Struggling keeping nurses in my unit

racing-mom4, BSN, RN · Dec 22, 2008

Money talks--so does a good workable schedual.

Are you doing exit interviews? Why are people leaving? A little bit in my mind goes along way. Is there a level of respect with in your staff? What complaints are you hearing?

RN1982 · Dec 22, 2008

This eerily sounds like the unit I used to work on. It was a progressive care unit. Management hired nurses and then lost nurses.

You have to ask yourself, are your nurses happy? Do you have enough staff? Are your nurses working short-staffed every night? Do you have enough UAPs? Perhaps, you need to have staff meeting to discuss the problems on your unit? And I'm sure there are problems otherwise your nurses wouldn't be leaving if there wasn't one. Are you as a manager offering enough support to your nurses?

These were the same issues my manager dealt with or didn't deal with when managing our unit. In the five years I worked on that unit, at least 30 employees, nurses and CNAs, left.

Jules A, MSN · Dec 22, 2008

I think you have gotten excellent advice especially about the exit interview. From my point of view an excellent wage speaks volumes as does having enough staff on the floor. I work in psych which doesn't seem to be the most popular speciality but we get paid very well which on those inevitable hectic days sure makes it easier to swallow.

rngolfer53 · Dec 22, 2008

I am a new NM in a stepdown unit and I am struggling to keep the nurses from leaving. Our unit has had some retention issues in the past. Any advice on how to keep the nurses around? I don't want to blow my budget on agency hours.

Why are they leaving? You can change something much more easily if you know what the dissatisfiers are.

Michifura · Dec 22, 2008

The exit interview suggestion given earlier sounds great, with the feedback received you will know what to improve on for staff retention. In the unit I am currently working in, staff are leaving due to high acuity patients not enough support staff, not feeling respected or supported and not having enough resources to do job.

ANnot4me · Dec 23, 2008

In my experience, and from what you have said about staffing, I would not work on your unit. I have left jobs that paid $100,000/year because I was not happy and my job satisfaction did not enter into the equation. I have said a million times, if I can not sleep at night because of my job it is time to go. Life is too short and my conscience too sensitive to be a perpertrator of systemic, profit-based negligence (like it or not, that is what it is).

catshowlady · Dec 23, 2008

In addtion to the above, I'm wondering whether your institution does an Employee Opinion Survey? Or, if you could do your own, for your unit? Anonymity may prompt more honest answers. Fairness goes a long way for most managers, along with being willing to stick up for your staff to upper management & families.

I will second the people who are talking about quality of worklife. I would - and currently do - work for slightly less money, in order to be in a unit that values quality pt care. Not only does that enable me to live up to my own ideals/conscience regarding the care that I give, I also feel like my license is not in jeopardy every day I work. I was a PCT on a step-down unit, and you couldn't pay me enough to take 4 pts on that floor as a nurse - 9 was too many as a tech (for what we had to do - Q2H vitals, baths, dressing changes, feeds, frequent incontinence, plus, traveling as a tele monitor in the middle of everything. 7 was do-able.).

If you do have days that are short, *please* recognize the staff that pitch in or are especially overworked. It doesn't have to be much - a drink coupon, a card acknowledging the employee's hard work, a "merit award" (we have little cardinal pins). I know not everyone values these things (some folks like cold hard cash :) ), but I at least like to know that my boss knows I am working hard and am a team player. And, whatever you do, don't take your people for granted - they will get tired of sucking up being short-staffed if it happens with regularity rather than rarity.

Also, what is the "climate" like on your unit? Is it toxic? Is there backbiting between shifts/coworkers? How would your employees treat a new grad in their midst? Again, I work at a smaller hospital for less pay, in order to be in an environment that is supportive to me as a new(er) nurse (just over 1 year of experience). If your unit morale is low, what steps can you take to fix it?

nerdtonurse?, BSN, RN · Dec 23, 2008

I work on a tele/ICU stepdown unit, and I'll tell you why I'm thinking of leaving my job for another hospital -- the reason I'm still there is my boss won't let me move off the unit, and I'm trying to survive until the end of spring semester, and spend the summer orienting at another hospital:

1) We have a new NM, and her style is "my way or the highway." She told a LPN who's about to take her final semester of RN school (and this LPN wanted to take a LOA/sabbatical, which is ALLOWED by our hospital) that she was hired for fulltime work, and she could either continue to work or quit. The nurse quit. She also told a divorced nurse with 3 small kids she had to work Christmas day, despite the fact that she had experienced RNs ready to split the shift with her, and the mom was working Christmas Eve, 12 hr shift, and the NM let the mom nurse know that she'd be working Christmas day, also, on....Saturday. I mean, this woman has the social graces of a starving hyena. D/t this woman's horrible management style, we literally enough nightshift nurses to fill only 5.5 days of a given week. So, my suggestion....the exit interview's good, but too late. Meet with your folks NOW and find out if there's "human factors" between nurses, assistant NM and the floor, or something. And that's all shifts.

