanwhile, the nurse is needed to discharge another patient home, which includes arranging for transportation, making follow up appointments, explaining prescriptions, and verifying their understanding of the discharge instructions. But before all of this occurs, she or he has to admit a new patient coming from the emergency room. This entails orientating the patient and family to the unit, verifying the admission orders, and completing a full head to toe assessment including past medical history. Furthermore, the nurse has to set up services for the new patient such as meals and therapies in addition to ordering supplies and medications.

Moral distress arises when the nurse has to prioritise patient care. The patient requiring the test and the new admission are going to take precedence over educating the terminal patient and their family on what they can expect to occur. Unfortunately, there are only so many hours in a shift with which to complete these tasks. Therefore, the education might not get accomplished. This can cause moral distress in the nurse. She or he knows the right thing to do would be to educate and spend more time with the terminal patient and their family preparing for their loss. However, due to the lack of assistance from other nursing staff, secondary to the shortage, the nurse is unable to do what she or he feels is right. This moral distress will ultimately lead to job dissatisfaction.

Job Dissatisfaction

There are multiple factors that contribute to an employee’s job satisfaction. Most of these are individualistic, yet some are universal. The work environment plays a large role in an employee’s contentment. In particular, the internal work environment of the healthcare industry is pivotal to employee satisfaction. This environment must protect the safety of both the patient and the nurse (Ellenbecker et al., 2007).

In the previous example of moral distress, the nurse might feel the assignment is unsafe. Maybe the patient who needs the procedure in DI has altered mental status and might be trying to climb out of bed. If the nurse is with her or his other patients, the nurse might not be able to protect the patient’s safety. What if the nurse was pregnant? Maybe she would feel uncomfortable traveling to DI due to risk factors regarding the pregnancy, such as radiation. Or maybe the nurse has multiple medications due for her or his other patients while the nurse will be away in DI. Therefore, they will not be administered on time, consequently making it an unsafe assignment. Meanwhile, the terminal patient and their family are still awaiting the education. In addition, the last patient is complaining, because they have not been discharged home. This nurse will be dissatisfied with the assignment, due to the inability to complete the basic nursing tasks. If someone is not satisfied in their current position, what is going to keep them from leaving?

Financial Impact

This turnover and loss of nursing staff is costly to institutions. The financial burden of replacing an experienced nurse is anywhere from 50 to 200 per cent of the nurse’s base salary (Ross, 2009).Staff salaries tend to account for the majority of an institution’s budget. With the current economic times and budgets being unyielding, there is little opportunity for the high cost of training new employees.

It has been shown that having experienced nurses on staff improves the quality of care that a patient receives and their presence directly affects patient satisfaction (Westendorf, 2007). Patient satisfaction can be transmitted to customers via public access or word of mouth. It is one of the main driving forces of consumers in choosing their healthcare facility. With financial reimbursements tied to performance outcomes and quality of care, it is essential that organisations preserve their experienced staff (Roman, 2008). These institutions need to devise a plan to increase the retention in their facility.

Retention Solutions

Nurses are stressed due to the lack of qualified staff which causes them to leave the organisation or profession. This intensifies the nursing shortage for the facility and creates more stress among the nursing staff remaining. In turn, they decide to leave. It is a cyclical event that needs to be broken. There are various tactics being introduced throughout the country to increase retention rates.

Residency programmes Organisations need to start retention endeavours from the very beginning of employment. It is estimated that one half of graduate nurses will leave their first employer in less than one year (Delegates to ANA, 2008).Some facilities are utilising mentorship programmes where graduate nurses and new hires are assigned to veteran nurses who assist them with learning the intricacies of the workplace. Other facilities are implementing a nurse residency program. These are hands on learning experiences for graduate nurses within the workplace. These typically work in conjunction with a mentorship program. Both of these programmes are relatively inexpensive and cost effective. A positive relationship between retention and nursing residency programmes has been previously demonstrated (Wishall, 2008). Ericksen (2009) states the first year turnover rates with these programmes is nearly one sixth of those without these programmes. Positive working conditions, which include an acknowledgement of work life balance, are crucial to nursing retention. This includes flexible work schedules, which allow the individual to plan their work around various activities and situations that arise in their personal life. Independence in scheduling has proven to be a key determinant in job satisfaction ratings (Ellenbecker et al., 2007).

