Bedside Nurses: Undervalued, Poorly Retained and What Experts Say

[J.Adderton]

In hospitals across the country, experienced nurses provide orientation to an ever-revolving door of new hires. The need to retain beside nurses is well known and solutions widely researched. Yet, work conditions in acute care settings are slow to improve and many nurses turn away (or run) from bedside nursing.

According to NSI Nursing Solutions, Inc., hospitals saw the highest turnover rates in 2018 when compared to the last 10 years. From 2014-2018, hospitals turned over a staggering average of 87.7% of staff. While most hospitals identify nurse retention in key strategic planning, it is not followed through in operational practice and planning. According to the report, only 43.2% of hospitals have put their strategic plan into formal retention strategies.

Do Graduate Programs Play a Role?

I recently read an editorial, authored by Maureen Kennedy, MA RN FAAN in the American Journal of Nursing, questioning if the push by colleges for students to attend graduate or doctorate nurse practitioner programs is contributing to the devaluing of bedside nurses. Research has clearly shown hospital working conditions to be the primary reason nurses are leaving the bedside. Most of us have experienced long hours, lack of flexibility and poor leadership while working in acute care at some point in our careers. And, the large need for advanced practice nurses in today’s healthcare environment, as well as the need for qualified nurse faculty, is undisputed.

Hospitals typically don’t have work environments that offer nurse autonomy or promote professional practices. Nurses may see an advanced degree as offering job opportunities that are more supportive, with greater autonomy and less stress. The editorial’s author summarized the issue by quoting a colleague:

Quote

“The narrative must be shifted to embrace the full range of roles and contributions of all nurses. Our healthcare system depends upon a well-trained, experienced workforce. The trend toward our hospitals being primarily populated with nurses with less than two years’ experience is worrisome”. If hospitals want to retain nurses long-term, workplace environments need to change and demonstrate the value of bedside nurses."

Keeping Nurses at the Bedside

Healthleaders magazine recently published an article sharing what three nurse executives did to retain RNs with the right skills and experience needed to deliver high quality care. Here are a few of the ways the executives improved their facility’s retention rates for the long haul.

Improve the Organizations Reputation

Rush Oak Park Hospital in Illinois was plagued with a negative reputation because of consistently poor quality outcomes. The hospital’s reputation bled into the work environment resulting in nurse dissatisfaction. In addition, there was a “revolving door” of chief nursing officers leading to inconsistent leadership and vision. Karen Mayer, chief nursing officer, knew the work environment needed to change and hospital leadership was up to the challenge. Over a period of years, leadership worked to improve quality indicators to improve patient care and nursing job satisfaction. After many years, turnover rates decreased from 22% to just 8.3%.

Entice Nurses Back to the Bedside

Press Ganey’s 2017 National Database of Nursing Quality Indicators RN Survey found newly licensed nurses and those who have been in practice 2-4 years at highest risk for attrition. Claire M. Zangerie, chief nursing executive at Allegheny Health Network saw the same trend within her organization. Under her direction, the RetuRN to Practice Program was created to address some of the issues leading to attrition. The program was designed to attract nurses who have stepped away from nursing and want to return to the bedside. As a result, the workload of all nursing staff was successfully lessened.

Attract nurses with flexible scheduling

RetuRN participants offer managers at least 3 hours availability at any time, on any day, day shift or night or any weekend or holiday. The nurses help ease workload in high need areas and perform “rover-type” duties, such as admissions, discharges, patient education, covering other nurses’ patients for breaks or for continuing education. Extensive on-boarding, remediation, training and support is offered to RetuRN participants to ease the transition back to the bedside.

Support Professional Development and Work Environment

Kelly Johnson, vice president, patient care services and chief nursing officer at Stanford Children’s Health understands a healthy work environment and professional development programs are critical to retaining nurses. Therefore, Johnson developed and implemented several programs to support nurses in various stages of their career. Nurses have opportunities to continue growing through personal success plans, a succession planning development program, certificate and advanced degree programs.

The organization has also committed to creating a healthy work environment and culture. This includes initiatives embracing HeartMath concepts that empower employees to “self regulate emotions and behaviors to reduce stress, increase resilience, and unlock their natural intuitive guidance for making more effective choices”. The goal is to create a work environment that is caring and healing, where nurses care for each other and themselves.

What programs or initiatives have you experienced that improved the work environment of bedside nurses?

Additional Resources

NSI Nursing Solutions 2019 National Healthcare Retention Report

Want to Keep Nurses at the Bedside? Here’s How

Nurses at the Bedside - Who Will Be Left To Care?

