Nursing orientation/retention

GinginRN · Jul 19, 2012

I stayed for several years with a facility that offered a complete orientation, including hands on phlebotomy, i/v skills, highlight hospital policies, and provide resources for areas that one would not be well-versed in. The ideal units would have a dedicated clinical educator, periodic mock codes, and offer educational classes/seminars. Management always welcomed suggestions on how to improve workflow, patient safety, and address employee concerns.

RNperdiem, RN · Jul 19, 2012

I have worked for 13 years in a low-turnover unit.

When I was first hired, I noticed that we had a strong core of experienced nurses. With those nurses, I was never left unsupported as a new nurse. When I float to high-turnover units, there is no strong core, but instead a patchwork of lots of new grads left struggling, float nurses, agency, and a few overworked senior nurses who are always in charge or precepting.

In my low-turnover unit, there is almost always enough ancillary staff to go around. It is rare that we don't have some kind of secretarial coverage. The CNAs we hire are all nursing students. These students usually come work in our unit as RNs after graduation, and are eager to make a good impression. Slackness and poor work are not a problem with our CNAs.

In my unit, the manager and the chief attending have worked hard to have good communication between doctors and nurses. Nurses are part of rounds on my unit. I float to places where the doctors come and go without the nurse being able to address any patient concerns with them.

Other small satisfactions include: self-scheduling, daily lunch(except under dire circumstances), management with backbone and a knack for hiring the right people.

FLmomof5 · Jul 19, 2012

As a new nurse, here is a dilemma you have to 'resolve'... Med/Surg is a high turnover location because most nurses do not want to work on Med/Surg. This is usually your entry point into hospital nursing. As soon as you have your 1 year in, you are eligible to apply for specialty units.

From what I have read, ER is a great unit for adrenaline junkies. Those adrenaline junkies wont be content with Med/Surg...not enough going on....but they have to train there to get a foundation of skills. Once there, you won't see them looking to leave for another unit. With PACU, you deal with someone coming into conciousness long enough to roll them off the floor. With OR, your patients are unconcious. The beauty of these units is multi-faceted..... No families around would be a strong point, the patient isn't demanding, they (I am assuming here - so PACU/OR nurses correct me if I am wrong) are not trying to crawl out of bed (ie: dementia patients with bed alarms). Most operations are done on day shift and during the week.

You must assess all the reasons why a unit is high turnover. In Med/Surg, you have to deal with families and patients who are ridiculously demanding, do it with a smile on your face and when they complain anyway, the nurse is penalized. Nurses on Med/Surg have to take a higher patient load. Day shift nurses have multiple doctors (some on the same patient) coming in all day writing orders so you have to constantly re-evaluate the plan of care. On night shift, many doctors are less than happy being woken up during the night. The night shift has to deal with sundowners crawling out of bed all night and in some hospitals, fewer CNAs to help with this.

My first hospital had a 12 week orientation. My second hospital has a 6 week orientation. I personally believe that the 12 week orientation is more beneficial for those who are new grads. I didn't mind the 6 week orientation at the second hospital because I had experience, but not all the nurses who were in orientation did. I felt sorry for them. They needed more time on orientation. Short orientations can set a new nurse up for failure or a high level of stress and frustration at the beginning of their career.

A suggestion I have would probably not float well with the Hospital Administrators.....If nurses leave after 1 year, then give them incentives to stay. If a nurse is an ADN nurse, allow them immediate hospital educational funds to obtain their BSN, with the obligation to stay on the unit for at least a year after they get their BSN. (That means that you have them for at least 3 years!) Another would be, bonuses. You get $$ bonus on your 2 year anniversary on the floor, more $$ each subsequent year. You could offer, instead, an "anniversary holiday" where they get 1 more paid day off for having reached each subsequent anniversary.

You have to address issues on the floor. Give the nurses adequate CNA coverage so that they aren't overwhelmed with that part of patient care. Make sure your N:P ratios aren't too high. (First hospital had 1:7 on nights. Second has 1:6....which is a nice improvement.) Supplies! Hospital #1 had adequate supplies and you never ran out. Hospital #2 runs out of supplies by end of week...even syringes! Have snack foods available for patients. Nothing is more frustrating than having a patient who wants a snack but there isn't anything beyond saltines or graham crackers (not even peanut butter). The patient then is hungry and frustrated. It reflects itself in the hospital and nursing care score.

