The first step in improving Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) performance is recruiting nurses with a focus on long-term retention. The national turnover rate for bedside RNs was 16.8% in 2017 with an average associated cost of $38,000 to $61,000 per nurse. Nursing turnover impacts each hospital’s bottom line, with costs averaging from $4.4 million to $7 million annually (source).
Multiple Costs of Turnover
More importantly, high nursing turnover negatively affects morale, quality of care, and HCAHPS scores. When there is a critical acute need to satisfy scheduling demands, hospitals cannot afford the luxury of being proactive in their recruitment efforts. Unfortunately, patching a schedule full of holes causes rapid hiring decisions instead of considering a quality applicant.
There are connections between patient perceptions of their health care experience and nurse staffing ratios. The hospitals with the highest number of nursing hours per patient day consistently rate higher on HCAHPS scores than other facilities. Nurses and patients alike thrive in a positive nurse work environment. But recruiting nurses with long-term retention factors is only half the battle.
Revisiting the Recruitment Process
Health systems have to streamline their recruitment process to re-focus on hiring and retaining nurses with targeted HCAHPs behaviors like responsiveness, ability to listen, and audience awareness. When interviewing candidates, it is essential to identify how the nurse will communicate with and answer patients. Optimal applicants will treat the patient with respect, communicate effectively, and respond quickly.
Hospitals must strive to recruit candidates who are committed to their work, patients, and the organization. When hospitals remain competitive to hire and retain talent, patients stand to benefit. Top-quality employees make for top-quality organizations and nurses are at the forefront.
Caitlin Goodwin MSN, RN, CNM is a Board Certified Nurse-Midwife and freelance writer. She has ten years of nursing experience and graduated with a MSN from Frontier Nursing University.
When the first nurse practitioner residency programs began, the term “residency” left many in the nursing community unsettled.
“One of the concerns of residency programs and that terminology is the suggestion that nurse practitioners are not prepared upon graduation, which is not accurate at all,” Kitty Werner, MPA, executive director for the National Organization of Nurse Practitioner Faculties (NONPF), told MedPage Today.
In considering the language debate, Werner said, “[I]f people look at them [residencies or fellowships] closely they see how they are specific to their practice site, it’s much more like an intensive on-boarding experience for new graduates. Or it might be for existing nurse practitioners who transition to that particular practice environment, but they don’t replace formal educational preparation.”
The NONPF, as part of a broader statement on post-graduate education, declared that the term “residency” is “not an optimal description for NP post-graduate support” because it may be confused with medical residencies which are required for physicians to gain licensure. Four other major nursing groups signed the statement, which was later endorsed by the largest, the American Nurses Association.
“The residency in medicine fulfills the required clinical focus of a particular specialty. In NP preparation that clinical focus is embedded in the NP educational program centering on the population focus that is the center of NP practice emphasis (e.g., family, pediatrics, women’s health, etc.),” the statement read.
Even more confusing, some nursing programs use “residency” specifically for the clinical hours already included in their programs. The statement urged post-graduate support programs to keep things simple and call themselves “fellowships” instead.
Britney Broyhill, DNP, ACNP-BC, the director of the nurse practitioner program at Carolinas Healthcare in Charlotte, N.C., said she prefers the term “fellowship” since the programs are voluntary and offer advanced practice clinicians a chance “to go above and beyond their formal education and training in a subspecialty.”
But there are dissenters, among them Margaret Flinter, PhD, APRN, senior vice president and clinical director of the Community Health Center in Middletown, Conn., who founded the first nurse practitioner residency program and still prefers that name.
“My feeling is still — though I’m always open to the conversation — that this kind of broad-based, very intensive clinical training across the full gamut of primary care is best described as residency.”
She noted that the Department of Veterans Affairs also uses the term “residency.”
This story was originally posted on MedPage Today.
Experience in New Jersey showed programs faltered without strong leaders
Effective leadership is crucial to the success of initiatives like implementing a nurse residency program in a post-acute care (PAC) setting. These programs can be a valuable asset for recruiting, educating, and retaining nurses in a healthcare environment that’s increasingly in need of skilled and knowledgeable staff.
The New Jersey Action Coalition (NJAC) launched a statewide nurse residency program in 2014, achieving a retention rate of 86%. New nurses and their experienced preceptors attended interactive, in-person education. Preceptors then applied their new knowledge to helping their new nurses become competent and engaged. The success of their experiences depended on many things; a nurse leader who championed the program in the clinical setting was often a linchpin.