2) Our acutity is everything from "near syncopy" that should have never went to the ER to "acute CVA's" that should be in the ICU. Problem is, the other floors and ICU will close when they don't have enough nurses. The reason 5 -- yes, FIVE -- of our best charge nurses all left for other units is that our NM won't let us say, "we don't have enough nurses" while every other floor in the hospital can. So, we get more than we can handle. The last night I worked, I had 3 bolus peg feeders, 2 q2h turns, one ortho with q2h cast checks, one trying to die from sepsis who I was suctioning about every 30 minutes (sinus tach in the 130's to 140's all night), a person with acute CVA who was completely disoriented and progressively lost the ability to swallow overnight, and when I go back, I'll probably have 4 pegs because of it. We had one CNA (she's ran those off, too). I've had as many as 8 patients, when with their acuity, I should have only had 4 to do the job safely. Look at your acuity, your staffing, and the way patients are allocated on your floor versus others. If the nurses are leaving for one particular floor or patient area, find out what they're doing right and copy it! Empower your nurses to say "no" to preserve patient safety.

3) Favoritism. On our floor it's blatant and obvious. One of the brown nosing nurses that's the scariest to follow (thinks nothing of not hanging pre-abdominal surgery antibiotics, and doesn't get in trouble for it, me, they'd fire me....) was bragging about her 1.25 raise. My charge nurse, who's good but not a brown noser, only got a quarter. Both RNs, the brown noser is 1 year out of school, the nightshifter that got a quarter is out of school 3 years. Everyone likes some folks better than others, and others you'll never be close to, but don't make it very, VERY obvious that sweeping the misdeeds of "favorites" under the rug is rewarded, and filing an incident report is grounds for retribution.

4) Time in title. At least, that's what we used to call it in the computer world. You could have every initial in the world behind your name, but if you hadn't had experience, your effectiveness was limited. Because we've lost so many of the experienced nurses to other units, the NM stopped laterals, and so now they are just quitting. We don't have the on the floor knowledge base that we need to have. I've worked nights where my charge has never even been IN a code, the other nurses have even less time as a nurse than I do, and I spend the night running the ACLS protocols thru my head because no one else was ACLS certified on shift! And it's showing in patient care. I had a patient that I got report on "multiple runs of v-tach, unstable heart rate, etc." I go in to do my assessment, thinking "ok, this one's going to be the one that codes" -- and I find they've put the monitor lead right over this woman's pacemaker. I put the leads in the right spots, and the pacer strikes start showing up and the rhythm is nicely stable with only the occassional vent pacer strike. I've also patients that were NPO, but no one on the prior shift "noticed" the patient's PEG tube, brought it to the doc's attention that he needed to write orders for Glucerna or Jevity or whatever. This woman had been in the hospital 2 days without anything but IV fluids (1/2 NS, no LR, no D5).

Finally....I wish I worked for someone who would actually ask what was wrong. It would never occur to the one I work for. That, in and of itself, gives me hope for your unit. I'm about to have my review, and I literally don't have any clue what this woman's going to tell me, and given what I've seen, I'm expecting the worst, and maybe a nickel raise if I get that. When I had folks working for me, we had quick 5 minute "touching base" meetings quarterly, about a 15 minute meeting at mid year, more if there were problems, of course. If I saw someone looking stressed in the hallway, I stopped and asked what was wrong, rather than running in the other direction. Point is, everyone knew what was going to be said at their review, to the point it was just a formality. I'm expecting a blood bath. Make sure your folks can't have that feeling.

Good luck.

newohiorn, BSN, RN, EMT-P · Dec 23, 2008

Like others have said, I suppose you need to ask your current staff what problems they believe the unit has.

Here are my thoughts on what I want in a nurse manager:

Be honest, fair and up front with me. Don't play favorites, don't blow smoke, tell me like it is and I will do the same with you.