This positive working environment also includes professional growth. Some organisations offer financial reimbursement or incentives for seeking advancement in education. Higher education allows for professional advancement which can heighten one’s self-esteem. With a heightened self-esteem due to career advancement, job satisfaction tends to follow. Many organisations are utilising financial incentives to assist with retention such as increased salaries, retention bonuses, and educational incentives. Individual units often give advantages to tenured employees, such as fewer holidays, scheduling perks, and freedom from being pulled to another unit (Ellenbecker et al., 2007).With the current economy, these incentives still play an important part in job satisfaction and retention. However, these tactics are typically short term and are utilised by many institutions. Therefore, they present no clear advantage over other facilities.

Autonomy is the ability to determine your actions or make your own decisions (Ellenbaker et al., 2007). Nurses do not want to just follow physician orders. Nursing is its own profession. Nursing has its own set of diagnoses and therapeutic measures. Nurses are important members of the healthcare team. Autonomy has been reported as a key factor in job satisfaction, therefore potentially increasing retention rates. This independence needs to be supported by upper leadership. A large determining factor in job satisfaction is the environment in which one works. Internal environments can be moulded by the current practices and philosophies of the management (Pierce & Gardner, 2002).Most healthcare facilities are regulated by certain governing bodies to ensure safety and security. However, there are more factors in the environment equation than the physical structure.

In addition, a manager must be in tune with their employees by listening to their concerns and letting the members know they have a voice. Employees who feel their ideas are being heard and considered are more likely to stay with the organisation (Gaddis & Cates, 2009). Many changes in policies and procedures have come directly from nurses at the bedside. These modifications were possible as a result of receptive management.

Overall, an employee wants to be a valued asset to the organisation. They want to be rewarded, either formally or informally, for good performance. Employees perform better when they are motivated by managers who display the attitude or behaviour which they are seeking (Gaddis & Cates).Employees who feel they are valued have better job satisfaction and therefore better retention rates. Many of these tactics are utilised by hospitals to obtain Magnet status. Magnet is a voluntary surveying organisation for nursing in hospitals. Westendorf (2007) reviews that Magnet hospitals must exhibit the eight essentials of magnetism: support for education, working with competent coworkers, positive nurse-physician relationship, nursing autonomy,
a working culture that places emphasis on the patient, control over nursing practice, adequate staffing, and administrative support. In order to achieve Magnet status, a hospital must undergo an evaluation by the organisation in which the hospital is visited. The nursing staff is interviewed and their current policies and procedures are reviewed. There has been a direct correlation with Magnet status and increased retention rates (Wishall, 2008). The title of Magnet status can also be beneficial when recruiting new nurses. It speaks to what kind of nursing organisation is present within the institution.

Barriers

First of all, society still has the stereotypical image of nursing as a subservient role. Nurses are still portrayed in the media as behind the scene servants and minor characters in the healthcare industry. In order to recruit the younger generations, this image needs to be addressed. In 2002, Johnson and Johnson launched the Campaign for Nursing’s Future. Its sole purpose is to improve the image of the nursing field (Rosseter, 2009). They utilised television and magazine ads, brochures, and launched an interactive website1. These images and personal testimonies display the various career choices a nurse has and the everyday rewards of being a nurse. This campaign is geared toward young adults, typically high school to college age. They have continued to run this campaign and plan to continue it throughout the current nursing shortage. In addition, the healthcare industry is not well versed in the strategies of recruitment. A study showed that 75 per cent of the surveyed hospitals did not respond appropriately to qualified applicants (Westendorf, 2007). Materials requested from these applicants were not delivered and when there was follow-up, there was a lack of personalisation. Also, technology was not utilised in the recruitment process. Snail mail was utilised as the primary method of communication. However, the applicants from the younger generations primarily use e-mail, Twitter, facebook, and texting (Westendorf).The industry needs to learn from its corporate fellows the fundamentals of good recruitment techniques.