Effective leaders elucidated the benefits of participation to administration and staff, justifying the expense of sending nurses to the program. Continuing leadership ensured new nurses and preceptors were given time to attend class and to meet regularly, and were given encouragement when difficulties arose.
Perhaps even more importantly, wise nurse leaders were open to ideas that participating nurses brought back to the workplace. For a facility to benefit fully from the education, it had to be willing to embrace fresh strategies.
In the NJAC experience, it became clear that when a nurse leader resigned, the program often lost its main advocate. Negative effects were seen in reduced attendance and support for nurse resident/preceptor activities at the facility, such as performance improvement project work. Nurse leaders provide preceptors with the organizational support for what can be a stressful role. Leadership is also required for the maintenance of a healthy work environment in order to retain nurses.
Qualitative research completed during the project revealed that new nurses clearly see the need for robust leadership. Their comments about the needs of PACs yielded a desire for “visionary, hands-on management” and “teamwork, respect, and kindness between colleagues.” Such insights from new nurses indicate that PACs are ripe for organizational culture change through imaginative and innovative leadership.
NJAC offers this advice for nurse leaders considering a nurse residency program:
- Know your costs for vacant positions (from overtime to onboarding). Quantifying savings achieved by improving retention via a residency program substantiates the return on investment.
- Choose preceptors wisely. Look for knowledge, skill, ability to use clinical teaching strategies, and dedication to helping nurses thrive. The importance for a good fit between preceptor and nurse resident was apparent in the NJAC experience and identified by Moore & Cagle (2012) and Richards & Bowles (2012). Once preceptors are chosen, invest in their education. Remember, precepting requires that even the most expert nurses acquire a new set of skills.
- Dedicate resources for success: time; space; supplies and computer/Internet access. Enlist other professionals, such as therapists, who have much to offer a novice nurse. Modify policies, job descriptions, and clinical assignments as needed.
- Prepare for bumps in the road and stay actively involved. Check in regularly with preceptors and new nurses to offer advice, problem solving, praise, and inspiration.
- Explore the wealth of literature available. NJAC and Rutgers School of Nursing have just published Developing a Residency in Post-Acute Care. Its guidance on implementing a residency program and detailed lesson plans will be valuable to nurse leaders/educators working with new nurses.
- Once the new nurse is ready for new challenges, identify opportunities such as committee membership and performance improvement projects to enhance developing professionalism, meaningful engagement, and retention.
One of the often-quoted pearls of wisdom stressed to nurses in the NJAC program is to “lead from wherever you are.” Implementing a nurse residency program is one way for PAC leaders to do just that. The rewards will be worth the voyage through uncharted waters.
This story was originally posted on MedPage Today.
Healthcare workforce gains seen with Medicare-funded test program
An increase in government funding for clinical training opportunities for advanced practice registered nursing (APRN) is a feasible and affordable way to grow the primary care workforce, according to a Report to Congress on the Centers for Medicare and Medicaid Services (CMS) Graduate Nurse Education Demonstration.
The $200 million initiative was started in 2012 to determine if Medicare funding for graduate clinical education for APRNs, similar to residency training for physicians, could help meet meet the health needs of the U.S. population.
“There is a shortage of primary care providers in this country and the education of more APRNs can be part of the solution to increasing access to care,” Barbara A. Todd, DNP, director of Graduate Nurse Education (GNE) Demonstration at the Hospital University of Pennsylvania in Philadelphia, told MedPage Today.
CMS awarded funding for clinical training programs to five hospitals, which then partnered with accredited schools of nursing and non-hospital community-based care settings to deliver primary, preventive, and transitional care to Medicare beneficiaries.
The five hospitals are Duke University Hospital in Durham, North Carolina; Hospital of the University of Pennsylvania, Memorial Hermann-Texas Medical Center in Houston, Rush University Medical Center in Chicago, and HonorHealth Scottsdale Osborn Medical Center in Arizona.
Lori Hull-Grommesh, director of demonstration at Memorial Hermann-Texas Medical Center, commented on program results in the Texas Gulf Coast area, noting that 95% of APRN graduates are employed in the community setting and are helping meet critical access needs. She said she believes that national funding would allow these results to be replicated in other states.
