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?

[Asystole RN]

23 minutes ago, OUxPhys said:

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.

Look up the rationale given for the PPS and DRG system, it is not a secret. There are many articles and published papers by CMS, OIG, and other government entities explaining the system in detail. Specifically, you can look up the base rate and labor portion rationale.

The labor portion of the DRG and the CBSA adjustment are publicly available as well. You can even look up the base and labor portion rate for your facility. You will have to do some skull sweat to decipher the Excels but they are available.

Labor costs are always the single largest and most controllable expense of any hospital.

Google: DRG Labor Cost Control

Second source on Google is an article from 1988 titled Using DRGs and standard costs to control nursing labor costs.

Abstract

Nursing care is a very significant part of a healthcare organization's costs. However, until recently, methods of controlling nursing costs were largely ineffective. With the implementation of the prospective payment system and the use of diagnosis related groups, budgeting and controlling nursing costs are now possible with the use of standard costing. In this article, methods and procedures are discussed and explained for controlling inpatient nursing costs with the use of DRGs and standard costs.

[Secretperson]

41 minutes ago, Asystole RN said:

Look up the rationale given for the PPS and DRG system, it is not a secret. There are many articles and published papers by CMS, OIG, and other government entities explaining the system in detail. Specifically, you can look up the base rate and labor portion rationale.

The labor portion of the DRG and the CBSA adjustment are publicly available as well. You can even look up the base and labor portion rate for your facility. You will have to do some skull sweat to decipher the Excels but they are available.

Labor costs are always the single largest and most controllable expense of any hospital.

Google: DRG Labor Cost Control

Second source on Google is an article from 1988 titled Using DRGs and standard costs to control nursing labor costs.

Abstract

Nursing care is a very significant part of a healthcare organization's costs. However, until recently, methods of controlling nursing costs were largely ineffective. With the implementation of the prospective payment system and the use of diagnosis related groups, budgeting and controlling nursing costs are now possible with the use of standard costing. In this article, methods and procedures are discussed and explained for controlling inpatient nursing costs with the use of DRGs and standard costs.

Nursing is viewed as an expense by US HCO’s and is recognized as such by the “market”....each HCO looks to the local “market” to determine pay for every level of nursing staff within their organization. Obviously, no HCO is benchmarking this to force competition, so wage improvements for new hires are extremely difficult because it would require increases for existing staff to ensure internal equity. And let’s face it, there are enough nurses that will say yes to what they pay so they are never forced have to actually find stainable measures to improve pay and hours.

Why is nursing viewed as an expense? Short answer is it because you cannot bill for what the nurse can offer. Nursing care in an acute care setting is packaged into the care for the diagnosis, procedure, or process meaning that when a nurse comes in and does something they cannot bill $37,000 like a provider who just did a cardiac cath. In a non-acute care such as LTC, HHC, or rehab, there is a small billable portion for “skilled nursing“ this amount usually will not even cover the costs associated with the logistics for the nurse to get to the room or the house, so you have to dip into the operating budget for every nurse visit.

It all comes down to revenue for the business, nurses bring in much less revenue than they cost. This requires a strict containment on expenses “nurses“. We all know most organizations have pretty deep pockets Especially the non-profits, they will build a new wing, heavily recruit physicians for obscene amounts of money, or introduce a new technology (that would sustain increases for a decade for the nursing staff), prioritizing and investing in human collateral is imperative, but obviously not required in nursing because we say yes and it goes on.

[Asystole RN]

5 minutes ago, Secretperson said:

Nursing is viewed as an expense by US HCO’s and is recognized as such by the “market”....each HCO looks to the local “market” to determine pay for every level of nursing staff within their organization. Obviously, no HCO is benchmarking this to force competition, so wage improvements for new hires are extremely difficult because it would require increases for existing staff to ensure internal equity. And let’s face it, there are enough nurses that will say yes to what they pay so they are never forced have to actually find stainable measures to improve pay and hours.

Why is nursing viewed as an expense? Short answer is it because you cannot bill for what the nurse can offer. Nursing care in an acute care setting is packaged into the care for the diagnosis, procedure, or process meaning that when a nurse comes in and does something they cannot bill $37,000 like a provider who just did a cardiac cath. In a non-acute care such as LTC, HHC, or rehab, there is a small billable portion for “skilled nursing“ this amount usually will not even cover the costs associated with the logistics for the nurse to get to the room or the house, so you have to dip into the operating budget for every nurse visit.

It all comes down to revenue for the business, nurses bring in much less revenue than they cost. This requires a strict containment on expenses “nurses“. We all know most organizations have pretty deep pockets Especially the non-profits, they will build a new wing, heavily recruit physicians for obscene amounts of money, or introduce a new technology (that would sustain increases for a decade for the nursing staff), prioritizing and investing in human collateral is imperative, but obviously not required in nursing because we say yes and it goes on.

