Nursing Staff Turnover


            Continuous quality improvement efforts require team learning, and leading empowered teams is crucial for healthcare reform. However, team learning takes time and effort, which can be disrupted by departure of trained staff and their replacement by people who may possess basic skills, but who are not familiar with the team’s specific ecosystem. Since people’s lives change, though, some turnover is unavoidable. And being realistic, some people will turn out to be bad fits for the job. The issue, then, is not zero turnover, but turnover at a rate that does not disrupt team function. Do we have any evidence as to what this might be?

            The Johns Hopkins Comprehensive Unit-Based Safety Program, or CUSP[1] publications emphasize that the program reduces unit turnover,[2] but analysis across multiple units suggests performance on the clinical safety survey starts to degrade once turnover exceeds 12% annually. This group emphasizes that turnover includes all members of the team, not just the RN’s, although for this discussion I will focus only on the latter.

            Nursing turnover has been a problem for years. A recently published survey of 113 hospitals showed that the 2013 turnover rate was 16.5%, up from 14.7% in 2012, while bedside RN turnover increased from 13.1% to 14.2%.[3] The lowest rate for RN turnover shown in the report was for 2011, when it was 11.2%. The author notes:

            When the labor market tightens, hospitals have historically sought to bridge the gap by utilizing overtime, agency staff and travel nurses. All of which are costly strategies and can lead to issues with quality, safety, physician satisfaction, employee satisfaction and the patient experience.

            The detailed breakdown of RN turnover shows different units experienced different rates of turnover in 2013. Surgical services turnover was the lowest at 10.7%, while the emergency room (20.3%), step-down units (22.9%) and Med/Surg nursing units (24.0%) were the highest rates reported. These data suggest that virtually none of these latter three areas has the ability to develop a sustained safety culture. I will explore why turnover is probably lower in the operating room than on general medical-surgical wards later.

             Turnover has a significant impact on costs. One study from 2007 reported RN turnover cost an average of $36,567.[4] Interestingly, none of the costs identified included the costs of impaired unit performance. In another analysis from 2009 decreased quality of care was noted.[5] Recent studies have emphasized high turnover rates are associated with poorer safety cultures and poorer patient satisfaction.[6] A study of 96 nursing units showed an independent association of nursing management of the unit, social capital, emotional exhaustion, and depersonalization with the outcome variables of job satisfaction, turnover intentions, quality of care, patient and family complaints, patient and family verbal abuse, patient falls, nosocomial infections, and medication errors.[7]   

            The issue has not gone un-noticed by hospital and nursing service administrators. HR leaders have identified issues that cause people to stay or to leave. Units that have low turnover have favorable perceptions of the work environment, workload, decision latitude, and low levels of burnout.[8] Senior administrators have focused on finding the right unit manager, a process that to me seems akin to a sports club with a losing record changing the manager, but none of the players, in hopes that somehow the team will start to win. Practicing physicians are aware of turnover, particularly when a nurse they have come to trust decides to leave and they have to start working with an unknown individual.

            I want to examine what can be done to reduce turnover from two viewpoints:  administrative and physician. There is overlap to be sure, but also some important differences. However, I need to point out that there are good data showing a significant difference between staff perceptions and those of physicians and administrators about how things really are.

            The Medicare Quality Improvement Organization (QIO) of West Virginia assessed the safety culture of 29 hospitals (out of 34 in the state) on two occasions using the AHRQ Hospital Survey on Patient Safety Culture.[9] There were 1,967 responses from 29 hospitals in the original survey, and 1, 717 responses from 26 hospitals in the second survey. In the baseline survey, 661 respondents (33.6%) were non-physician providers and 333 (16.9%) were administrative/management staff. On the second survey 578 (33.7%) were nursing staff, and 225 (13.1%) were management. Only two physicians participated in the original survey and only six at the second survey. The remainder were clerical and ancillary support staff. The responses on both surveys tracked the AHRQ benchmark.

            The authors note several dimensions in which the perceptions of staff differed significantly from management.  In each of these areas, management perceptions were significantly more positive than staff perceptions. The first was “non-punitive response to error.” At baseline, administration perception was more positive by 12.7%, and on repeat had increased to 17.6%. This was also the lowest ranked by nursing, with only 36.1% giving their units a positive response. I am reminded of a recent meeting with management at my hospital where the administrators used the term “accountability” in regard to a safety issue. I felt compelled to point out this was a management term; what staff heard was “who was going to be blamed?” Now our administrators are good people who mean well. Consequently, they found it hard to believe I was giving honest feedback. Private conversations with several of the physicians, though, suggest their perception is similar to mine. Of course, administrators could make the same points about us as physicians and we would find it equally hard to credit.

            Second was “communication openness,” a measure that gauges the staff’s sense they are free to speak up and question those with more authority. Here again administrators were 11.5% more positive than staff at baseline, and this increased to 14.1% at the second survey.

            Third was teamwork across units. Initially, the positive gap of administrators compared to nurses was small at 4.2%, but increased to 9.6% on the second survey. Since the nurse response did not change with time, most of the increase was due to changes in administrator perspectives. Teamwork across units may mean different things to nurses compared to administrators.  To the former, it may be how well patients are transferred from the ward to the operating room, radiology, or the ICU. To the latter, it may be how easy it is to float staff successfully between units.

