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.
With the stress of the health care profession, it can be challenging to rally your energy or exude optimism on a daily basis. If you’re in an administrative or management role, you may notice signs of dwindling happiness among the staff. Things like arguments among colleagues, less camaraderie, or increased turnover rates may be clues to indicate your coworkers are in need of a morale boost.
The best way to tackle a slump in team morale is to head it off at the pass with positive changes. Recognizing the extra time and effort your nursing colleagues give to the job and providing them with opportunities to learn and grow in the profession are a couple of the ways to improve job satisfaction. Here, we’ll look at four other ways to boost morale in the workplace.
1. Allow time for a lunch break.
Studies indicate only one in five people step away from their job duties to take a lunch break. But following the same fast-paced routine day in and day out without a pause can drain your energy and your creativity. Kimberly Elsbach, a professor at the University of California, Davis Graduate School of Management, told NPR, “We know that creativity and innovation happen when people change their environment, and especially when they expose themselves to a nature-like environment, to a natural environment.”
Encourage your nurses to take their lunch breaks and escape from the usual monotony of the day. They can head outside for a stroll around the block, order from a new restaurant, or sip on some antioxidant-rich green tea. Even just a few minutes a day can have mood-elevating effects and lead to a more positive work environment.
2. Foster an atmosphere of caring among your coworkers.
It’s so easy to get wrapped up in your own life. However, if you can celebrate your colleagues’ milestones — a work anniversary, an engagement, a promotion, a birthday, etc. — you can foster an atmosphere where your fellow nurses feel valued. The gesture of making sure your employees and coworkers know they are treasured assets to the company will go a long way toward getting people excited about coming to work each day!
3. Offer free continuing education or professional development courses.
When budgets are tight, continuing education and professional development courses are often the first items to be slashed. But continuing education and professional development courses bolster the tools that nurses need to help their patients, and sometimes, the cost of these courses comes with hefty price tags. By offering free, educational opportunities or subsidizing a portion of an enrollment fee, you support your employees in their desires to improve their skill set, cultivate their professional passions, and accomplish their long-term goals—which leads to highly-trained, loyal employees and a more uplifting work setting for everyone.
4. Learn effective communication strategies.
“To help prevent morale issues in the workplace, leaders need to spend time communicating their vision to ensure that ‘everyone is on the same page,’” suggests Jeff Parke, author of a Linkedin article about low morale in health care.
Communicating a concise message is key to managing employee expectations and conveying practical productivity guidelines. Parke states that capable leaders will permit employees to discuss these messages either in-person or during designated staff meetings, where employees have the opportunity to express their opinions and ask questions.
Allowing for feedback and the open exchange of ideas shows nurses that their thoughts and opinions matter when it comes to boosting morale in the workplace.
We’d love to hear your thoughts and ideas on how to boost workplace morale, so feel free to leave us a comment below.
How many patients can a nurse reasonably care for at one time? This is perhaps the biggest issue facing the nursing profession right now. In fact, there are two bills in Congress right now that seek to decide just this, not only to protect patients but also the nurses who care for them.
California is the only state in the United States that regulates the number of patients a nurse can have under his or her care. The safe staffing law was passed there in 1999 (more than 15 years ago!) and it went into effect in 2004. The law breaks down the maximum number of patients for a nurse by acuity and type of care.
But in 49 other states and in the District of Columbia, there is no mandated limit to the number of patients a nurse can safely or reasonably be expected to care for.
What does this mean? This means on busy days in an emergency department, nurses may be caring for 4-6 acutely ill patients, some of whom need to be transferred to the intensive care unit, to a telemetry unit, or to the OR. This means a psychiatric nurse could be expected to care for more than 10 patients at a time, or that on a low-staffed unit at night, a med-surg nurse may be caring for up to eight or more patients.
A nurse’s name on a patient’s chart confers ultimate responsibility for that patient’s safety and well-being. The expectation is that the nurse will prevent a patient from harm and will keep a patient safe. It is the nurse who will discover a medication error before it gets to the patient (whether it be an error on the part of a resident or the doctor or the pharmacist); she or he will keep a patient from falling should they try to get up out of bed unassisted, and he or she will medicate, assess, chart, document, comfort, and care. But what happens when that nurse is stretched so thin there is no possible way for her to ensure a patient’s safety? The patient is at risk, and so is the nurse’s license. How can she be everywhere at once when she is caring for five or even six patients at a time?
