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?

[L-ICURN, BSN, RN]

Just posing a question here, but what part does the world of academia play in this. It appears they've become a big business model that keeps pushing for bigger, more expensive degrees. You can't just have an ADN. Nope. It's got to be a BSN. Nope. You need a master's. The floor RN (who has seen all that we've described) gets pushed to the wayside for the person with the bigger, fancier degree. I've had bad luck with unions in the past, but maybe it's time to say that dirty word hospitals don't like to hear: unionize.

[Secretperson]

37 minutes ago, L-ICURN said:

Just posing a question here, but what part does the world of academia play in this. It appears they've become a big business model that keeps pushing for bigger, more expensive degrees. You can't just have an ADN. Nope. It's got to be a BSN. Nope. You need a master's. The floor RN (who has seen all that we've described) gets pushed to the wayside for the person with the bigger, fancier degree. I've had bad luck with unions in the past, but maybe it's time to say that dirty word hospitals don't like to hear: unionize.

Academia has everything to do with this. Only in the nursing world would a doctorate of nursing practice (DNP) be the “most qualified” person to run the operations for the nursing business end in many large organizations, and now some small organizations.

Where is the doctorate in medicine and leadership degree for a chief medical officer? Awfully interesting that almost every large organization has their COO or CEO with a business degree, such as an MBA, MHA, or MBA/HCA. I have never seen an ELT post a position asking for a doctorate in business to run their organization as chief executive officer.

My point is that nursing as a whole, because of academia pushing more degrees, are equating and substituting education for merit, skills, and sadly emotional intelligence.

[guest974915]

4 hours ago, Secretperson said:

Academia has everything to do with this. Only in the nursing world would a doctorate of nursing practice (DNP) be the “most qualified” person to run the operations for the nursing business end in many large organizations, and now some small organizations.

Where is the doctorate in medicine and leadership degree for a chief medical officer? Awfully interesting that almost every large organization has their COO or CEO with a business degree, such as an MBA, MHA, or MBA/HCA. I have never seen an ELT post a position asking for a doctorate in business to run their organization as chief executive officer.

My point is that nursing as a whole, because of academia pushing more degrees, are equating and substituting education for merit, skills, and sadly emotional intelligence.

^^^agree! This is the problem I have with this whole debate. Somehow, our 'experts' are going to weigh in from their comfortable offices on a problem that most of them are far removed from-i.e. the current state of bedside nursing. Most, if not all, of these 'experts' (our nurse leaders) that I have known personally, or know of, left bedside nursing years ago to pursue advanced degrees. Not to deride education, but why is it that our ten, twenty, thirty experience in clinical nursing doesn't qualify us as the subject experts in this area?

[Eph]

Nurses are not appreciated at all!

[Secretperson]

21 minutes ago, morelostthanfound said:

Not to deride education, but why is it that our ten, twenty, thirty experience in clinical nursing doesn't qualify us as the subject experts in this area?

I think you are right, I think that 10, 20, 30 years experience is perfect as a SME in nursing. However, Kickass subject matter expert nurses, do not always make good leaders just like a doctorate does not qualify you as a good manager, CNO, or director of nursing.

Again we are thinking that education or experience in nursing equates to decent managerial and/or leadership skills. This whole thread is based on under valued clinicians and poor retention of nurses.... guess what? We’ve done this to ourselves, all of our nursing leadership is put in place by good nurses who turned out to be terrible managers who had very little influence in the operations of their HCO, that is why we can’t retain, recruit, or improve culture....

Good leaders “in theory “ should know they’re not the smartest person in the room, and will identify and rely heavily on their SMEs, and will develop their approach around that, this inevitably improves culture, retention, and value.

[guest974915]

3 minutes ago, Secretperson said:

I think you are right, I think that 10, 20, 30 years experience is perfect as a SME in nursing. However, Kickass subject matter expert nurses, do not always make good leaders just like a doctorate does not qualify you as a good manager, CNO, or director of nursing.

Again we are thinking that education or experience in nursing equates to decent managerial and/or leadership skills. This whole thread is based on under valued clinicians and poor retention of nurses.... guess what? We’ve done this to ourselves, all of our nursing leadership is put in place by good nurses who turned out to be terrible managers who had very little influence in the operations of their HCO, that is why we can’t retain, recruit, or improve culture....

Good leaders “in theory “ should know they’re not the smartest person in the room, and will identify and rely heavily on their SMEs, and will develop their approach around that, this inevitably improves culture, retention, and value.