[OUxPhys, BSN, RN]

43 minutes ago, KlineRN said:

In the 80s, most patients were 150-250 pounds with a few health problems and a couple of medications. Visiting was limited so sick people could rest. I worked with good NAs & LPNs & didn’t care about your degree. We helped each other. The public mostly treated us with respect. My 30th year, I had 4 stepdown patients with average weight load of 1000 pounds per night, easily. Screamed at almost daily & rarely sat down. Retired from bedside.

I left a hospital like this for a hospital where this isnt as common but its very slowly becoming the norm. Its not hard to see why bedside nurses leave after only a few years between the patients and lack of help.

2 hours ago, futurepsychrn said:

That's the point, where I work the way they do the schedule, I never get 4 days off in a row.

Ah man, thats terrible. My previous job had a very nice schedule policy but the place Im at now it isnt worth doing the 3 12’s, thats why Im now more interested in 2 12’s and 2 8’s.

[CardiacRNLA, BSN]

5 hours ago, chacha82 said:

I am going to limit this because otherwise I could go on.

1. Have visiting hours twice a day AND STICK TO IT. I cannot provide good care in a cramped room of 2 patients and they each have 5 family members who want to be updated all day and ask "What's taking you so long."

2. Stop with the hotel mentality! I can never be as good as the Ritz. Provide each patient with a phone number to call for ROOM SERVICE for their trays. I cannot get "fresh, hot french fries" for my patients when I have other things to do and no extra staff to go get them. And then to get a report that I didn't do everything that the patient asked. ?

3. Trim down the bedside admission database for the RN. Many of the questions can be asked by case management during their rounding. I'm happy to make sure they're not suicidal and check their belongings, as well as verifying that they want to be treated. I need to start caring for the patient, and care for the other patients in my assignment.

As far as number three is concerned, I think you need a bit of education on what case management does. Firstly, while you have five patients, case managers can have between 20-40 on their case loads.

You want me to hurry up with the placement of your “problem” patient? Guess what I need the bedside nurse’s help. CM can’t possibly go to interdisciplinary rounds on multiple floors, complete clinical reviews, and work on discharge planning for such a caseload without help from bedside nurses.

ALL aspects of nursing, yes case management involves nursing are stretched thin. Case managers have to deal with higher caseloads, less post acute resources, and pressure to decrease length of stays and saving money, while adhering to insane regulations are real.

I know you didn’t mean anything by your post. But it did strike a nerve lol. I know bedside nurses are stressed out. But please know we all are, case managers included. At least the good ones are because we are working nonstop.

[chacha82, ADN, BSN]

17 hours ago, CardiacRNLA said:

As far as number three is concerned, I think you need a bit of education on what case management does. Firstly, while you have five patients, case managers can have between 20-40 on their case loads.

You want me to hurry up with the placement of your “problem” patient? Guess what I need the bedside nurse’s help. CM can’t possibly go to interdisciplinary rounds on multiple floors, complete clinical reviews, and work on discharge planning for such a caseload without help from bedside nurses.

ALL aspects of nursing, yes case management involves nursing are stretched thin. Case managers have to deal with higher caseloads, less post acute resources, and pressure to decrease length of stays and saving money, while adhering to insane regulations are real.

I know you didn’t mean anything by your post. But it did strike a nerve lol. I know bedside nurses are stressed out. But please know we all are, case managers included. At least the good ones are because we are working nonstop.

I apologize, I did not mean to sound like I was dumping on case management. I agree 100% we all need to help each other, and I know case managers work very hard. So I am sorry that my comment was rude. For me, sometimes it just seems like the questions are beyond the scope of the bedside RN. I do not mean to hurry the case manager along at all.

[bbyRN, BSN, RN]

More or less like many other nurses have commented, but in my own words: Is anybody listening (ie active listening like we are supposed to do) and do they have the commitment and power to make the necessary changes?

How do we find these people and impress upon them the emergent needs for nurses?

Myself? I write my State reps and senators, sometimes feds, with research showing all the things that the nurses write on allnurses. I also talk with my colleagues in a non-provocative way about writing the politicians.

[Tron8622]

On 9/20/2019 at 8:29 AM, J.Adderton said:

In hospitals across the country, experienced nurses provide orientation to an ever-revolving door of new hires. The need to retain beside nurses is well known and solutions widely researched. Yet, work conditions in acute care settings are slow to improve and many nurses turn away (or run) from bedside nursing.