Unfortunately, this is an issue that is unlikely to be resolved in the near future, despite the two bills currently before Congress. Over the next decade, the number of aging baby-boomers continues to increase while the number of new nurses entering the workforce decreases (not to mention those nurses leaving the profession altogether as a result of burnout and fatigue). Administrators still incorrectly fear the cost ramifications of nursing mandates. Specifically, the bill would require hospitals to write a staffing plan, and “allows a nurse to object to, or refuse to participate in, any assignment if it would violate minimum ratios or if the nurse is not prepared by education or experience to fulfill the assignment without compromising the safety of a patient or jeopardizing the nurse’s license.” Importantly, the bill also carries an anti-retaliation clause. The bills are a start, but are not a panacea by any means. And, they have yet to pass.
Earlier this week, a report released by Johns Hopkins purports that medical errors are the third leading cause of death in the United States each year. The high number of deaths relating to errors point not to bad doctors or to mistakes, but more to systemic problems, a lack of standardization, a lack of reporting and data collection about mistakes, and issues with medical staff turnover, burnout, and fatigue. Many people are quick to point out the myriad studies correlating positive patient outcomes and higher levels of nurse staffing, as well as the decrease patient lengths-of-stay.
It’s not that data don’t exist, as hundreds of studies demonstrate the positive relationship between patient safety and nurse staffing. Moreover, studies also show that increasing nursing staff does not contribute to higher hospital costs. A longitudinal study by the Agency for Healthcare Research and Quality concluded that it actually decreased costs over time, including a decreased patient length-of-stay. Additionally, increased nurse staffing has been shown to decrease patient mortality, increase patient satisfaction, and decrease nursing turnover and job dissatisfaction.
Safe staffing is an issue that is not likely to fade, and many nurses are eagerly tracking the legislation before Congress. A rally to demonstrate support of safe staffing is planned in Washington, DC, for May 12th. More information can be found here.
It seems that the new buzzword in health care is “patient satisfaction.” The Affordable Care Act allows Medicare to tie a portion of a hospital’s reimbursement money to patient satisfaction. Patients are mailed a survey after discharge called the HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems), and depending on their responses, Medicare can withhold up to 1% of that hospital’s reimbursement.
At first glance, this measure of accountability makes sense; the HCAHPS rewards hospitals whose patients report receiving a high level of care. The problem, however, is that the survey’s standard of care is very high, and patients’ perceptions are not always an accurate representation of the clinical care that was delivered. The responses are too subjective, and there’s no real data to be measured or evaluated.
The HCAHPS questions cover nursing, physicians, communication, cleanliness, and an overall rating. Most questions have four possible answers: never, sometimes, usually, and always. The only answer that counts toward a hospital’s rating is “always.” For example, one question asks patients how often they received help as soon as they wanted it after pressing their call light. Even if the patient responds “usually,” this is a fail. (I’ll spare an enumeration of the possible reasons a nurse may be unable to deliver a blanket within two minutes, and simply point out that this question doesn’t differentiate between an emergent request or a routine one.)
Because of the monetary incentive to keep patients satisfied, many hospitals have changed their model of care delivery to one that, well, keeps patients happy. Customer service training has become a part of many orientation programs (some hospitals go as far as to script patient dialogues), and in many places, you may find a standard that the patient, and not the doctor, is always right.
But the patient is not always right. One example is the over-prescription of antibiotics for viral illnesses. I triage patients all the time who are prescribed antibiotics for rhinovirus, because they demand them, and providers know a refusal will cause low scores on the question, “How often did doctors listen carefully to you?” Or consider the patient with an ankle sprain who requests narcotic pain medication. A satisfied patient in this case may become a drug-dependent, narcotic-addicted one. Is this really what we want health care to look like?
For now, let’s set aside the issue of whether patients are able to separate the evaluation of their actual care from a rating of the food in the cafeteria or noise in the hallway, and move to the larger issue: Patient satisfaction does not equal patient safety. In fact, they seem to be inversely related. According to several recent studies, high patient satisfaction leads to higher health care costs, to increased nurse burnout and nursing job dissatisfaction, and most alarmingly, to higher patient mortality.
I understand the pressure to increase patient satisfaction not just to maximize reimbursement but to keep patients coming back through the doors. Health care is changing: Patients have a say in where they are treated and by whom. We live in an age when people write Yelp reviews before they even leave a restaurant, and the same is happening to health care (websites such as Zocdoc or Healthgrades.com come to mind, and the purported purpose of the HCAHPS survey is to allow consumers to compare hospitals and evaluate their quality).
Patients have rights, certainly, but the highest emphasis should be on their safety and not on their satisfaction (and it is infuriating that the answer of “usually” on a survey doesn’t count as a high score). Some patients, after all, will never be satisfied, and will not like the answer that they cannot eat, cannot get out of bed, or cannot have six people in their hospital rooms all in the name of their safety. Linking hospital reimbursement to safety measures, such as rates of infection or hospital readmission, seems reasonable. Core measures exist for this very reason, to quantify performance in areas of patient safety. Instead of spending money on mobile charging stations or Keurig coffee makers in each room, investments should be made in hiring more nurses—recent studies have demonstrated that nurse-patient ratios are crucial to both patient satisfaction and safety.