I think you touched on the key element missing that nursing is not fighting for. Since nurses do not bill for time (outside of internal department billing) nursing will never "generate money."

I have long advocated for an independent billing system for nursing and/or a reimbursement program tied to nursing hours instead of a flat labor rate based upon the wage index.

CMS values physician time and skill, we need to let them know that they need to value nursing time and skill.

If hospitals were reimbursed for nursing time then there would be a 7 nurses per patient ratio instead of 7 patients per nurse.

I do disagree with you on the "deep pockets" comment. As an industry, hospitals have terrible operating margins, typically in the low single digits. Even for profit hospitals. Hospitals are generally at or 1-2 points above grocery stores which have some of the worst operating margins of any industry.

Many other industries operate well into the teens, 20's, or even above. The low single digit margins are remarkable considering the relatively small organizational size for hospitals as well.

[Secretperson]

15 minutes ago, Asystole RN said:

I think you touched on the key element missing that nursing is not fighting for. Since nurses do not bill for time (outside of internal department billing) nursing will never "generate money."

I have long advocated for an independent billing system for nursing and/or a reimbursement program tied to nursing hours instead of a flat labor rate based upon the wage index.

CMS values physician time and skill, we need to let them know that they need to value nursing time and skill.

If hospitals were reimbursed for nursing time then there would be a 7 nurses per patient ratio instead of 7 patients per nurse.

I do disagree with you on the "deep pockets" comment. As an industry, hospitals have terrible operating margins, typically in the low single digits. Even for profit hospitals. Hospitals are generally at or 1-2 points above grocery stores which have some of the worst operating margins of any industry.

Many other industries operate well into the teens, 20's, or even above. The low single digit margins are remarkable considering the relatively small organizational size for hospitals as well.

Totally agree, and “deep pockets” might be the wrong verbiage. What I should say is prioritizing expenses.... most non-for profits and VC’s have a six-figure job specifically for “gifts“ these do a lot of the funding for certain expenses such as wings or new technology. Re-organizing where the money goes could be exponentially beneficial for the nursing staff.

[OUxPhys, BSN, RN]

57 minutes ago, Asystole RN said:

I think you touched on the key element missing that nursing is not fighting for. Since nurses do not bill for time (outside of internal department billing) nursing will never "generate money."

I have long advocated for an independent billing system for nursing and/or a reimbursement program tied to nursing hours instead of a flat labor rate based upon the wage index.

CMS values physician time and skill, we need to let them know that they need to value nursing time and skill.

If hospitals were reimbursed for nursing time then there would be a 7 nurses per patient ratio instead of 7 patients per nurse.

I do disagree with you on the "deep pockets" comment. As an industry, hospitals have terrible operating margins, typically in the low single digits. Even for profit hospitals. Hospitals are generally at or 1-2 points above grocery stores which have some of the worst operating margins of any industry.

Many other industries operate well into the teens, 20's, or even above. The low single digit margins are remarkable considering the relatively small organizational size for hospitals as well.

They have no problem finding money for administrators though and I think that’s the biggest issues nurses have.

I love when they say they dont have money to hire more staff then send a hospital wide email welcoming the new administrator they just hired.

[Wizard 1]

^^^^^^May be one reason why hospitals are forming mega corporations.

I also agree that nurses need to lobby strongly to be a separate "cost center" and not bundled into "facility costs".

What, I wonder, do administrators actually DO and how does this directly relate to patient care?

[OUxPhys, BSN, RN]

31 minutes ago, Wizard 1 said:

^^^^^^May be one reason why hospitals are forming mega corporations.

I also agree that nurses need to lobby strongly to be a separate "cost center" and not bundled into "facility costs".

What, I wonder, do administrators actually DO and how does this directly relate to patient care?

Nothing except make themselves look smart by understaffing floors and then getting big bonuses at the end of each year.

My mom is an executive secretary for a large hospital system in the area and she see’s all the large salaries and bonuses administrators get while workers get next to nothing.

Healthcare is a business now just like higher education.

[Asystole RN]

17 hours ago, Wizard 1 said:

^^^^^^May be one reason why hospitals are forming mega corporations.

I also agree that nurses need to lobby strongly to be a separate "cost center" and not bundled into "facility costs".

What, I wonder, do administrators actually DO and how does this directly relate to patient care?

You can Google the investment articles related to hospitals. What is often stated over and over again is that hospitals are generally bad investments due to their rather low margins and volatile nature. A way to reduce the volatility is grow but also to capture more of the customer cycle, the supply chain, or rather the patient's cycle. This means not only grabbing more hospitals but also grabbing post and pre acute organizations such as LTC/Rehab, home health, primary care, and urgent care, along with insurance companies, and pharmaceutical or device supply distribution and manufacturing if possible.

Depends on the role of the admin. The CFO is in charge of the financial health of the organization. Not only are they responsible for the accounting but they also look for growth opportunities and investments.

