The American Nurse 2002
Satisfaction guaranteed? A sampling of strategies to keep experienced nurses on the job
by Susan Trossman, RN
They're often described as veterans or "die-hards". They're hospital nurses who've been through it all: team nursing, SOAP charting, downsizing and DRGs. But their numbers are dwindling, and many are poised to retire within the next 10 to 15 years. That's if they don't quit
Florida Nurses Association member Nancy Hartley knows senior RNs who left the profession largely because of the ever-increasing workload.
"I fear we're losing more and more nurses, because they're willing to work for less money as a cashier or in a card store -- anywhere where there's less stress," said Hartley, RN, an ER staff nurse. "And of course when they leave, that increases the stress of the experienced nurses who remain."
As the nursing shortage has taken hold, many veteran nurses have watched their employers offer sign-on bonuses, increase starting salary levels and promise new employees premium shifts, while long-time RNs' loyalty and experience has gone unrewarded.
"Sign-on bonuses do not recognize the long-term staff who put their shoulder to the wheel day after day. And they don't create loyalty, because they allow nurses to bounce from facility to facility," said Arizona State Nurses Association (AzNA) member Rhonda Anderson, MPA, RN, chief operating officer at Desert Samaritan in Mesa, AZ, and a nurse for 30 years.
New and veteran nurses know that having a solid core of experienced nurses is the key to patient safety. So they are working harder than ever with their administrations to create or maintain workplaces designed to retain experienced staff.
So what do long-time nurses want?
"There's not a global, magic answer," Anderson said. "But they want a reasonable wage
and flexibility in scheduling
and time off
. They want respect
from both physicians and hospital administrators for the work they do and the real protection that their seasoned assessment ability brings to patient care."
And, experienced nurses say they want what all nurses want -- control over their practice and a safe working environment
Nurses nationwide have been working on various efforts to decompress wage structures for experienced nurses, who saw their salaries stagnate while starting pay for new nurses escalated.
"Many hospitals in the state were experiencing retention problems, and ours at Yuma Regional (Medical Center) was growing," said AzNA member and telemetry staff nurse Ray Kronenbitter, RN. "Nurses were burned out and were leaving to take on less rigorous nursing roles."
To keep experienced staff, Yuma Regional altered its salary structure to bring it more in line with hospitals in the Phoenix, Tucson and San Diego regions. In July 2000, Yuma Regional nurses saw their wages increase an average of $2 an hour, six months ahead of the routine annual performance raises. Then in December 2001, they gained an average of another $2 an hour as part of their annual performance raises. These changes have resulted in reducing the turnover rate to 14.36 percent annually, as compared to the 26.68 annual statewide average.
Other strategies to make the salary structure more equitable include:
* Administrators at Shands Teaching Hospital at the University of Florida agreed to reward long-timers by raising all nurses wages by $1.79 an hour (on top of their annual performance raises) and providing one-time bonuses, said Hartley, the bargaining unit president. Bonuses ranged from $500 to nurses on staff for less than five years to $1,250 to those with 15-plus years at the facility.
* Minnesota Nurses Association member Jacquie Luoma, RN, said her bargaining unit at Fairview University Medical Center -- Riverside Campus negotiated annual longevity bonuses that ranged from $1,500-3,500 (depending on length of service), in addition to any step increases for employees who have not yet topped out on the pay scale.
* At Sparrow Hospital in Lansing, MI, nurses at the top of the scale recently won salary improvements that increased the previous maximum hourly pay from $25.58 to $28, according to Gail Jehl, RN, co-chair of the negotiating team and a nurse at Sparrow since 1988.
* And nurses at Appalachian Regional Healthcare, Inc.'s hospitals won the addition of another step in their salary structure that rewards nurses who've been on staff for 25 years or more. They now get $1,000 annually, according to Pat Tanner, Kentucky Nurses Association director of labor.
Nurses also gained other financial incentives that are attractive to long-time staffers. For example, Fairview nurses negotiated additional pay for nurses who serve as preceptors.
"It seems like putting a dollar amount to the preceptor role made administrators realize experienced nurses' value," said Luoma, a critical care float pool nurse and co-chair of her bargaining unit. (Preceptors also gained more autonomy over their role and are no longer expected to take full assignments while overseeing new nurses
Fairview nurses also won increases in shift differentials
-- $2.50 an hour for working evenings and $4 an hour for nights.
At Appalachian Regional, nurses stopped a hospital plan that would have led to long-time staffers paying more for their health insurance premiums because they were going to be pegged to nurses' salaries. Instead, they negotiated that the premium would be based on the average salary of the entire bargaining unit, Tanner said.
Control, respect & recognition
One of the key wins for veteran staffers at Fairview involves a contract provision that respects the decision-making ability of nurses regarding unsafe staffing
. Under their new agreement, charge nurses have the right to close down
a unit to new admissions if they believe there are not enough RNs to provide safe care. (Other Twin Cities hospitals won this contract language, as well.)