(For more information about HCAHPS, visit medicare.gov.)
Faculty from the School of Nursing at the University of Michigan know the value of students making mistakes while treating patients, but when the patients aren’t real it’s a better scenario for everyone involved. This led to the building of a new state-of-the-art Clinical Learning Center which houses six simulation rooms with high-fidelity mannequins that act just like real patients, even capable of bleeding, vomiting, and giving birth.
Some students find the mannequins intimidating because of the things they can do, but they can’t deny the valuable skills they are gaining from the real-life issues being simulated. The mannequins can even simulate high-risk issues that don’t typically occur in a hospital setting, preparing students for how to react in emergency situations. The nursing school has a team of specially trained simulation instructors who sit behind a one-way mirror with screens in front of them, using wireless controls to prompt any possible physiological response in the mannequin.
The major benefit of learning clinical skills through mannequin simulations is that students can learn by trial and error without harming a real-life patient. Students remember the cases where they screw up, and learning from those simulations builds confidence and comfort when working in hospital settings. Many students don’t experience life-threatening or advanced care skills in their clinical rotations, but with mannequin simulations students can practice suctioning secretions from the trachea, electrically shocking the heart into starting again, and administering intravenous drugs.
University of Michigan is far from being the only nursing school that uses mannequin simulations in their curriculum, but they are the only school that allows all undergraduates, even first-year students, to take part in simulation training. Studies have shown that undergraduate students can replace up to half of their clinical hours with simulations without impacting a student’s ability to pass the nursing certification exam. After each simulation, students immediately go through a debriefing session to review what they did well and where they have room for improvement, simultaneously teaching students invaluable critical thinking skills.
Kathy Kump, RN, remembers the first time she was bullied. She remembers the intimidation and disrespect that accompanies such unwelcome acts as early as her first semester. Later, she would encounter it again at the beginning of her career, and even well into her professional journey as she entered into newer positions and ranks. Like many of her colleagues, Kump has been a victim of bullying as a nurse.
Unfortunately, bullying has become all too common in nursing. According to studies, 35% of workers in the U.S. reported having been bullied, while another 15% witnessed workplace bullying.
But there is hope. Understanding why bullying in nursing is rampant and what to do about it can help those effected get a handle on it.
“It Comes with the Territory”
Nurse bullying is so universal that it has its own expression. In 1986, nursing professor Judith Meissner coined the phrase ‘Nurses eat their young’ as a way to encourage nurses to stop bullying new and inexperienced coworkers.
Kump says there are many factors that contribute to the overall cause of bullying in this profession, but sadly the continuing and underlying theme has always been ‘it comes with the territory.’
“Certainly, many of the nurses who contributed to my own early feelings of ineptness or unworthiness as a new nurse most likely experienced the same ramifications when they began their nursing careers,” says Kump, director of nursing at Ottawa University. “Even more disturbing, this negative learned behavior seems to have evolved into a vicious cycle: comparable, in a broader sense, to that of hazing, which was once considered a ‘normal’ ritualistic initiation at some fraternity, sorority, or other group settings.”
The Who Behind the What
The foundational motivation for distinct behaviors of incivility and bullying in nursing may be a reaction to what may be perceived by the profession’s organizational “insecurities” and internal frustrations in the market place. For example, Kump says unlike other health care counterparts in the industry, nurses have struggled to find their “voice” as both a collective and cohesive group, and have grappled with defining their true identity.
Thus, it may be theorized that this superimposed “oppressed” perception contributes to an individual’s sense of powerlessness that may demonstrate itself with unkind words and actions toward others that are seen as less influential and more vulnerable.
“To put it simply and in a real-life context, a nurse may think the following, ‘I can’t take a lunch break because we are short-staffed today and since no one in upper management seems to care, I will take my frustrations out on that new nurse, Sara,’” says Kump.
Call to Action
Kump says whatever the causative factors may be, as long as the nursing profession continues to let this happen, and do nothing about it, it will continue to be a problem for generations to come.
For nurses who may be a victim of bullying, Kump suggests the following:
- Report it. Any incident in which an employee feels harassed, is made to feel uncomfortable in their workplace setting, and/or bullied should report this immediately to their supervisor. There should be a culture of zero-tolerance for bullying at every organization and all leaders should take this initiative very seriously.
- Keep composed and maintain the upper hand. Don’t lower yourself or stoop to the bullies’ level. If you feel comfortable and safe in doing so, calmly confront the bully by acknowledging and pointing out the negative behavior and asking them to stop.
- Be a role model: do not bully others. The negative cycle of bullying will only continue if its victims eventually become the victimizers.