COO is generally in charge of the operations of the hospital. All the department heads that work in functions that keep the lights on and the floors waxed. The COO has to make sure the O2 tanks are filled and there are warm tacos in the cafeteria. The actual operations of the hospital.

CNO is generally the lead of either all clinical operations or all nursing operations. In this role they oversee the general clinical care provided, set the budgets, and may get into supply issues.

The CEO is generally the overall business leader for the hospital. Sets the strategic direction for the facility and generally has to develop and then execute on a multi-year fiscal plan to the board. They are in charge of the overall hospital and ensuring that the hospital is growing. Lots of meetings with investors, other companies for partnerships, function leaders, etc.

How do these functions impact patient care? Well, they make sure you have a paycheck, the lights are on, the payments for the new CT are made, negotiate with the insurance companies, your hospital is investing in the future, the hospital is competitive, etc.

If you are really interested in learning how the hospital functions I would recommend attending an ANA or AONL meeting and networking with some of the nursing leadership there.

[Asystole RN]

17 hours ago, OUxPhys said:

Nothing except make themselves look smart by understaffing floors and then getting big bonuses at the end of each year.

My mom is an executive secretary for a large hospital system in the area and she see’s all the large salaries and bonuses administrators get while workers get next to nothing.

Healthcare is a business now just like higher education.

LOL. Healthcare has always been a business.

To a CNA a nurse has a large salary. To the housekeeper the CNA has a large salary.

To dismiss your leadership is shortsighted in my opinion. If you want to affect change and make a positive impact you have to understand all of the various functional elements of the hospital. Dismissing leadership is like dismissing radiology or the lab. Most everyone has a purpose and needs. Find that purpose and those needs and you can start making change happen.

[OUxPhys, BSN, RN]

3 minutes ago, Asystole RN said:

You can Google the investment articles related to hospitals. What is often stated over and over again is that hospitals are generally bad investments due to their rather low margins and volatile nature. A way to reduce the volatility is grow but also to capture more of the customer cycle, the supply chain, or rather the patient's cycle. This means not only grabbing more hospitals but also grabbing post and pre acute organizations such as LTC/Rehab, home health, primary care, and urgent care, along with insurance companies, and pharmaceutical or device supply distribution and manufacturing if possible.

Depends on the role of the admin. The CFO is in charge of the financial health of the organization. Not only are they responsible for the accounting but they also look for growth opportunities and investments.

COO is generally in charge of the operations of the hospital. All the department heads that work in functions that keep the lights on and the floors waxed. The COO has to make sure the O2 tanks are filled and there are warm tacos in the cafeteria. The actual operations of the hospital.

CNO is generally the lead of either all clinical operations or all nursing operations. In this role they oversee the general clinical care provided, set the budgets, and may get into supply issues.

The CEO is generally the overall business leader for the hospital. Sets the strategic direction for the facility and generally has to develop and then execute on a multi-year fiscal plan to the board. They are in charge of the overall hospital and ensuring that the hospital is growing. Lots of meetings with investors, other companies for partnerships, function leaders, etc.

How do these functions impact patient care? Well, they make sure you have a paycheck, the lights are on, the payments for the new CT are made, negotiate with the insurance companies, your hospital is investing in the future, the hospital is competitive, etc.

If you are really interested in learning how the hospital functions I would recommend attending an ANA or AONL meeting and networking with some of the nursing leadership there.

That’s all well and good but its not justification to reward yourself and then stiff the people doing the actual physical work.

Do you work as an administrator?

1 minute ago, Asystole RN said:

LOL. Healthcare has always been a business.

To a CNA a nurse has a large salary. To the housekeeper the CNA has a large salary.

To dismiss your leadership is shortsighted in my opinion. If you want to affect change and make a positive impact you have to understand all of the various functional elements of the hospital. Dismissing leadership is like dismissing radiology or the lab. Most everyone has a purpose and needs. Find that purpose and those needs and you can start making change happen.

No it hasnt. It was once focused on caring for the patient. That’s not the case anymore.

[guest974915]

15 minutes ago, OUxPhys said:

That’s all well and good but its not justification to reward yourself and then stiff the people doing the actual physical work.

Do you work as an administrator?

^^^Agree with this. I don't think anyone is disputing the necessity/importance of senior administrators or the slim profit margins of hospital systems some years. Rather, most nurses take issue with the enormous salaries, benefit packages, and golden parachutes that upper management consistently rewards themselves while the worker bees continue to be unappreciated, overworked, and dangerously overextended.

[Secretperson]

15 minutes ago, Asystole RN said:

If you are really interested in learning how the hospital functions I would recommend attending an ANA or AONL meeting and networking with some of the nursing leadership there.

As a hospital nursing administrator, I would never recommend going to a nursing leadership convention or meeting to discuss operations within healthcare. If You truly want to know how it all works meet with your ELT, and operations leadership, you will find that nursing leadership does play part of the operations, but just a small piece, and outside of nursing itself they have very little influence.