Leadership and Professional Image

Leadership and Professional Image – C493

Western Governors University

Registered nurses are a necessity in hospitals and facilities in the United States and around the world. Unfortunately, for a number of reasons, the nursing profession consistently faces a problem with employee turnover. Compared to most other professions, nurses have a higher rate of turnover and this problem has consequences for hospitals, patients, and all levels of staff involved. My written proposal will address the problem of high nursing turnover.

Registered nurses are the biggest group of healthcare professionals working in hospitals. Nurse turnover has many negative consequences. It causes a shortage of nurses which is bad because an adequate number of nurses need to be staffed to provide the safest patient care possible. Another consequence that nurse turnover has is that retained staff are forced to take on an increased workload and responsibility to compensate for the lack of staff and/or new staff that isn’t fully up to speed. These are the most significant direct and indirect consequences of increased nurse turnover at my area of practice.

Currently, my facility where I practice as well as other hospitals and other facilities are aware of the problem of increased nurse turnover. There are many strategies that have been implemented to try to reduce turnover and retain nurses for as long as possible. These strategies address or try to address the most common known reasons for nurse turnover. My facility and other facilities maintain a strict nurse to patient ratio, to keep the workload as manageable as possible for the staff. Another strategy is fostering a positive and friendly work environment that staff can feel comfortable and happy working in. Promoting cohesiveness of staff by setting up activities and events is a current practice many facilities try. Another strategy is encouraging participation and leadership in hospital specific professional councils and meetings. This participation allows nurses to feel more involved and gives them a chance to voice ideas and concerns. Some facilities offer monetary bonuses for staying a certain number of months. Another current practice is providing nurses with as many resources as possible, to reduce the workload that nurses take on. By having more ancillary staff and support, nurses can focus more on their primary responsibilities specific to their job title, and this can decrease stress and burnout. Another current practice that is sometimes seen is nurse managers providing support on the floor in times of need. Lack of hands on support from management has been mentioned as a reason for nurse turnover. While there are many practices attempting to address the problem of high nurse turnover, these strategies can only do so much due to a lack of resources and other factors that are often out of the facilities control.

High nurse turnover effects my organization, among many others as well as patients on a few different levels. My organization must allocate more resources to replace nurses. These resources are money, time, and effort are all required to replace the lost nurses. An organization can also develop a bad reputation among employees and potential employees if it becomes known as a facility with high turnover. When there is high turnover, it can cause reduced morale among remaining staff. This reduced morale can affect the nurse’s personal satisfaction with their position. Patient care can be compromised if nurses are unhappy. Another impact the problem has on my organization is that management and the human resources department needs to devote more time and resources to recruiting which takes away from other responsibilities that can help the organization. High nurse turnover effects the patients as well. Without a consistent staff, the patient population may not receive the best care it can get. Newer staff that relocate and fill in may not understand the patient populations cultural backgrounds specific to the facilities location. Being able to understand the patient population as much as possible is important to provide optimal nursing and medical care as well as provide culturally competent care. Staff that is settled in the location and facility long term is best able to provide this optimal level of care.

A research study, a qualitative descriptive study by Hayward, Bungay, Wolff, and MacDonald, was conducted at 2 acute care facilities in Canada. 12 participants, selected using purposeful sampling, were interviewed for the study. The purpose of the study was to determine the major factors and decision-making process that led the nurses to leave their practice setting or seek alternative places of employment (Hayward, Bungay, Wolff, MacDonald, 2016).

Another research study, a qualitative descriptive study by Cote, was conducted at a single facility in Canada. 26 participants were selected using purposeful sampling and they were interviewed using a life-narrative technique with each interview lasting 2.5 to 3 hours. The author found some common findings in the participants. One of the main reasons for the high turnover was a general theme of unmet expectations of the position. Many of the employees felt that the job description and their actual responsibilities were incongruent. Some noted a lack of leadership supervision and support. Others noted an erratic work schedule and hours available to work. Some participants also mentioned a higher than expected workload. Some participants cited that they left their positions because of non-work related factors such as family and personal life. They were satisfied with their position but had to leave the position to better support their family and personal life. Other participants mentioned they left their positions because they wanted to grow professionally and increase their responsibilities and autonomy. These opportunities were not available at their respective organizations. (Cote, 2016)