Respect. I appreciate it when my boss knows that I'm dependable and a hard worker and, frankly, I appreciate it when the manager runs a tight ship and doesn't let the slackers get away with murder.

I don't need a friend--I need manager. If we can be friends that's a bonus but not necessary. I want to know my manager has my back when the docs are being unreasonable and shifting blame to nurses when it is not warranted.

Keep the staffing safe so (as someone else already said) I can sleep at night.

Try to accommodate scheduling as much as reasonably possible so we can have decent home lives.

Just my 2 cents.

RN1982 · Dec 23, 2008

I work on a tele/ICU stepdown unit, and I'll tell you why I'm thinking of leaving my job for another hospital -- the reason I'm still there is my boss won't let me move off the unit, and I'm trying to survive until the end of spring semester, and spend the summer orienting at another hospital:
1) We have a new NM, and her style is "my way or the highway." She told a LPN who's about to take her final semester of RN school (and this LPN wanted to take a LOA/sabbatical, which is ALLOWED by our hospital) that she was hired for fulltime work, and she could either continue to work or quit. The nurse quit. She also told a divorced nurse with 3 small kids she had to work Christmas day, despite the fact that she had experienced RNs ready to split the shift with her, and the mom was working Christmas Eve, 12 hr shift, and the NM let the mom nurse know that she'd be working Christmas day, also, on....Saturday. I mean, this woman has the social graces of a starving hyena. D/t this woman's horrible management style, we literally enough nightshift nurses to fill only 5.5 days of a given week. So, my suggestion....the exit interview's good, but too late. Meet with your folks NOW and find out if there's "human factors" between nurses, assistant NM and the floor, or something. And that's all shifts.
2) Our acutity is everything from "near syncopy" that should have never went to the ER to "acute CVA's" that should be in the ICU. Problem is, the other floors and ICU will close when they don't have enough nurses. The reason 5 -- yes, FIVE -- of our best charge nurses all left for other units is that our NM won't let us say, "we don't have enough nurses" while every other floor in the hospital can. So, we get more than we can handle. The last night I worked, I had 3 bolus peg feeders, 2 q2h turns, one ortho with q2h cast checks, one trying to die from sepsis who I was suctioning about every 30 minutes (sinus tach in the 130's to 140's all night), a person with acute CVA who was completely disoriented and progressively lost the ability to swallow overnight, and when I go back, I'll probably have 4 pegs because of it. We had one CNA (she's ran those off, too). I've had as many as 8 patients, when with their acuity, I should have only had 4 to do the job safely. Look at your acuity, your staffing, and the way patients are allocated on your floor versus others. If the nurses are leaving for one particular floor or patient area, find out what they're doing right and copy it! Empower your nurses to say "no" to preserve patient safety.
3) Favoritism. On our floor it's blatant and obvious. One of the brown nosing nurses that's the scariest to follow (thinks nothing of not hanging pre-abdominal surgery antibiotics, and doesn't get in trouble for it, me, they'd fire me....) was bragging about her 1.25 raise. My charge nurse, who's good but not a brown noser, only got a quarter. Both RNs, the brown noser is 1 year out of school, the nightshifter that got a quarter is out of school 3 years. Everyone likes some folks better than others, and others you'll never be close to, but don't make it very, VERY obvious that sweeping the misdeeds of "favorites" under the rug is rewarded, and filing an incident report is grounds for retribution.
4) Time in title. At least, that's what we used to call it in the computer world. You could have every initial in the world behind your name, but if you hadn't had experience, your effectiveness was limited. Because we've lost so many of the experienced nurses to other units, the NM stopped laterals, and so now they are just quitting. We don't have the on the floor knowledge base that we need to have. I've worked nights where my charge has never even been IN a code, the other nurses have even less time as a nurse than I do, and I spend the night running the ACLS protocols thru my head because no one else was ACLS certified on shift! And it's showing in patient care. I had a patient that I got report on "multiple runs of v-tach, unstable heart rate, etc." I go in to do my assessment, thinking "ok, this one's going to be the one that codes" -- and I find they've put the monitor lead right over this woman's pacemaker. I put the leads in the right spots, and the pacer strikes start showing up and the rhythm is nicely stable with only the occassional vent pacer strike. I've also patients that were NPO, but no one on the prior shift "noticed" the patient's PEG tube, brought it to the doc's attention that he needed to write orders for Glucerna or Jevity or whatever. This woman had been in the hospital 2 days without anything but IV fluids (1/2 NS, no LR, no D5).
Finally....I wish I worked for someone who would actually ask what was wrong. It would never occur to the one I work for. That, in and of itself, gives me hope for your unit. I'm about to have my review, and I literally don't have any clue what this woman's going to tell me, and given what I've seen, I'm expecting the worst, and maybe a nickel raise if I get that. When I had folks working for me, we had quick 5 minute "touching base" meetings quarterly, about a 15 minute meeting at mid year, more if there were problems, of course. If I saw someone looking stressed in the hallway, I stopped and asked what was wrong, rather than running in the other direction. Point is, everyone knew what was going to be said at their review, to the point it was just a formality. I'm expecting a blood bath. Make sure your folks can't have that feeling.
Good luck.

