Experienced nurses are leaving the ED at a quicker rate than their peers decades ago. Although docs aren’t on the front lines in recruiting nurses, they do play an important role in keeping them. Here’s how to keep them in your ED longer.
It seems like just about every shift we are down several nurses, which has a terrible impact on our ability to deliver safe and effective care. This is incredibly frustrating. We’ve been short-staffed on the physician side in the past and always find a way to fill the shift. Any suggestions on how to fix the RN staffing problem? I’m almost ready to give up…
Nurse staffing has had its ups and downs over my entire career. I’ve seen agency use soar and then plummet when hospitals found other solutions to hire nurses. As I’ve always said, it’s easier and cheaper to retain someone than it is to recruit and train a new person. While it’s hard for us to play a significant role in nurse recruitment, we definitely make an impact.
Even though the HR mantra may be employees leave “their boss” and not necessarily their job, EPs can play a big role in nurse satisfaction and retention even without directly being the boss.
ENDURING THE SHORTENED EXPERIENCE CYCLE
There is a growing need for nurses because of the aging population. Some have referred to Baby Boomer impact on healthcare as the “Silver Tsunami.” Additionally, it’s estimated that one-third of the 2.8 million nurses and approximately 1 million working physicians will retire in the next decade. The Bureau of Labor and Statistics predicts the nursing shortage will continue until 2025 when the supply of new nurses will catch up to the demand.
When I started working, it was pretty common to have an ED full of nurses with 15-20 years of experience. I remember several of them leaving the ED to go to the PACU at the same time because they felt like they had spent their adult life in the ED and were ready for an easier day-to-day job. Now, it feels that nurses who stay in the ED for five years are our most experienced.
Nurses today have more opportunities for better money and work life balance than nurses 20 years ago and are leaving bedside nursing quicker than before. I just interviewed two of our nurses who are completing their NP programs and want APP jobs in our ED. Neither of them have more than five years of nursing experience. I contrast this to the first NPs I worked with when I started my career that had been ED bedside nurses for 30 years.
I’ve also heard discussions about millennials switching jobs more quickly than other generations or leaving a job for a $2/hour raise at the next hospital over. However, data shows that millennial nurses leave jobs at the same rate of Gen Xers and that millennials and Gen Xers have similar rates (about 22%) of staying five years in a position.
Nursing shortages compound other problems. There may be higher nurse to patient ratios, an increased demand for overtime and more burn out. This combination frequently contributes to call outs, which only exacerbates the potential burnout problem. Nurse shortages typically puts hospitals in the position of offering more money to recruit, but at some point, the money has to top out (we see this with physician shortages as well) and hospitals refocus on building teams. The logic goes that if you have a great team and a great boss, people won’t leave for $2/hour more.
MOTIVATION FOR MILLENNIAL HIRES
Millennials enter the nursing profession at twice the rate of the previous generation and are quickly making up a large percentage of the nursing work force. Therefore, a lot of our recruitment and retention strategies require a good understanding of millennials.
There are a couple of significant differences when managing millennials compared to other generations. Although we typically don’t manage them directly, we can certainly provide input to our nurse manager. Millennials want frequent feedback. One survey found that millennials want feedback 50% more frequently than other generations. Much of this will fall to nursing leadership, but we can and should be taking opportunities after interesting or tough cases to give feedback.
Millennials also want to be part of something bigger than the individual. Working in an ED often leaves us with the feeling that it’s us against the world and that’s great for building a team. Interestingly enough, this is no different than what the chairman of a residency program said to me when I was a fourth-year med student during the match process. He said, “You’ll have few opportunities in life to associate yourself with greatness, so you shouldn’t pass this one up.”
Being a part of something bigger than yourself tends to resonate with all of us and as a department leader, it’s important to make sure everyone working in the ED understands the mission, values and purpose of our work home.
Additionally, millennials want to align their personal mission and goals with an organization’s mission and sense of purpose, even to the extent of sacrificing money for purpose. Does this mean there’s an opportunity for nurses to do mission trips associated with the hospital or even participate in community health fairs?
BOND BUILDING BUFFERS
While perhaps not intuitive, your interactions with your nurses in the ED greatly impact how they feel about the workplace. This impacts the quality of care patients receive and nursing retention. Research suggests that the daily interaction between nursing and physicians impacts morale.
