Nurse Retention: Turning the Tide

May-June 2010


For years, researchers have pointed to alarming statistics that warn of a shortfall of nurses — in the hundreds of thousands — while tens of millions of baby boomers are passing retirement age and facing rising health care needs. Against that backdrop, Bon Secours Richmond Health System has made it a top organizational priority to not only hire knowledgeable, compassionate and highly skilled nurses, but to also retain them. To do anything less would allow the inexperience of a new nurse, the family demands of a mid-career nurse or the physical limitations of an experienced, mature nurse steal some of our best and brightest talent.

We believe retention is crucial to our mission. To that end, our efforts are focused on five themes: support for first-year nurses; opportunities for professional development; talent acquisition; employee engagement; and keeping experienced nurses in the workforce.

The average turnover for first-year nurses nationwide was 27.1 percent in 2007, according to a PricewaterhouseCoopers Health Research Institute report. This staggering statistic affects patient care and requires organizations to relegate countless dollars to a vicious cycle of recruitment, orientation and turnover.

Investigating the issue of first-year turnover, we learned through surveys, interviews and "Six Sigma" management methodology work that the root cause tended to be a less-than-adequate orientation process for new nursing school graduates.

The evidence makes it clear that the initial orientation of new nurses is critical. During the orientation phase, the new nurse is transitioning from student to novice nurse, integrating into an unfamiliar organization and work setting and assimilating complex knowledge and skills. Placing new nurses into the clinical setting with little or no follow-up or support leaves many feeling unable to adapt or build confidence in their practice — thus they resign before the end of their first year.

First-year nurses need a source of information and encouragement when long days and difficult situations are making them rethink their employment options. Health care systems need to institute strong programs to help new nurses in their transition from dependent, uncertain student to highly qualified, independent RN.

At Bon Secours St. Mary's Hospital, Richmond, Va., the RN residency program is an essential component of support for nurses entering the profession for the first time. The full-time RN residency coordinator/retention officer oversees curriculum development and the success of each new hire's orientation experience.

Other essential parts of the program are:

  • Education. Clinical preceptors and coaches give recent graduates extensive training for the first six months. During this time, orientation focuses on gaining competency in the domains of interpersonal, technical and critical-thinking skills. This is how the new graduate is introduced to what it means to be a professional registered nurse.
  • One-on-one support. For their first two weeks of employment, recent nursing graduates partner with experienced nurses. We choose the experienced nurses for their ability to mentor and coach and give them specialized training as a "super preceptor" whose sole assignment is to work with one or two new nurses. During this time, the preceptor ensures the new graduate is proficient in basic competencies needed to practice in any area of nursing. We have found new graduates respond positively to this kind of orientation, and it has been a major factor in the reduction of turnover. The impact of this orientation is evident in that 93.4 percent of new graduates are retained after their first year.
  • Peer-group support. During class and clinical hours together, new graduates naturally form informal support networks. We nurture and foster such peer-to-peer support. The need for community and having someone who cares about them as a person are important to a novice nurse's long-term employment, confidence and professional growth.
  • Ongoing support. At a large hospital such as Bon Secours St. Mary's, it would be very easy for a new graduate to become lost in the system. Through a well-developed, comprehensive program, we have worked hard to make sure new graduates always have someone to seek out for support and guidance throughout the first year of hire.

Just as the first year of a new nurse's career provides important opportunities for retention, so do the second and third years. By this time, nurses are becoming proficient in their clinical areas and are gaining knowledge and skills. We are committed to a culture of learning to foster continued professional growth and development.

At Bon Secours Richmond, we offer numerous educational opportunities as well as tuition reimbursement. The education and development department offers dozens of classes for employees at every level within the organization. Additionally, tuition assistance is available to both full- and part-time employees earning degrees or specialized certifications.

Along with encouraging individual growth and development as an organization, we have intentionally sought to reach the pinnacle in nursing excellence with the American Nurses Credentialing Center's Magnet recognition. In the last two years, St. Mary's and Memorial Regional Medical Center have achieved Magnet status. See "Magnet Recognition: One Hospital's Journey," on page 29. This designation places our facilities among the top six percent of hospitals in the United States. To say that our nurses are proud to be part of a Magnet facility underestimates the prevailing feeling. More importantly, there is a deep desire to continue to move forward and no room for complacency.

Achievements such as Magnet designation are positive factors in our recruitment and retention efforts, but Bon Secours Richmond finds careful hiring improves retention odds. In just the last two years, the human resources department has completely revamped how it selects and screens new employees and has drastically reduced first-year turnover and vacancy rates. The average time to fill a nursing position fell from 96 days to 83 in 2008.