Linda H. Aiken, PhD, coordinator of the GNE Demonstration Consortium of University of Pennsylvania, agreed. “If permanent Medicare funding were available for the clinical training of advanced practice nurses in all states, the national shortage of primary care could be solved and Americans would be able to get timely healthcare where ever they live.”
The report stated that demonstration schools had significantly greater APRN enrollment and graduation growth than comparison schools. It also touched on financial incentives: clinical training for an APRN came to a total of $30,000 compared with $150,000 for just 1 year of community-based residency training for primary care physicians.
Although the GNE demonstration is slated to conclude at the end of June 2018, the five hospitals are currently collaborating with major national stakeholders in order to promote permanent funding to roll out the program nationally.
“All five sites are working together to promote efforts for ongoing funding, along with major stakeholders AARP and [American Association of Critical-Care Nurses], who were instrumental from the beginning,” explained Hull-Grommesh. This is being done through publications, meetings, presentations and discussions with our legislators, she added.
Aiken noted that various types of healthcare organizations, including physician practices and retail clinics, are hiring nurse practitioners in larger numbers and supporting efforts like the demonstration to increase the supply for advanced practice nurses. Also, healthcare settings are working to recruit more advanced practice nurses, especially for their valuable role in ending the opioid epidemic and addressing unmet mental healthcare needs, she pointed out.
This story was originally posted on MedPage Today.
After 1 hour of overtime, nurse-to-nurse collaboration drops significantly
Though it is common, working overtime may negatively influence nurses’ collaboration with their colleagues, according to a study by researchers at New York University’s Rory Meyers College of Nursing.
“Our research suggests that the more overtime hours nurses work, resulting in extended periods of wakefulness, the greater difficulty they have in collaborating effectively,” one of the two co-authors, Amy Witkoski Stimpfel, PhD, RN, said in a news release.
Nurses often work long, irregular hours and have unexpected overtime, which puts them at risk for fatigue and sleep deprivation and can lead to impaired emotional, social, and cognitive processing. This, in turn, may hurt nurses’ ability to collaborate, the researchers said.
The study, published in the Journal of Nursing Administration, assessed how shift length and overtime impact nurses’ perceptions of collaboration with other care providers — specifically with other nurses and physicians.
The researchers used 2013 survey data from the National Database of Nursing Quality Indicators, and analyzed responses from 24,013 nurses in 957 units from 168 U.S. hospitals.
Among the study’s findings:
- Across the five types of nursing units measured, the average shift length was 11.88 hours
- 12-hour shifts appear to be the predominant shift schedule for hospital nurses
- Nurses worked, on average, 24 minutes longer than their scheduled shift
- 33% of the nurses on a unit reported working longer than initially scheduled
- 35% of nurses said that the amount of overtime needed from nurses on their unit increased over the past year
“One in three nurses reported working longer than scheduled. This appears to be a chronic problem for nurses – one that extends an already long work day and appears to interfere with collaboration,” the study’s lead author, Chenjuan Ma, PhD, said in the news release.
Interestingly, the researchers did not find a significant relationship between average shift length and collaboration — meaning that longer-scheduled shifts did not necessarily lead to less collaboration. However, collaboration appeared to suffer in nursing units with longer overtime shifts and more nurses working overtime.
Collaboration on a unit was measured using the nurse-nurse interaction scale (RN-RN Scale) and nurse-physician interaction scale (RN-MD Scale). In addition, 1 hour of overtime was associated with a 0.17 decrease on the RN-RN scale and was marginally associated with a 0.13 decrease on the RN-MD Scale — in other words, a 0.17 decrease from the mean score on the RN-RN scale suggests that a unit’s rank on the RN-RN score would drop from the 50th percentile to roughly the 30th percentile, the team explained.
Advice for Nurse Leaders
The researchers advised that nurses, nurse managers, and hospital administrators should use overtime as infrequently as possible. Stimpfel and May said that while they recognize that longer shifts are the norm and that eliminating overtime may not be possible, offering fatigue management training and education would be helpful, as well as training to help nurses and physicians communicate effectively and respectfully.
“Our findings support policies that limit the amount of overtime worked by nurses,” said Ma. “In practice, nurse managers should monitor the amount of overtime being worked on their unit and minimize the use of overtime.”
Collaboration among healthcare professionals is critical for quality care and patient safety, the team emphasized. Previous studies have shown that patients receive superior care and have better outcomes in hospitals where nurses collaborate well with other healthcare providers. In fact, a study by Ma and two other co-authors published May 2 in the International Journal of Nursing Studies found that both collaboration between nurses and physicians and collaboration among nurses are significantly associated with patient safety outcomes.