Also agree! However, in corporate healthcare today it's all about the money. Our nurse leaders know that their paycheck and longevity with the company hinge upon them parroting the demands of senior management-do more with less-i.e. short staffing, stagnant wages, reduction of benefits.... It is totally disingenuous for them to pretend that they don't know what the core issues behind nursing retention are. The problem is that they chose to talk around the issues rather than pony up with the money needed to fix the problems.

[Wizard 1]

From bbyrn:

"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."

****Especially note the last paragraph. Also important to inform via phone calls and follow up. Continuous, persistent, committed action. Schedule a meeting with representatives and senators and those running for political office, bring good data about the value of nursing care, inform them about what nurses really do, and remind them regularly. Get involved. Change doesn't come from the top down. It comes from the rank and file and the grassroots.

[Wizard 1]

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I've had bad luck with unions in the past, but maybe it's time to say that dirty word hospitals don't like to hear: unionize.

This is one option. The first is that the profit motive is removed from healthcare. In the old days before money and profits became the primary motivator, caring for people was the priority and experienced nurses were valued.

[Secretperson]

18 hours ago, morelostthanfound said:

Also agree! However, in corporate healthcare today it's all about the money. Our nurse leaders know that their paycheck and longevity with the company hinge upon them parroting the demands of senior management-do more with less-i.e. short staffing, stagnant wages, reduction of benefits.... It is totally disingenuous for them to pretend that they don't know what the core issues behind nursing retention are. The problem is that they chose to talk around the issues rather than pony up with the money needed to fix the problems.

Very good point.

[Asystole RN]

11 hours ago, Wizard 1 said:

This is one option. The first is that the profit motive is removed from healthcare. In the old days before money and profits became the primary motivator, caring for people was the priority and experienced nurses were valued.

In general, hospitals are terrible profit generators with most generating single digit profits at best, in-line with the historically worst business which is grocery stores.

The death of the "old days" started in 1983. In 1983 the concept of PPS and DRGs, specifically the MS-DRG, started.

What most people do not know is that hospitals do not staff the way they do because they are greedy or inherently evil, they do so because the Federal Government, specifically CMS, punishes them if they staff correctly. Yes, you read that right.

Within the DRG base rate (commonly known to as the bed fee) there is a labor and non-labor portion. The labor portion is adjusted by the labor index organized by CBSA.

The labor portion is artificially kept low as a cost containment intervention by CMS.

Hospitals are simple entities. They want to consume more, or at least equal, to what they expend. Not unlike a living organism. CMS comes in and tells hospitals to cut and limit staffing and actively punishes them if they staff too heavily.

If you want decent staffing talk to CMS, or at least your local representative. They are the ones who are actively suppressing nursing.

[L-ICURN, BSN, RN]

24 minutes ago, Asystole RN said:

The death of the "old days" started in 1983. In 1983 the concept of PPS and DRGs, specifically the MS-DRG, started.

What most people do not know is that hospitals do not staff the way they do because they are greedy or inherently evil, they do so because the Federal Government, specifically CMS, punishes them if they staff correctly. Yes, you read that right.

Within the DRG base rate (commonly known to as the bed fee) there is a labor and non-labor portion. The labor portion is adjusted by the labor index organized by CBSA.

The labor portion is artificially kept low as a cost containment intervention

Interesting. I did not know that. This opens up a new way of looking at this. I'll need to learn more about this.

[OUxPhys, BSN, RN]

28 minutes ago, Asystole RN said:

In general, hospitals are terrible profit generators with most generating single digit profits at best, in-line with the historically worst business which is grocery stores.

The death of the "old days" started in 1983. In 1983 the concept of PPS and DRGs, specifically the MS-DRG, started.

What most people do not know is that hospitals do not staff the way they do because they are greedy or inherently evil, they do so because the Federal Government, specifically CMS, punishes them if they staff correctly. Yes, you read that right.

Within the DRG base rate (commonly known to as the bed fee) there is a labor and non-labor portion. The labor portion is adjusted by the labor index organized by CBSA.

The labor portion is artificially kept low as a cost containment intervention by CMS.

Hospitals are simple entities. They want to consume more, or at least equal, to what they expend. Not unlike a living organism. CMS comes in and tells hospitals to cut and limit staffing and actively punishes them if they staff too heavily.

If you want decent staffing talk to CMS, or at least your local representative. They are the ones who are actively suppressing nursing.

Do you have any links to back up the claim CMS forces hospitals to understaff? I find this hard to believe.

Dont get me wrong, I think CMS does more harm than good but I dont buy they force hospitals to understaff.