One of the keys in this process is a talent interview that measures not only a job candidate's values and commitment, but also his or her "fit" for a certain position. A set of questions developed by assessing Bon Secours Richmond's top employees helps us add an important element of science and predictability to our recruiting. Once a candidate moves beyond the initial talent interview, he or she then is interviewed by a manager. This system makes the most of the manager's time and also provides Bon Secours Richmond with a database of candidates who showed promise.

Along with this more scientific approach to hiring, Bon Secours Richmond also has improved recruitment by focusing on the best graduates from its college of nursing. Through the early decision program, nurses from the college can interview for positions before graduates from other schools of nursing. Those near graduation who demonstrate the greatest promise are then committed to Bon Secours Richmond before they even begin their job search.

The Bon Secours Richmond orientation program for all employees also offers a wonderful introduction to our organization. This three-day program instructs all new employees on the importance of our mission, our values and our commitment to service excellence.

Since 2005, Bon Secours Richmond has concentrated on employee engagement. We believe that when employees are engaged and committed to the mission and goals of the organization, the employees will take ownership and accountability for doing what they do best every day. This will lead to quality, service and financial success.

Over the past several years, we have partnered with the Gallup organization to measure engagement through its Q12 Survey. It uses 12 tested questions to assess how employees feel about their work and workplace. In our first year, we scored a 3.64 out of a possible 5. In 2009, that number rose to 4.52 out of 5. This placed us in the top one percent of all health care organizations surveyed by Gallup.

We promote engagement in myriad ways — through daily unit meetings called "huddles," through training by the Ritz-Carlton organization, through our unit leadership and our standards of excellence, by working to create a supportive environment for employees.

Support for mid-career and more experienced nurses reflects what's often a different set of needs. Nurses with family concerns — young children or aging parents — need scheduling options allowing them to care for their loved ones. They may want to work part-time but still need benefits. Thus, flexible schedules and benefits have become an important part of nursing retention at Bon Secours Richmond.

Flexible work arrangements allow employees to move from full-time to part-time and even to on-call status. Health care systems, with their 24-hour-a-day, 7-days-a-week schedule, provide room for this kind of flexibility. For example, we accommodate compressed work weeks when we can — four 10-hour days to allow for a day off during the week — or scale back hours to make it possible for someone taking care of a dying parent to be where they are needed most. Then, when their lives settle down, they are free to return to a more demanding work schedule. Hand-in-hand with flexible scheduling is the need for flexible benefits. At Bon Secours Richmond, any employee who works 16 hours a week or more can receive benefits.

This flexibility has led Bon Secours Richmond to be recognized on Working Mother magazine's "best companies" list for more than 10 years, making the Top 10 out of 100 in 2009. Our on-site family centers offer childcare along with programming that supports concerns of working parents and of aging employees.

A complete nursing retention effort must not ignore the needs of experienced nurses too. When we lose an experienced nurse, we lose years of valuable knowledge. When we are able to retain that employee, even on a part-time basis, we see numerous benefits for the patient, the nurse and the health care system.

At Bon Secours Richmond, we first began addressing this question of mature workers in 2003, when we pursued a benchmark application with AARP as a "Best Employer for Workers over 50." That process revealed the necessary structures other employers had in place that improved employee retention, and it helped us understand some of the reasons people choose retirement.

Our research showed nurses retire for three main reasons: Changing interests; being called on to care for aging family members or grandchildren; and the physical demands of nursing work. To address these three areas, we created a phased retirement system giving nurses the option to scale back on hours and retain benefits. We created opportunities for experienced nurses to mentor new nurses. We also created "lift teams" to assist nurses in moving patients. This removed much of the physical burden that mature nurses had listed in their reasons to retire.

We have been on the "best" list ever since 2003, and in 2009 we ranked No. 4.

In the past four years, first-year turnover for all employees has dropped from 51 percent to 16.92 percent, and two Bon Secours Richmond hospitals received Magnet recognition. Employee engagement scores have soared from 3.64 in 2005 to 4.52 (out of 5) in 2009.

What's more, by reducing new-hire turnover while maintaining a strong cadre of experienced nurses, Bon Secours Richmond has reduced costs and seen quality patient outcomes improve. Engaged, professional nurses practicing in a healthy work environment have contributed to our numerous national awards and improvements in patient outcomes.

FRANCINE BARR is vice president/chief nursing officer at Bon Secours St. Mary's Hospital in Richmond, Va.


Copyright © 2010 by the Catholic Health Association of the United States
For reprint permission, contact Betty Crosby or call (314) 253-3477.

Nurse Retention Turning the Tide

Copyright © 2010 by the Catholic Health Association of the United States

For reprint permission, contact Betty Crosby or call (314) 253-3490.