This story was originally posted on MedPage Today.
Stress manifests among nurses in various forms and can affect patient outcomes
Being a nurse can be fulfilling and rewarding. We get the privilege of helping new lives enter the world, comforting those who are exiting this world, and everything in between. Yet nursing is also taxing and draining at times. Off-shifts (nights and weekends), hectic workloads, violence from patients and families, and incivility among staff members can all cause physical and emotional wear and tear among nurses.
Unfortunately, issues like depression, burnout, and fatigue are extremely prevalent among nurses. As Alexandra Wilson Pecci writes in a recent article, one 2016 study found that nurses experience depression at twice the rate of those in other professions.
This is bad not just for nurses but also for patients. Another study Pecci highlights found a link between nurses reporting poor health, particularly depression, and higher rates of reported medical errors.
That’s a serious issue and one that certainly needs to be addressed.
Some recent HealthLeaders articles offer solutions to address stress among RNs.
Beating Clinician Burnout
There’s a common belief that burnout is a personal failing and that resolving dimensions of burnout — emotional exhaustion, cynicism, inefficacy — are that individual’s responsibility. Eat a salad, go for a walk, take a yoga class, and you’ll be fine. In reality, however, burnout is a sign that something is amiss within an organization, and healthcare leaders need to uncover both the prevalence of burnout at their organizations as well as its root causes.
“There needs be a framework to understand where the pain points are, and then how an organization can do something about that,” said Karen Weiner, MD, MMM, CPE, chief medical officer and CEO at Oregon Medical Group (OMG), a physician-owned, primary care–based multispecialty group of about 140 healthcare providers, with offices in the Eugene and Springfield area.
Weiner advises that leaders implement system-wide changes to address the factors contributing to burnout. After administering the Maslach Burnout Inventory at OMG, the organization made multiple changes including creating a physician-organization compact, developing new compensation practices, and redistributing workloads.
Creating Culture of Caregiver Support
A 2015 Gallup survey found that more than half of all healthcare workers report thriving in none or only one element (purpose, social, financial, community, physical) on the Gallup-Healthways Well-Being Index.
To better help employees cope with the emotional demands of caring for others, some organizations are implementing programs to prevent problems like burnout, suicide, and substance abuse.
“Strategies that could support employees include reducing the stigma about mental health concerns, providing resilience training and care for the caregiver support programs, and providing health and wellness benefits, including policies that allow for time off for mental health concerns as well as for physical health concerns,” said Celeste Johnson, DNP, APRN, PMH CNS, a member of the board of directors of the American Psychiatric Nurses Association and director of nursing, psychiatric services at Parkland at Green Oaks Hospital in Dallas.
For example, the University of Missouri Health System’s forYOU program provides support to healthcare workers experiencing symptoms of “second victim syndrome.”
Parkland provides universal screening for suicide risk, including for those employees seen in the employee clinic.
How to Handle Cyberbullying in the Nursing Unit
Another source of stress among nurses is workplace violence, and cyberbullying meets that definition. Thanks to technology, bullying behaviors can now occur in digital form via means such as instant messaging, email, text messaging, social networking sites, or blogs.
According to the National Council for the State Board of Nursing’s policy on social media, any online comments posted about a co-worker may constitute lateral violence — even if the post is from home during non-work hours.
To confront cyberbullying, the policy states, individual nurses should save evidence of bullying comments. Then, during a private conversation, present the evidence to the person who made the comments. Document the conversation and its outcome and if there is a second instance of cyberbullying, report it to the nurse manager. If the behavior continues, alert the chief nursing officer.
Nurse managers should verbalize to their staff that there is a zero-tolerance policy for bullying of any kind, including comments made online. Managers should also educate staff on standards and polices regarding cyberbullying and should take derogatory remarks seriously.
Creating a work environment that addresses issues that contribute to nurse stress and burnout is more than something that’s just nice to do; it’s also a way to improve patient care. There are plenty of reasons to improve. Research by Linda H. Aiken, RN, PhD, at the University of Pennsylvania in Philadelphia, has found that patients who had surgery at hospitals with better nursing environments and above-average staffing levels have better outcomes at the same or lower costs than other hospitals.
Need any more proof?
This story was originally posted on MedPage Today.