"This provision gives us some control over our practice and the care we are providing," Luoma said. "We can say 'Stop sending us more patients, because we can no longer provide safe care and practice at the level to which we are ethically, morally and legally bound.'"
And nurses at Appalachian Regional won language that prohibits mandating overtime
for any RN with 16 years of seniority at any time. These nurses are still eligible to work overtime based on seniority, but it entirely is up to them, Tanner said.
On the East Coast, Colleen Smith, MSN, RN, CNA, vice president for nursing at Middlesex Hospital in Connecticut, and Kathleen Stolzenberger MS, RN, director of program development, also have been working to provide nurses at their facility with more opportunities to participate in decision-making, as well as reward them for their expertise.
Middlesex is the first hospital in Connecticut to be designated a "Magnet" facility by the American Nurses Credentialing Center for its excellence in nursing services. To be a "Magnet," hospitals and long-term care facilities must show that they have created a work environment that attracts and retains high-caliber nurses.
"Our whole focus is how can we create a better working environment so nurses will want to stay here," said Stolzenberger, a Connecticut Nurses Association member.
Middlesex has several initiatives under way to strengthen the professional practice climate, including the creation of councils that give staff nurses more voice and authority in controlling and improving their own practice.
A second initiative involves a new clinical advancement program. Many staff nurses were not participating in the previous program, because they believed it did not sufficiently acknowledge clinical excellence and the application process was onerous, Smith said. As a result, experienced bedside nurses were not being recognized and rewarded financially for their expertise.
Now, the program is designed as an easy-to-use "menu" that offers options for advancement based on nurses' individual goals and interests. At the time of their annual performance reviews, nurses demonstrate how they've progressed toward their goals through participation in various activities, which are awarded certain points. If nurses accrue sufficient points, they move up the career ladder.
Middlesex also has been encouraging nurses to take on more facility-wide leadership and has been promoting its seasoned nurses as experts throughout the hospital and the community. Smith added that they now host a Department of Nursing Annual Meeting as another way to reward and recognize staff nurses. The meeting showcases individual and unit accomplishments and concludes with a peer award ceremony for excellence in practice.
Desert Samaritan also places a high value on keeping the nurses they have happy by helping them achieve their career goals. Nurse managers are required to discuss staff nurses' career goals and determine ways they can achieve them -- even if it means that a staff nurse wants to transfer to a different unit, Anderson said.
"Many senior nurses have said to me, 'It's beginning to kill me to do 12-hour shifts,'" Hartley said. Her facility offers a variety of schedules
, including one that allows nurses to work seven days straight and have the next seven off. Because flexibility -- in terms of scheduling and benefits -- makes a difference to long-time staffers, hospitals are getting more innovative in what they offer, such as:
* In Minnesota, Fairview nurses convinced their administration to implement a new alternative weekend schedule, where nurses work either two 12-hour shifts or three eight- hour shifts and get paid for 36 hours
. This allows long-time nurses to work fewer weekend shifts.
* Desert Samaritan offers nurses the opportunity to work 4-hour shifts
, for example, during heavy admit times. Administrators at Sparrow recently agreed to explore RNs working shorter shifts.
* Desert Samaritan also created several scheduling options, which can further lead to experienced RNs having more control over their work hours
. The seasonal option allows nurses to work full time for nine months and get three consecutive months off. Nurses who are willing to switch from day to night shifts for 30 days receive an additional $1,000. And those who choose to work solely in the winter months, when the area's population surges, can make an additional $5 an hour.
* Anderson also pointed to her facility's flexible benefits package, whereby nurses can chose to receive pay in lieu of benefits.
* In Michigan, Sparrow nurses persuaded their administration to create a transitional work program. Nurses who cannot perform their normal job functions because of an injury, for example, can work up to six months in a less strenuous role and get paid at their current rate, Jehl said.
It's still about working conditions!
"Hospitals aren't going to retain nurses by just throwing money at us. That's just a short-term solution," Kronenbitter said. "We need to change the environment."
To do that, ANA and its constituent member associations (cmas - the state nurses associations) are continuing their campaign to address nurses' main concern -- staffing -- through state and national legislative efforts, as well as through other avenues. Specifically, they are focusing on efforts to restrict mandatory overtime; increase whistleblower protections; mandate health care facilities to collect workforce and nursing-sensitive quality data; and, require health care facilities to establish valid patient classification systems to determine the appropriate level and mix of nursing staff.
Through lobbying and negotiating, many CMAs and their members made great strides in these staffing issues, but more must be done. Cautioned Kronenbitter, "We're sitting on the fence of a public health crisis. If we don't take positive steps now to keep our experienced nurses, we're going to fall off that fence -- and quicker."
Susan Trossman is the senior reporter for The American Nurse. >>
past issues: http://www.nursingworld.org/tan/