A non-research source titled “More Nurses Means Safer Patients” is from the Queensland Nurses Union of Employees. Nurse researcher Professor Linda Aiken was interviewed by the author because of her years of research and knowledge on the impact of nurses on health outcomes. Professor Aiken was asked many questions related to the need for nurses and issues related to nurse staffing. She noted that from her personal experience and her research she found that a problem common across all hospitals is nurses having to take on non-patient responsibilities that takes away from valuable patient care (Queensland Nurses Union of Employees, 2014). The article explains that Professor Aikens research is the basis for the Magnet Hospital Program, which began in the United States and spread throughout the world. Magnet is an initiative that sets the high safety standards and health outcomes by establishing strong, high quality nursing (Queensland Nurses Union of Employees, 2014). The article states that Magnet hospitals support nurses in a number of ways such as employing good managers, investing in nurse education, having nurse representatives on committees, and helping other hospitals achieve Magnet status. Professor Aiken explains that nurses love the idea of Magnet hospitals and are attracted to working there because of the difference in culture and management these facilities feature. She explains that getting management to take a different approach to nursing is important and she states “So, we showed them the research. We showed them the hospitals that had no vacancies were the same hospitals who were investing in their workforce. Hospital managers were very impressed with this because turnover is so expensive.” (Queensland Nurses Union of Employees, 2014). Professor Aiken explains that her research has shown that facilities that are good places for nurses to work are the places that have shown the best outcome for patients. So her research shows that investing in nurses is a win/win situation; management can save money and use the resources in other needed areas and most importantly, patients see better outcomes in their care. The author also asks Professor Aiken about the mandatory staffing ratio in California, United States. According to her research, they have worked and exceeded expectations, resulting in drastically decreased turnover rate which has led to better patient care and outcomes. She also discusses the importance of more awareness of the issue of nurse staffing so that the public and facilities can be aware of its importance for the safety of the patients.

An innovation that would lead to better patient outcomes would be to foster a more positive work environment and allocate more resources to implement this. By allocating resources to hire more nursing staff, the nurse patient ratio will be decreased. This lowers the workload for every nurse on the unit and the result of this is less stress and more work enjoyment. Because increasingly high patient acuity is not something that can be reduced directly, it should be addressed in other ways. An effective way to do this is lower each nurse’s workload so that more time can be spent with higher acuity patients that need more time and resources. Another factor that causes nurse turnover is relations between colleagues. Negative relationships can be caused by high stress and lack of work enjoyment. By hiring more staff, the stress level of the entire unit goes down. Staff now have a better chance at developing positive, healthy relationships with colleagues. This causes more work enjoyment and helps with nurse retainment. Hiring more staff also effects the workload of management and leadership. Because there is adequate staffing, management does not need to devote as much time to recruitment, scheduling, and other issues related to understaffing. This extra time is a resource that can be used to support staff and address issues that come up. Lack of leadership support is a major factor that has caused increased nursing turnover and by having leadership more available to provide support, this can be addressed and further decrease the chances of nurses leaving. Another way to increase nurse retention is to increase educational incentive benefits. This encourages nurses to stay on the unit, gives them opportunities to expand their roles and responsibilities, and contributes to a positive work environment. Another common factor that is a reason for nurse turnover is inflexible scheduling. This is related to nurses’ personal life, which is also noted as a reason for nurse turnover. By allocating more resources to hire more staff, there is more flexibility that can be allowed when scheduling. This allows staff the opportunity for better work and home balance and helps keep stress levels lower. Less stress is very beneficial for many reasons and another benefit is that the nurse avoids negative health behaviors. Stress causes unhealthy habits such as sleeping less, lack of exercise, and unhealthy eating habits. Addressing the work environment by hiring more staff, providing supportive leadership, and encouraging positive colleague interactions has numerous benefits for nurses, organizations, and most importantly, patients. A problem common across all hospitals is nurses having to take on non-patient responsibilities that takes away from valuable patient care (Queensland Nurses Union of Employees, 2014) With more staff on the unit, patients are given more attention, better quality care, safer care, and better patient outcomes overall. This has another benefit as patient’s families also feel more satisfied and the patient surveys are also more positive, something that hospital leadership appreciates.

Some resources that can be used to implement these innovations and solutions would be money and time. Money would be needed to hire more staff and more qualified leadership. Money is also needed to implement changes to have a better and more positive work environment. Programs, events, and activities all need money to be set up but these can all have a positive effect and foster a more positive work environment. Another resource that is needed is time. Time needs to be devoted to tackling this problem because it is complex and needs active and consistent involvement to effectively be addressed. By allocating time to address this issue, it becomes a conscious problem that more people are aware of and can consciously work towards improving. With more time spent on the issue, more people will become aware and this could lead to newer and possibly better ideas that can help decrease or even solve the problem.