According to NSI Nursing Solutions, Inc., hospitals saw the highest turnover rates in 2018 when compared to the last 10 years. From 2014-2018, hospitals turned over a staggering average of 87.7% of staff. While most hospitals identify nurse retention in key strategic planning, it is not followed through in operational practice and planning. According to the report, only 43.2% of hospitals have put their strategic plan into formal retention strategies.

Do Graduate Programs Play a Role?

I recently read an editorial, authored by Maureen Kennedy, MA RN FAAN in the American Journal of Nursing, questioning if the push by colleges for students to attend graduate or doctorate nurse practitioner programs is contributing to the devaluing of bedside nurses. Research has clearly shown hospital working conditions to be the primary reason nurses are leaving the bedside. Most of us have experienced long hours, lack of flexibility and poor leadership while working in acute care at some point in our careers. And, the large need for advanced practice nurses in today’s healthcare environment, as well as the need for qualified nurse faculty, is undisputed.

Hospitals typically don’t have work environments that offer nurse autonomy or promote professional practices. Nurses may see an advanced degree as offering job opportunities that are more supportive, with greater autonomy and less stress. The editorial’s author summarized the issue by quoting a colleague:

Keeping Nurses at the Bedside

Healthleaders magazine recently published an article sharing what three nurse executives did to retain RNs with the right skills and experience needed to deliver high quality care. Here are a few of the ways the executives improved their facility’s retention rates for the long haul.

Improve the Organizations Reputation

Rush Oak Park Hospital in Illinois was plagued with a negative reputation because of consistently poor quality outcomes. The hospital’s reputation bled into the work environment resulting in nurse dissatisfaction. In addition, there was a “revolving door” of chief nursing officers leading to inconsistent leadership and vision. Karen Mayer, chief nursing officer, knew the work environment needed to change and hospital leadership was up to the challenge. Over a period of years, leadership worked to improve quality indicators to improve patient care and nursing job satisfaction. After many years, turnover rates decreased from 22% to just 8.3%.

Entice Nurses Back to the Bedside

Press Ganey’s 2017 National Database of Nursing Quality Indicators RN Survey found newly licensed nurses and those who have been in practice 2-4 years at highest risk for attrition. Claire M. Zangerie, chief nursing executive at Allegheny Health Network saw the same trend within her organization. Under her direction, the RetuRN to Practice Program was created to address some of the issues leading to attrition. The program was designed to attract nurses who have stepped away from nursing and want to return to the bedside. As a result, the workload of all nursing staff was successfully lessened.

Attract nurses with flexible scheduling

RetuRN participants offer managers at least 3 hours availability at any time, on any day, day shift or night or any weekend or holiday. The nurses help ease workload in high need areas and perform “rover-type” duties, such as admissions, discharges, patient education, covering other nurses’ patients for breaks or for continuing education. Extensive on-boarding, remediation, training and support is offered to RetuRN participants to ease the transition back to the bedside.

Support Professional Development and Work Environment

Kelly Johnson, vice president, patient care services and chief nursing officer at Stanford Children’s Health understands a healthy work environment and professional development programs are critical to retaining nurses. Therefore, Johnson developed and implemented several programs to support nurses in various stages of their career. Nurses have opportunities to continue growing through personal success plans, a succession planning development program, certificate and advanced degree programs.

The organization has also committed to creating a healthy work environment and culture. This includes initiatives embracing HeartMath concepts that empower employees to “self regulate emotions and behaviors to reduce stress, increase resilience, and unlock their natural intuitive guidance for making more effective choices”. The goal is to create a work environment that is caring and healing, where nurses care for each other and themselves.

What programs or initiatives have you experienced that improved the work environment of bedside nurses?