As silly as it sounds....recognition. I am a second career nurse. Although I was very good at what I did in my first career, I never got formalized recognition for a job well done. At my first hospital, a letter was sent to the hospital director applauding specific people in the care of the family member patient. As a result, I was mailed a "Huddle Award" certificate for my part in the care of this patient. It was silly. It was mailed to my home (because I am night shift). It made my day!

Non-punitive reporting of incidents. Reporting of incidents is 2 fold. Identify a systemic issue and fix it and a growth opportunity for the nurse. When you emphasize the non-punitive nature of the system, you are more likely to get self-reports that can improve care. New nurses WANT to learn, but if they live in fear, they won't stay long.

NM's that back up the nurses! As an example, we just had a patient who was crude with all the female care providers. He had been that way ALL day. At the night shift he was assigned our largest male nurse! It didn't help the poor ACP. He called her a F*g C*nt! Our NM addressed the patient with security backing her up (and our security uses a cadre of REAL police officers working a second job with us). Anyway, that patient claimed that everything was great on day shift with the NM knew wasn't true and she called him on it. This arrogant POS got angry and left AMA. We were glad to see him leave.

As Med/Surg nurses, we need to know that the NM has our back. We need to work without fear of retaliation or punishment. We need recognition for the work we do. For those of us who want to advance our education, we need a hospital that supports that with $ to pay for it. (Hospital #1 didn't fund their program while I worked there. Hospital #2 requires that you work there for a year before you can benefit.)

Some other things that I have noticed.... both hospitals encouraged us to take our meal break. At hospital #2, they have the bistro on campus open until 1 AM! We have regular pot lucks on night shift on weekends! (And with the variety of cultures we have in our hospital, the food items can be very interesting and delicious!) Frozen meals and sandwiches get old very quick!

Just my .02. Good luck!

Good Morning, Gil · Jul 23, 2012

I work in the ICU, and I might be able to list some reasons why turn-over is high there. (firstly, do you have multiple ICU's? is the turnover rate the same in all ICU's or just one? if it's all ICU's, CV, NT, MSICU's, then it's likely a hospital problem, orientation length, etc. If it's just one, then it's probably either the patient population or the nurses on the unit, i.e lack of teamwork. You can't really fix either of those...other than hiring nurses that are hard working and work together and as a team and not "well, my patients are easy, so I will sit here and do nothing while you run all night long.").

Team work will vary. Typically, every unit has nurses that really work well together, help each other out, and then others that just care for their patients and don't offer any help unless begged. That's just how it is, though; some people work harder than others. A person has to be cut out for ICU as far as the acuity, patient population (they're either sedated or delirious most of the time), death/emotional stuff, fast-paced at times. It really isn't for everyone, and if it's not a good fit, then people leave soon. Also, people get ICU experience for CRNA school, etc...you could look into how many people left after 2 years for school? But, it sounds like people aren't staying even a year....that is a problem, especially when orientation is longer in ICU. I'm hoping you give a new nurse/ICU nurse a good orientation, and even an experienced nurse that's new to ICU, a good length of orientation, as well.

Either give the nurses a CNA or 2 on your floor, or a charge nurse that doesn't have any patients of her own so they're free to help with anything. We have no CNA's, and usually no secretary at night, and it would be really nice if we had even just 1 CNA. However, I have been there almost a year and am not looking to leave any time soon since I like who I work with, and enjoy work most of the time, feel like I'm making a difference, and I'm not a prima donna in that I realize nursing is hard work (believe it or not, some people don't know that nursing is hard work, requires multi tasking, quick thinking, etc until after they graduate lol) Though I never make special requests as some do and just take my assignment as is, our charge nurses are very good about mixing up which patients we get: i.e. I don't always get ETOH withdrawals every night; I get some really sick ones, then not so sick. This is key on any unit: a good charge nurse that helps out when needed, is available, and doesn't assign someone a withdrawal pt 10 nights in a row.