My proposed solution would be to foster a more positive work environment and allocate more resources to implement this. By allocating resources to hire more nursing staff, the nurse patient ratio will be decreased. There are costs and benefits to this proposed solution. To have a more positive work environment, there needs to be more nurses hired to the unit. This costs money because new nurses must be oriented and go through training as well. There is always the risk that the nurse does not fit on the unit and they leave before even having a chance to contribute. That would cost money without any benefit. These are all costs that are accounted for when hiring new nurses for the staff. In addition, there is also the cost of spending time to hire new staff. The nursing leadership has to spend time in finding appropriate candidates and go through the process of hiring them. Having the new staff oriented and trained also requires hours of time and this is costly as well. One can see that in the short term, the costs of hiring more staff are significant and cause a strain on the budget. Hospital budgets are already strained as it is so there may need to be sacrifices made to other areas of the budget to accommodate the increased spending needed on hiring new staff. This is another cost of my proposed solution. While there are a number of costs to my proposed solution, there are many benefits as well. With more staff on the unit, the nurse to patient ratio is reasonable and lowers the stress level for the staff. This helps foster a positive work environment and helps retain staff long term. With staff tending to stay long term, it decreases the need to hire more staff long term as well. This saves a lot of money and is a significant benefit. That money can be invested in other areas. Another benefit is that patients are better taken care of. The nurses are under less stress because of the positive work environment and can focus on providing the best care for patients. Also, because the nurse to patient ratio is lower, there is more time that can be spent with each patient. This is a benefit for patient safety and the quality of care they receive. One can see that although there is a large initial cost of hiring more staff, it leads to a better work environment and less nurse turnover. In the long run, there is a benefit of nurses having great work satisfaction and staying on the unit longer than they would otherwise. Less money is spent to replace nurses who constantly leave and this is a benefit.

The timeline for implementation could be relatively quick. I believe the early results of the change could be apparent within months, possibly 3-6 months. The first step would be to have the stakeholders agree to the proposed changes and this would take possibly a few meetings and days. Resources would need to be sourced and this might take a few weeks to go over the budget and find approval for the changes. It’s possible there would need to be additional funding because the major resource needed is money and that may take some time, possibly months. At this point, the resources can be implemented by hiring new staff, improving the work environment, implementing new leadership on the floor, and making nurse turnover a priority when making time commitments. All this can be implemented quickly once the resources are made available and within 3 months, the work environment can be drastically improved.

A key stakeholder in implementing this practice change would be hospital management that is responsible for allocating budget and resources. They are important for the implementation of the solution because they have the power to allocate budget and funding. They also have a lot of decision making power, so this makes them an important stakeholder for implementation of the solution. The best way to have them buy into this would be to show them research that provides evidence of the many benefits that retaining nurses can have with the organization. Hospital management often has limited budget to work with, so providing them ways to save money is something that would definitely catch their attention. They would also be pleased that they have the potential to provide better patient care and improve their organizations’ reputation. After speaking with a member of hospital management, the director of nursing, I received positive feedback on the solutions and innovations I had for the problem of high nurse turnover. I was told she was well aware of the problem at the facility and many other facilities and she has already been implementing different solutions to address the problem. I told her that there is always room for improvement and she said she was open to improve in any ways possible. I plan to work with hospital management by attending meetings and presenting ideas and solutions to provide them information and awareness of the problem.

Another stakeholder that could help implement this change is whoever is responsible for funding the facilities. They are an important stakeholder for implementing the solution because money is finite and limited. To fully address the problem, more money for the budget would be needed. This is why these stakeholders are so crucial to fixing this problem. Facilities are funded in different ways and from different sources. Some can be government funded, some funded by insurance, some are funded from donations, and other sources. Because there is only so much money that is available to be allocated, if these stakeholders could be convinced of the importance of more funding, it would lead to better nurse retention and better patient outcomes. While it would be financially costly to increase hospital funding, if the potential benefits are realized, it would help save money in the long run. Everyone would potentially benefit from this. It would improve the healthcare system overall and set an excellent standard for the future. My engagement with these stakeholders has been to provide information and awareness to any possible people who can potentially help address the problem. Sending emails and networking are ways I have engaged with these stakeholders and I plan to continue these methods in the future to help bring awareness to this problem. My strategy is to build positive and friendly relationships with these stakeholders and hopefully it makes it easier to have them agree to act in favor of implementing the solution.