---

Additional Resources

NSI Nursing Solutions 2019 National Healthcare Retention Report

Want to Keep Nurses at the Bedside? Here’s How

Nurses at the Bedside - Who Will Be Left To

Ill say it folks Nursing is Officially dead . We have a bunch of cosplay nurses allover the business . Nurses now hire all there little buddies whether they are good or just horrible just becuase they like them . We are not dumb We can see you trashy managers and charges giving us the bad assignments and having your little pocket buddies float around . I have to work with new nurses that look like they should be parking my car at the valet or taking my order at restaurant and I have deal with all their behavioral issues and quirks. We nurses see you bad charges and managers put us in illegal situations and when we hand off to the charge to another nurse we see your wheels turning on how to terminate us . I really think they use the fact some people have starving children and need a roof over their head to do all this crazy illegal crap . Thank God I dont have kids and Im not starving . Id admit my jobs are slim pickins but I have a covnant not to sue from lifepoint sitting in my dresser from their illegal activities, I have a settlememt from the Giant HCA for 10k and Prime healthcare lol I divulge . Nowadays they dont want to train anybody they want to work everyone .I remember I was on my 3rd day at orientation in CATH LAB and they wanted me to help with a LUNG BIOPSY !!!! Staff or mangers that lack experience, lack of policies , lack of education , Equipment that doesnt work and lazy biomed. In accurate lab results and questioning of their ability to run labs , No transport , No techs . MDs that dont tell stages of care for the pt . dirty broken beds , crappy food . Cheap equipment. cant make this up . I tell you I had 10 interviews at some one of the best hospitals in the world at different branches . And the disrespect of the administration to get up 2-3 times to take of pts or reschedule in the actual interview is horrible . Im like Dang see why You dont have staff you lack professionalism. I love doing it becuase I after I graduated HS I had no purpose . My mother and father graduated from princeton . I justed wanted to not mooch off my patents like my friends . But TBH Id rather be a good man than a good nurse and put someones life in danger or provide less than sub par care . Whats sad is everyone is looking for a payday but whats sad is nobody is making any money . It dead folks . physical therapy is the future . cuz nobody cares and they dont work

[MunoRN, RN]

On 9/20/2019 at 10:37 AM, CKPM2RN said:

Why has every unit gone to the 12 hour staffing model? It is sold to the staff as a way to have more days off and pursue other things. What really happens is you burn out faster, spend the first day or two inert and by the time you're refreshed its back to doing it all over again. Who really benefits from 12 hour shifts? I would guess management does. Less nurses to hire, hour blocks that are fixed and only two shifts to staff.

I'm looking for non-12s. My friend who became a RN the same time I did told me last night that he is going to start classes for his NP to get away from the 12-hour sprint that he lives in CCU. I don't blame him.

Everybody's different, but in general 12 hour shift staffing has been shown to reduce fatigue, errors, burnout, etc. This is mainly due to the effects of 8 hour shifts on night shift workers compared to 12 hour shifts, the effects are less distinct when it comes to day shifters. Basically, working 5 nights a week with only 2 nights of recovery results in far more cumulative fatigue than working 3 nights with 4 nights of recovery time.

Hospital administrators actually prefer 8 hour shifts since in theory they require fewer nurses overall, this is because typically a full time 12 hour nurse works 36 hours a week, while a full time 8 hour nurse works 40, so for every ten 12 hour nurses you have, you could instead have nine 8 hour nurses (again, in theory).

[Secretperson]

4 minutes ago, MunoRN said:

Everybody's different, but in general 12 hour shift staffing has been shown to reduce fatigue, errors, burnout, etc. This is mainly due to the effects of 8 hour shifts on night shift workers compared to 12 hour shifts, the effects are less distinct when it comes to day shifters. Basically, working 5 nights a week with only 2 nights of recovery results in far more cumulative fatigue than working 3 nights with 4 nights of recovery time.

Hospital administrators actually prefer 8 hour shifts since in theory they require fewer nurses overall, this is because typically a full time 12 hour nurse works 36 hours a week, while a full time 8 hour nurse works 40, so for every ten 12 hour nurses you have, you could instead have nine 8 hour nurses (again, in theory).

Trust me, as a hospital administrator, it is much more advantageous for 12 hour shifts for the hospital.

The 12 hour shift was never brought into operations with the end user in mind (nurse or the patient). It is used for cost control and staffing stabilization. Otherwise all licensed professional nurses would be exempt employees like most other respected professions.

I will not argue the fact that some nurses appreciate a 36 hour pay period, but do not drink the Kool-Aid, this is an operational expectation and is not intended to benefit the nurse.

[MunoRN, RN]

20 minutes ago, Secretperson said:

Trust me, as a hospital administrator, it is much more advantageous for 12 hour shifts for the hospital.

The 12 hour shift was never brought into operations with the end user in mind (nurse or the patient). It is used for cost control and staffing stabilization. Otherwise all licensed professional nurses would be exempt employees like most other respected professions.

I will not argue the fact that some nurses appreciate a 36 hour pay period, but do not drink the Kool-Aid, this is an operational expectation and is not intended to benefit the nurse.

I agree that the hospitals and hospital consulting groups that push for a transition to 8 hour shifts based on supposed cost savings are incorrect in believing it will save costs, but there are certainly hospitals and consulting groups, notably the Huron group, that push for 8 hour shifts.

Everybody's different, so ideally there is at least some availability of shorter shift lengths, but overall, 12 hour shifts have been shown to reduce errors, near misses, and cumulative fatigue, aka 'burnout', so whether they were intended to or not, overall they benefit both patients and nurses.