Many incentives are currently used to recruit new hires such as sign-on bonuses, free housing, relocation support, international recruitment,liberal shift differentials, and benefits for part-time employees which are equivalent to those of full-time employees (Westendorf, 2007). However, the organisation needs to tread lightly in this arena with regards to their tenured staff. These recruitment methods may cause animosity amongst the long-term hospital employees (Westendorf 2007). The organisation should offer these same benefits for retention purposes. Therefore, exhibiting equality and not alienating the existing employees. In addition, temporary sign-on bonuses tend to encourage the job hopping phenomena (Ericksen, 2009).

The nursing shortage is further compromised by the lack of qualified faculty in the nursing schools (Roman, 2008). Nurses seeking higher education are going into clinical roles as opposed to the education system. Faculty pay and benefits cannot compete with those of the larger healthcare organisations. Therefore, the schools are only able to accept a limited number of applicants. This reduces the amount of available candidates for these new positions.

Due to the current state of our economy, there are many people that might be looking for a career change into the healthcare industry due to job security and numerous employment opportunities. These might be second career candidates or high school graduates. As previously stated, nursing residency programmes are successful in both recruitment and retention of new graduates (Westendorf, 2007).

Organisations need to go to schools and actively recruit these potential employees. Most schools offer on-sight job fairs that the organisations can have their human resources attend. In addition, the organisation can partner with the schools by offering student job opportunities and guest lecture series. Some organisations are utilising their nurse leaders as instructors for associated courses. The students attend lectures given by these leaders then rotate through the various units of the hospital (Ericksen, 2009). This familiarises the student with the facility and already fosters a working relationship.

Westendorf (2007) suggests we need to foster these relationships earlier on. She suggests visiting school-aged children in the classroom to open their eyes to the nursing profession. These school-aged children will be entering the workforce in 15 to 20 years when the shortage is supposed to be at its peak. Gearing them towards the nursing profession at this early age influences them before they determine what is or is not a desirable career(Westendorf, 2007).

Recruitment of experienced staff is geared more toward incentives. However, as stated before, these incentives must be available for the long-term staff. Tuition reimbursement, clinical ladders, and vacation packages are examples of incentives that can be offered to both new recruits and existing employees (Westendorf, 2007).

The mentorship program for experienced nurses, like the nurse residency program for new graduates, fosters a welcoming environment and encourages staff to join the organisation (Erickson, 2009). Mentorship is also a great way to unify the staff by partnering the established staff with the new hires. This programme, like the residency programme, contributes to higher retention rates. The existing staff can also benefit from the use of recruitment strategies. Some organisations offer finder’s fees and tour bonuses to employees for recruitment of staff (Westendorf, 2007). In addition, participating in an interview panel or becoming a mentor are excellent opportunities to get the current staff involved and motivated for the recruitment process.

Conclusion

The nursing shortage is here and is expected to worsen over the next few years. The shortage affects everyone from fellow nurses, to physicians, to patients and society as a whole. If organisations and educational facilities do not respond quickly, matters are only going to get worse.

Organisations need to realise that employees are their most valuable resource. Therefore, organisations should first put forth the effort to retain these existing staff members. In addition, recruitment of new employees should begin in the school system, starting as early as school-age students all the way to those graduating from nursing school. The healthcare organisations need to welcome these new hires with mentorship or nurse residency programmes to solidify the employee’s place within their institution. Where these efforts fail, management needs to step forth and analyse the current work environment. They need to make efforts to reduce the moral distress and workload, therefore increasing job satisfaction (Ellenbecker et al., 2007). In addition, these organisations should consider obtaining Magnet status. This status helps the organisation address recruitment and retention issues by analysing their current practices.

Nevertheless, there is a positive side to all of this. The shortage has revealed the importance of the role the nurse plays in the healthcare field to both lay people and fellow healthcare providers (Roman, 2008).Nursing is a great profession with the ability for autonomy and a work life balance. Nurses are the frontline members of the healthcare industry. They are with the patients, caring for them at the bedside around the clock. Nurses are the first ones to detect complications and prevent adverse patient outcomes. As Johnson and Johnson states in their Discover Nursing campaigne to be a nurse”.

References:

1 www.discovernursing.com

--Issue 45--

Author Bio

Uche Nwabueze

Uche Nwabueze is an Instructional Professor of Management in the Department of Maritime Administration at Texas A&M University.

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