One of the main barriers in being able to apply evidence to practice changes is money. Because there is an initial cost to hire more nurses per unit, it will take a lot of evidence to put forth any significant changes. Because budgets are already so constrained, it is a major barrier to overcome despite all the evidence that supports the benefits. When there is a finite supply of a resource, careful and strategic allocation of that resource becomes paramount. Another barrier to overcome is resistance to change. Hospitals have been understaffed for years and it seems to be the standard at many organizations. There needs to be a change in philosophy and the problem of understaffing must be recognized and taken seriously. Until there is more public awareness of the importance of adequate staffing in healthcare facilities, there will only be a certain amount of money that can be budgeted. A possible strategy to overcome this is to rethink and re-budget how funds are allocated by organizations. If there is a limited finite amount of a resource, that resource should be used strategically to make the most use of the resource. The evidence can be presented and the decision makers can have the information they need to make an informed decision that benefits as many people as possible. Another strategy that can help overcome the barrier of resistance to change, is to increase public awareness of the problem. If the public is aware that the healthcare system needs more funding then they can put pressure on those who can increase funding. More public awareness also includes those who are responsible for healthcare funding so it is important that they are made aware as well.

My proposed solution would be to foster a more positive work environment and allocate more resources to implement this. How could this be implemented when there are limited resources such as money and time? There are a few strategies that could be implemented to achieve the solution. Bringing more awareness would have a large effect. With more people understanding that better work environments are needed for nurses and that it effects patient care, people will realize it is a significant issue. Money could then be raised and added to the budget which would allow the hiring of new staff. Those who are responsible and have the authority to allocate money to the budget would be important people to bring awareness to. If they can be convinced how vital it is to have more nursing staff, then they would have the power to directly add funds to the hospital and unit’s budget. The first step to implementation would be to speak with middle and upper management and explain the issue to them thoroughly. Show them studies and facts that can prove to them that change is needed if they want better outcomes. By showing them all the improvements, including improvements in money savings long term, it would go a long way to implementing the proposed solution. They have the power to make changes to the hospital budget and can lobby and request from outside sources the need for more funding. Once there is money available to hire new staff and improve the work environment, the next steps to implement the solution are to hire new staff and make changes on the unit to make it a better place to work. Funding for events and group activities can be added. New staff can be screened, hired, oriented, and then trained. With the nurse to patient ratio kept low and the work environment positive, nurses will have high job satisfaction. They will work hard and be motivated to stay on the unit for years and this will be one indicator of success of the proposed solution.

An indicator that can measure the outcome and measure of success is the rate of nurse turnover. If the rate of nurse turnover decreases, then it would be an indicator of the success that the recommended practice change has. Because less nursing turnover has proven to lead to better patient outcomes, this indicator would show that patients are provided better quality and safer care.

During my investigation and proposal development, I acted in the role of scientist by using the scientific process. I formed a hypothesis that low staffing would have a negative influence of patient outcomes. After forming this hypothesis I began to research and found evidence that supported my hypothesis. I collected data and analyzed results that helped me make a conclusion to support my hypothesis. During my investigation and proposal development I acted as a detective by searching for clues or evidence that was not readily apparent. I did this by speaking with different people who would be able to provide me information based on the specific questions I would ask. I would bring the topic up when speaking with other nurses at different facilities so that I could get the inside scoop on the information I was looking for. I fulfilled the role of manager of the healing environment by having patient outcomes in mind during the process of investigation and process development. I understood that the problem of high nursing turnover caused negative patient outcomes, so my proposal and implementation would hopefully benefit patients and cause increased and improved patient outcomes in the future.

References

Yang, H., Lv, J., Zhou, X., Liu, H., & Mi, B. (2017). Validation of work pressure and associated factors influencing hospital nurse turnover: A cross-sectional investigation in Shaanxi Province, China. BMC Health Services Research, 17(1). doi:10.1186/s12913-017-2056-z

Park, S., Gass, S., & Boyle, D. (2016). Comparison of Reasons for Nurse Turnover in Magnet(R) and Non-Magnet Hospitals. Journal of Nursing Administration. doi:10.1097/NNA.0000000000000344

Nei, D., Snyder, L. A., & Litwiller, B. J. (2015). Promoting retention of nurses. Health Care Management Review, 40(3), 237-253. doi:10.1097/hmr.0000000000000025

Hayward, D., Bungay, V., Wolff, A. C., & Macdonald, V. (2016). A qualitative study of experienced nurses voluntary turnover: Learning from their perspectives. Journal of Clinical Nursing, 25(9-10), 1336-1345. doi:10.1111/jocn.13210

Côté, N. (2016). Understanding Turnover as a Lifecycle Process: The Case of Young Nurses. Relations Industrielles, 71(2), 203. doi:10.7202/1036607ar

Queensland Nurses Union (2014, December 1). More Nurses Means Safer Patients. Queensland Nurses Union, 22-25.