[Secretperson]

7 minutes ago, MunoRN said:

but overall, 12 hour shifts have been shown to reduce errors, near misses, and cumulative fatigue, aka 'burnout', so whether they were intended to or not, overall they benefit both patients and nurses.

Don’t confuse your opinion and anecdotal statements with reality.... The real world runs off of data.

Review recent studies related to safety and 12 hour shifts, one recently from the university of Maryland, and then comment.

And remember, just because you believe something , it does not mean that it matters or it is important philosophically and translates operationally to all of nursing.... i’m wrong a lot, but I am where I am because I’m right sometimes;)

[MunoRN, RN]

7 minutes ago, Secretperson said:

Don’t confuse your opinion and anecdotal statements with reality.... The real world runs off of data.

Review recent studies related to safety and 12 hour shifts, one recently from the university of Maryland, and then comment.

And remember, just because you believe something , it does not mean that it matters or it is important philosophically and translates operationally to all of nursing.... i’m wrong a lot, but I am where I am because I’m right sometimes;)

I am referring to data, including those that originated the U of Maryland including Roger et al 2004 and 2006, Trinkoff, and Geiger-Brown 2010, as well as other studies such that of Stone et al 2006, Johnson et al 2008, and the NIOSH white paper on shift length.

The most notorious research 'finding' comes from Ann Rogers of the U of Maryland, who claimed to have found that working 12 hour creates "2-3 times the risk of an error compared to 8 hour shifts". Which is an incorrect conclusion based on her research either due to intentional data manipulation, or statistical analysis incompetence. Since is not the only error in the conclusions of Rogers or her U of M partners, it seems unlikely it's accidental.

The "2-3 times the risk" claim is based on errors "per shift", which of course then requires the risk to be corrected based on a common risk for error, since there is more opportunity for error in a 12 hour period than an 8 hour period. When analyzed correctly, based on a common "per hour worked" denominator, her research actually shows an increased risk of error in 8 hour shifts, with 1 error per 377 hours worked compared to 1 error for 720 hours worked in 12 hour shifts.

[Secretperson]

6 minutes ago, MunoRN said:

I am referring to data, including those that originated the U of Maryland including Roger et al 2004 and 2006, Trinkoff, and Geiger-Brown 2010, as well as other studies such that of Stone et al 2006, Johnson et al 2008, and the NIOSH white paper on shift length.

The most notorious research 'finding' comes from Ann Rogers of the U of Maryland, who claimed to have found that working 12 hour creates "2-3 times the risk of an error compared to 8 hour shifts". Which is an incorrect conclusion based on her research either due to intentional data manipulation, or statistical analysis incompetence. Since is not the only error in the conclusions of Rogers or her U of M partners, it seems unlikely it's accidental.

The "2-3 times the risk" claim is based on errors "per shift", which of course then requires the risk to be corrected based on a common risk for error, since there is more opportunity for error in a 12 hour period than an 8 hour period. When analyzed correctly, based on a common "per hour worked" denominator, her research actually shows an increased risk of error in 8 hour shifts, with 1 error per 377 hours worked compared to 1 error for 720 hours worked in 12 hour shifts.

So you are arguing that research directly relating to this is wrong...all of it? You are suggesting that the last few hours of a 12/hr shift actually has a decrease in possible errors? Yeah ok.....

However, You cannot argue that it is NOT cost effective for the organization to continue with 12's. The reason you cannot argue this based on two things:

1. You are staff and have never assumed a multi-million dollar budget for your units.

2. You have not sat in ELT meeting debating the need for improved staff morale and engagement by improving staffing ratios and reducing dependence on 12's and every other weekend staffing. Then subsequently being destroyed for having to increase your budget by 25%, so you go back to your staff and continue to crack the whip.

Something tells me you are the nurse who knows so much more than your leadership...wait till you get there, your tone will change.

[MSO4foru, ADN]

So I think have a secret crush like thing for Monroe. That notwithstanding, while I have never sat in on any' leadership ' meetings in my 14 years as an RN, those 12 hrs make it really convenient for nurses to be flexed off a half shift or more due to purely # of pts in beds. No matter # climbing over rails or requiring frequent prn meds or need for family education ( I do inpatient hospice currently). All management seems to care about are numbers- and I was recently reminded it's Numbers not Need/Acuity that are driving staffing. ( nor even size of unit..... recently had a pt who was PhD in Physics who had much to say on manpower vs sq footage). And every single month I am asked to do more with less and less. That has been the case since 2005.