Wow, your job sounds like a nightmare. Please find another job. What you are describing sounds exactly like my progressive care job except we didn't have LPNs. The patient care was suffering, moral was suffering. My friend who had moved in from another state and worked on the same unit as me until I finally resigned, she was pulled into the office because of her "negative attitude" when she was really just pointing out the things that could improve with the unit. There was tons of brown-nosing, though no matter how much I brownnosed by working extra shifts to fill their schedule gaps which there was many, when it came time for my evaluation, it was bad. Other nurses who blatantly sucked up to management had better reviews as did the nurses who had been on the unit for less time. One nurse who had only been there for a year had an excellant review, but not me the nurse who had been there for 2 and a half years. I was relieved when I left like it was a big weight taken from my chest. I just knew that if I stayed at that job any longer, I was gonna crack.

My exit interview which was a form I had to fill out was long and scathing. Since my departure, my then NM left to be replaced by a tyrannt of an NM who is alienating all of the staff. She pulled out 3 months of my friend's charting to point out some very small documentation error, a reassessment of pain. Now they are very short staffed so assistant managers and the unit manager have all had to start taking assignments. Can't use agency nurses because of the budget.

And I'm in agreement, when nurses are leaving a unit in mass exodus, administration needs to be looking into "why".

nursemike, ASN, RN · Dec 23, 2008

I am a new NM in a stepdown unit and I am struggling to keep the nurses from leaving. Our unit has had some retention issues in the past. Any advice on how to keep the nurses around? I don't want to blow my budget on agency hours.

My facility has recently openned a dedicated stepdown unit. Before that, stepdowns were attached to several different units. That's still the case with cardiac stepdown and with neuro/neurosurg (where I work). I like the way it is on my unit, because even though I'm coming to prefer stepdown, I like the variety of rotating between floor and stepdown assignments.

Both the stepdown unit and the (relatively new) cardiac stepdown have had their problems with staffing, so I have been floated to both. In both cases, I think a fair part of the problem has been that as new units, they have had to do a lot of hiring from outside the facility, including a lot of new grads. New grads in stepdown have a lot of the same challenges as new grads in ICU, and while a lot of them meet the challenges, some don't. There's a certain amount of turnover built-in, just by the circumstances. It also leads to shifts when all of the staff is pretty green, which adds a lot to the stress levels. And a lot of shifts where there isn't enough staff to allow for a "free" charge--the CN has to take an assignment, along with doing charge, so they aren't as available to back up the other nurses. Finally, since our dedicated stepdown is new (in a new wing) with lots of fancy equipment, on my couple of visits, there, it looked to me like a lot of their patients could have easily been ICU status.

So, based on what I've seen, I think it's important to have safe ratios. At my facility, stepdown is 3:1, and that seems about right. Cardiac actually takes 4:1 fairly regularly, and that isn't terrible, because usually one or two of them seem to be about ready to move to floor status. But 3:1 is a lot better. More than that, and I don't see how you can really call it a stepdown--it's acute care, with tele. After that, I think you need a good mix of experienced and new nurses. If there's anyway to ensure that each shift has at least one nurse who has been there, done that, and is willing to mentor a bit, that would be a huge plus. That's often the case on my floor, and stepdown is a lot less scary when there's someone around who knows what they're doing. And it's probably a huge plus if your sharpest nurses can do free charge, so they aren't tied up pulling their own people out of the jaws of death while you're trying to figure out why an art line won't read. (Even a not-so-experienced free charge is in a better position to back-up another nurse, and maybe see that, hey, this one needs to go to the unit, or maybe, hey, look, this lead's off.)