How Work Environment Impacts Retention

How Work Environment Impacts Retention

Kate Christmas, RN

Nurs Econ. 2008;26(5):316-318. ©2008 Jannetti Publications, Inc.
Posted 12/02/2008
Introduction

Nurses hold lives in their hands. The best incorporate art, science, experience, and intuition to advocate for the patients in their care in a human and humane way. They play a very complicated and critical role within our health care system. It is not surprising that the public rates nurses near the top of the list when surveying trusted professionals.

We may sometimes lose sight of the amazing work that nurses perform as second nature, and become complacent about turnover issues. But increasingly, health care organizations are developing and implementing strategies to retain the valuable nurses they hire.

There is a realization dawning that this nursing shortage is different from previous ones, and that it is vital to focus more resources to keep the nurse workforce invested. Driven largely by research of the past decade, leaders are also appreciating that nursing is more demanding and multifaceted than it has ever been, and that demands on these professionals continue to increase due to patient acuity, changes in reimbursement, access to care, and technology.

In reality, a combination of factors may be brewing into a perfect storm that will once and for all focus efforts on retention. Faculty shortages, capacity issues, RN and advanced practitioner scarcity, and a rapidly aging workforce are just the beginning. As Baby Boomers age, their sheer numbers will change the health care system just as they have impacted everything from the toy industry to the educational system. Things are not going to get easier any time soon.

Despite a slowing economy, health care continues to boom, and nursing shortages are slated to persist through the next 2 decades. Expected demand for RNs will continue to grow 2% to 3% each year. In addition, during the next decade, the number of people aged 65 and older will increase twice as much as will the U.S. population at large (Buerhaus, Staiger, & Auerbach, 2009).
The Day-to-Day Influence on Retention

Dissatisfaction with management, scheduling difficulties, and departmental relationships are all contributors to turnover. But an even more subtle influence is the tone of any workplace, often referred to as work environment.

Work environment is a major aspect of the day-to-day grind that drives the retention (or turnover) of RNs. In hospitals, many factors influence this, such as staff relationships, the patient population, nurse to patient ratio, unit geography, and documentation.

Many nurse leaders have had the experience of seeing a shift or unit become unstable when one key staff member leaves the department. The departure of any linchpin can create an exodus within a formerly solid work group, as co-workers evaluate their own options in light of personnel changes. These friendships provide one of the most enduring support systems in the hectic world of health care, and can be one of the most positive influences on the work environment.

Relationships can also have a negative impact. If peer behavior is threatening, isolating, or hostile, then this negativity can also drive turnover. Recent studies and the Healthy Work Environment initiative by the American Association of Critical-Care Nurses address how behavior and communication among peers must be as blameless and outstanding as are clinical skills (Ulrich et al., 2006).

Patient population has an impact, as no matter where you look throughout the U.S. health system, patients are of much higher acuity and care is increasingly complex. From the tiniest preemies to the frail elderly, nurses are coping with complicated populations, and with the exception of work areas like the operating room or some ICU patients that are one-on-one, nurses must juggle multiple high-need patient situations (Fagin, 2001).

Nurse/patient ratio has received a lot of attention in the past decade with programs like Magnet® designation, acknowledging that ratios must be manageable to provide adequate patient care. Research from Linda Aiken and her team demonstrated that staffing ratios not only impact patient outcomes, they directly influence the likelihood of patient mortality (Aiken, Clarke, Sloane, Sochalski, & Silber, 2002).

As to geography, it is true that the physical unit layout greatly affects how much walking each RN must do during each shift. Older facilities often have long halls and centralized storage areas that necessitate more hikes for staffers. And many organizations are implementing lift teams or installing equipment to ease the strain on nurses' necks, backs, shoulders, and arms. Otherwise, older nurses and heavier patients can translate into costly injuries.

In addition, the availability of necessary equipment in each work area and ease in locating it are among the top things that will influence workflow and nurse satisfaction. Most hospital settings have traditionally had meager storage capacity on each unit, and many organizations are simply not realistic in evaluating how much equipment is required, leaving nurses to scramble for the tools they need to get things done.

A recent study of more than 700 medical-surgical unit nurses showed that each RN spent on average 6.6% of a 10-hour shift (over 35 minutes) engaged in wasteful "hunting and gathering" behaviors. How sad to allot this time on activities that could be resolved with the proper technology.