Not surprisingly, there also appears to be a link between disruptive physicians and nurse satisfaction and retention. The advice I’ve shared before from Professor Robert Sutton on not hiring “assholes,” likely has a greater impact on nurse retention than it does on physician retention.
The relationship with nurses has also changed over the last 20 years. There are two big differences. First, the EMR has allowed me to click away at orders, including typing nursing orders like “ambulate hallway and check pulse ox.” In many ways, it’s eliminated the need, or at least significantly decreased the need, to talk to our nurses. Also, in the pre-CPOE days, at least once every other shift nurses would have to talk to me to ask me what my order said. Mostly, they were laughing at my bad handwriting or because I wrote for a med like ibuprofen IV by mistake. But having them laugh at me was good for bonding and for them seeing me as human.
Not only do we not really have to talk to the nurses any more, instead of sitting next to them, we now have a new body between the nurse and us. And that’s the scribes. In the pre-scribe era, when the ED was quiet, we’d sit around and tell stories with the nurses. While it’s probably a little less quiet in the ED now than it was years ago (ED visits are up nationally and we have fewer EDs), when I have free time now, I’m usually talking to my scribe about college, why they’re a scribe or the med school application process. While I love having a scribe, there’s no way this hasn’t impacted our relationship with the ED nurses.
CONNECTING BUILDS CONNECTIONS
There’s a lot we can do as doc leaders and bedside clinicians to positively impact nursing retention. Patient care relies on collegial partnership with each person doing his or her job to maximize the care the patient receives. We have to partner with nursing to achieve success. This means being more collegial, getting rid of the historical hierarchy and treating them as professionals. Millennials want to know the “why” and what they need to look out for in critical patients, so there’s plenty of opportunity for teaching.
Some of this needs to occur in real time at the bedside while sometimes it can occur after the patient leaves. Also, engage with nursing staff meetings to do short educational reviews on topics like toxicology, EKG interpretation, pain management and sepsis. Make it educational and fun, but don’t be condescending.
We have to take responsibility for the behavior of our docs. Establishing the culture of professionalism starts during our own recruitment process and then continues with occasional reminders at staff meetings. Getting feedback from nurse leadership is critical as is providing the appropriate counseling to docs who aren’t acting with the desired behavior. Conducting 360-degree evaluations provide opportunities for individual nurses to give specific examples of good and bad behavior.
On the positive side for doc behavior, we need to be sure we’re treating our nurses as professionals and teammates. Nurses have saved us all so we shouldn’t blow off their opinions on patients, but rather we should ask for their opinion. I’ve walked out of plenty of rooms through the years and felt like I was missing something. I’ve been glad when I’ve had an experienced nurse who I can ask ‘what am I missing?’ and who either fills in the gaps in the history for me or validates that I’m overthinking the case.
Docs who are well liked by my nurse team also have the human touch and enough social awareness to ask if someone is okay after a code or a traumatic case. I think we can do more than say “thank you” as we finish our shift (and this is a must do if you’re not doing it). My nursing director and I are trying to get creative with ways to thank and recognize staff and are using hand written thank you notes.
A former colleague of mine used to send everyone a handwritten note at the end of the year along with a lottery ticket. The staff loved him for the way he recognized them and everyone bonded over who won money in the lottery. It’s equally important to recognize when you’re being a jerk and apologize for it the next day.
As an added perk, food is always welcome, but needs to be in addition to being a good teammate. Buying pizzas for the staff on a particularly bad day (pediatric codes, heavy boarding) is an easy way to show your appreciation as is showing up to your shift with donuts or cookies.
Sponsoring events such as a staff holiday party and lunches during nursing week is best handled through an annual budget but is yet another opportunity to show your appreciation for staff. There are also groups who recognize ED staff with awards (ranging from monthly to quarterly to annually) and still others who sponsor educational scholarships. These definitely require budgeting and in my opinion, are worth the small amount that wouldn’t get rolled into physician salary or group profit.
Duke University basketball Coach Mike Krzyzewski says “teamwork is the beauty of our sport, where you have five acting as one.” The ED runs at its best when each member of our team is showing up to work and doing their part. Having a full compliment of nurses is critical to an effective ED. Although nursing shortages may continue for several years, physicians have an important role in helping with nurse retention.
We need to work with our physician teams and with our nursing leadership to bring a team approach to staff retention. Ultimately, this improves the quality of care that we provide and makes for a more enjoyable work environment.