For RNs, time spent on documentation is a top source of dissatisfaction, with hours exhausted in making sure records are kept up to date. In the same recent study of hundreds of medical-surgical nurses, documentation accounted for more time per shift than any other nursing activity (Hendrich, Chow, Skierczynski, & Lu, 2008).

Most health care organizations are moving to electronic health records, and computer charting is considered cutting edge. One issue is how to customize records and data in ways that work in every unit from the emergency department to the operating room. However, inefficiencies exist, and other solutions should be generated to reduce time spent in documentation and to improve workflow.

Add to these factors a health care system working full-tilt with an extremely ill patient population, a matrix of caregivers, and ever-shortening patient stays, and it is easy to see why the work environment is challenging, and why it is a chief contributor to turnover.

With ever-shrinking reimbursement, MDs are pushed to reorder their work priorities to include extended office hours or additional block time in surgery, often leaving the RN struggling to find ways to resolve pressing problems for the patients in their care due to lack of availability of the responsible physician.

It is easy to understand how the RN can begin to develop a mentality of "us against them" when just covering the basics becomes a daily hassle. Distractions like these can have a direct effect on individual and team morale and, of course, patient outcomes. The RN is expected to coordinate care, not just provide it, and doing so in this complex and fast-paced arena can be like jumping off a cliff every shift — parachute optional!
"You Had a Bad Day"

That catchy song by Daniel Powter was a hit because it resonated! Anyone can have a bad day at work. If you have been in the workforce for awhile, it is likely that you have had your share. But when every workday is negative, you are on a slippery slope, and it is human nature to seek another situation. When opportunities abound, it is easy to jump ship, and when turnover begins, it is usually the best and brightest who are first to depart.
New Graduates

Another group that turns over quickly are the most vulnerable: the novices. There are data to show that work environment chaos has an extremely negative impact on new graduate nurses, who, in addition to being on a steep learning curve, are terrified of inadvertently harming — or even killing — patients. Most new graduates have had limited experience in handling a full patient load, and the ability to multi-task and triage priorities is a skill every successful RN must possess. It is arguably not learned in college, and comes with time and experience. Compound this with the time it takes to locate equipment or coordinate care and it is easy to understand how quickly they can become disenchanted and decide that leaving is their only option.

It is disheartening to hear new RNs describe feeling unsupported, overwhelmed, and "hung out to dry" as they enter the workforce. And it is more than just hearsay. Recent research reported a whopping 27.1% average voluntary turnover rate among new graduate nurses during their first year of employment (Isgur, 2008).

Many of these new graduates do not just leave the position; they leave the profession. This is an extreme loss that must be corrected. Perhaps we should consider changes to the educational process itself, to assess how well prepared our new nurses are to meet the myriad challenges they will find in any workplace.

Most U.S. nursing programs are struggling to find adequate faculty or sufficient clinical placements, and almost all turn away qualified students because of capacity issues (American Association of Colleges of Nursing, 2008). Most states regulate the number of patients that can be managed by one RN instructor, necessitating very limited patient assignments throughout the college experience, as one instructor oversees six or eight students in a clinical setting.

For a new grad who becomes accustomed to managing two patients during college clinical rotations, the transition to facilitating care for three or four times that number on the first shift at work is shocking, and even overwhelming. When lives are at stake, the large numbers of new graduates that turn over within the first year are almost predictable.

Universal adoption of nurse residency programs would offer a safe and structured way for nurses to master the skills they need to succeed. Many organizations are offering such residencies, and some state boards are considering making residency a mandatory part of the transition from education to work. Although they do add cost, if retention increases as a result, the money spent is worthwhile. Having students leave the profession entirely after a 2 to 5 year college experience is a costly waste of resources, capacity, and time (Keller, Meekins, & Summers, 2006).
Mature Workforce Issues

Aging of the nurse workforce may be the largest factor impacting health care work environments, as employers struggle to diminish the physical effect of lifting thousands of pounds and walking several miles during each shift. Ever popular 12-hour shifts are being reconsidered and greater flexibility in scheduling, as well as innovative work roles, are coming to the fore (Robert Wood Johnson Foundation, 2006).

The natural physiological changes that aging brings should be factored into the work environment, even as the wisdom gained over decades of experience should be treasured. Many organizations are looking at tenure across shifts to ensure that unseasoned workers have the resources, counsel, and depth of assistance they need when caring for complex patients.
Building Boom for the Boomers

The U.S. hospital industry is on a virtual spree to replace outdated structures and to accommodate technological advances. Much of the U.S. health care infrastructure was built more than 60 years ago. As new surgical suites, units, towers, and hospitals are constructed, it would be smart for organizations to not only improve design for patients, but to also take into account the changing needs of the workforce. Designs that incorporate ergonomic and technologic advances that make working easier for the caregiver should be created. Those institutions that incorporate evidence-based design, which considers patient safety, flexibility of use, and work efficiency may literally save lives and lower workers' stress levels.

The Baby Boomer generation will be accessing the system in record numbers, and many of the design changes are aimed at making their hospital stays better by allowing them to access the Internet and control their surroundings. And we are not just talking bed and TV controls, but other innovations such as window shades, room temperature, and lighting; even access to dietary requests that can be performed without leaving the bed. These innovations will also hopefully lower the burden on the average RN by empowering patients and promoting them to take a more active role in their care (Carpenter, 2006).
Summary

In short, every influence on the work environment (management, peer behavior, patient acuity, equipment availability, the physical plant) should be assessed for impact on the workforce. Even when things are going well, there is always room for improvement.

While we cannot hope to create paradise in each work setting, we can promote an environment that is healing both to patient and to caregiver. This holistic thinking put into action will result in retention and hopefully translate to improved patient satisfaction and better clinical outcomes.

This Boomer is hoping for sharp, engaged RNs at the bedside when the time comes that she needs them!
References

1. Aiken, L.H., Clarke, S.P., Sloane, D.M., Sochalski, J., & Silber, J.H. (2002). Hospital nurse staffing and patient mortality, nurse burnout and job dissatisfaction. JAMA, 288(16), 1987-1993.
2. American Association of Colleges of Nursing. (2008). Nursing shortage fact sheet. Retrieved July 2, 2008, from http://www.aacn.nche.edu/Media/FactSheets/NursingShortage.htm
3. Buerhaus, P.I., Staiger, D.O., & Auerbach, D.I. (2009). The future of the nursing workforce in the United States, data, trends and implications. Boston: Jones and Bartlett Publishers.
4. Carpenter, D. (2006). The boom goes on. Technology and consumer demands keep driving construction and renovation. Health Facilities Management, 19(2), 31-36, 38, 40.
5. Fagin, C.M. (2001). When care becomes a burden: Diminishing access to adequate nursing. New York: Milbank Memorial Fund.
6. Hendrich, A., Chow, M., Skierczynski, B., & Lu, Z. (2008). A 36 hospital time and motion study: How do medical-surgical nurses spend their time? The Permanente Journal, 12(3).
7. Isgur, B. (2008). What works: Healing the healthcare staffing shortage. Presented at National Conference of Nursing Workforce Leaders, June 11, 2008, Denver, CO.
8. Keller, J.L., Meekins, K., & Summers, B. (2006). Pearls and pitfalls of a new graduate academic residency program. Journal of Nursing Administration, 36(12), 589-598.
9. Robert Wood Johnson Foundation. (2006). Wisdom at work: The importance of the older and experienced nurse in the workplace. Princeton, NJ: Author.
10. Ulrich, B.T., Lavandero, R., Hart, K., Woods, D., Legget, J., & Taylor, D. (2006). Critical care nurses' work environments: A baseline status report. Critical Care Nurse, 26(5), 46-50, 52-57.


Sidebar: Executive Summary

Work environment is a major aspect of the day-to-day grind that drives the retention (or turnover) of RNs.

When opportunities abound, it is easy to jump ship, and when turnover begins, it is usually the best and brightest who are first to depart.

Recent research reported a whopping 27.1% average voluntary turnover rate among new graduate nurses during their first year of employment.

Aging of the nurse workforce may be the largest factor impacting health care work environments, as employers struggle to diminish the physical effect of lifting thousands of pounds and walking several miles during each shift.

Every influence on the work environment (management, peer behavior, patient acuity, equipment availability, the physical plant) should be assessed for impact on the workforce.

While we cannot hope to create paradise in each work setting, we can promote an environment that is healing both to patient and to caregiver.