            Nursing perception of organizational learning and CQI did improve, so the initial 12.5% gap had narrowed to 5.1% on the repeat survey, suggesting nurses did think more CQI was going on (2005 compared to 2007.) The biggest gap of all was on management support for patient safety, where the administrators were 22.9% more positive than the nurses on initial survey, which was still at 19.1% on the second survey.

            So what is going on that administrators seem to consistently see things as going better than the front line staff?  The authors suggest several possibilities, but note the simplest answer is that nurses have a more pessimistic view of patient safety.

            Why nurses should have a more pessimistic view of safety culture than management is an area of some conjecture, and the literature for this line of inquiry is sparse…

            A study conducted in 15 California hospitals using a safety culture survey designed to discover “problematic responses” found a definite discrepancy between the attitudes and experiences of senior managers (particularly non-clinicians) and those of non-managers, and that nurses in particular gave more problematic responses than non-clinicians, regardless of management status. The researchers hypothesized that this could imply a tendency for frontline workers to gloss over patient care problems when briefing senior management, and that this in turn could make it difficult for non-clinician executives to understand the true state of their organization.

            The problem of differences in perceptions between physicians and nurses could not be assessed in this study due to scant number of responses, but they did find literature relevant to the question, suggesting discrepancies similar to that between administrators and nurses.

            Comparisons of nurse vs. physician attitudes regarding safety issues are somewhat more prevalent. In an international cross-sectional study comparing error, stress, and teamwork in medicine and aviation, although 77 percent of intensive care doctors reported high levels of teamwork with nurses, only 40 percent of nurses reported high levels of teamwork with doctors. Similarly, in another study, operating room surgeons rated the quality of their collaboration and cooperation with other surgeons “high” or “very high” 85 percent of the time, but nurses rated their collaboration with surgeons as “high” or “very high” only 48 percent or the time.

            So why is turnover so high in some areas, but relatively low in others? Consider the operating room. From a staff perspective, they are somewhat insulated from the pressure of high volumes.  One surgeon and one OR team can only do one patient at a time. Yes, management may be able to turn the room around faster, and overtime may be required, but there is no expectation of “multi-tasking.” Second, each person in the OR team has a specific skill and the contribution of that person to the team effort is direct and evident to all. Third, even though there may be many surgeons who use the OR, there are always a handful who are the “big dogs.”  These are the surgeons with the highest volumes and who have the respect of the other surgeons and the staff. If things are going badly, these informal leaders are well-positioned to exert pressure on administrators to get changes made.

            On a general med/surg ward, though, there is no defined special skill set, and the contribution of any individual to the “team” effort is hard to define and hard to see. In fact, the team itself is hard to see.  If there are 30 beds on the unit, there are probably at least 15 different physicians involved, so none are easily recognized as the influential leader who can affect change. When many physicians are involved none is likely to feel any ownership of the clinical issues on that ward, either—a sort of medical “Kitty Genovese syndrome.”

            All of these observations bear on the issues that drive nursing turnover—work environment, work load, and decision-making latitude. What can be done to ameliorate turnover, particularly in high-turnover areas?

A Management Perspective on Turnover

            The work environment, workload, and decision-making latitude are factors driving departures that are all potentially amenable to management decisions. A recent paper, though,  found relatively few “best management practices” are consistently applied. McConnell and associates focused on four dimensions of management: (1) operations; (2) performance monitoring; (3) target setting; and (4) employee incentives as used in coronary care units across the United States.[10] They used trained interviewers and open-ended questions designed to get informative answers rather than a check list approach. They managed to obtain interviews with 597 hospitals who had at least 25 discharges/year of patients with an acute myocardial infarction. (51.5% of the total.) The surveyed hospitals were somewhat more likely to be not for profit and to offer open heart surgery than those who did not respond. The authors note

          Overall hospitals performed best on Question 10 (performance review,) and most poorly on Question 18, (retaining talent.) All of the 18 questions suggest considerable room for improvement: fewer than 50% of hospitals scored a 4 or 5 (out of 5) on all but two questions, (Q5, Patient Focus, and Q10, Performance Review.)…Fewer than 20% of hospitals score a 4 or a 5 on more than nine measures, and a majority score a 3 or lower on 15 out of 18 measures.

            Examination of the questions and the scoring show that best practices emphasize standardized care processes including not only the business functions of registration and discharge, but also communications and hand offs, use of continuous improvement methods and routine audits with feedback, setting targets, and rewarding those who exceed them. Many of these functions are unit-level activities as defined in the introductory discussion, not just individual knowledge, skills, and abilities. Perhaps the most interesting best practice is when senior managers had a portion of their pay based upon voluntary turnover rates.

            Although I have no data, I suspect one of the main reasons current management practices do not seem to be aligned with goals of improving clinical performance and safety is the inability to see the centrality of teams to achieving those goals. If the focus is always on the individual with most of the training and all of the disciplinary actions directed at the individual, the team becomes lost in the shuffle. Increasing financial pressure on hospitals only serves to exacerbate the problem, because it is challenging to experiment with new ways of doing things when the financial impact of the changes is uncertain or difficult to measure.

A Physician Perspective on Turnover
        
            The safety and CQI literature emphasize the use of protocols, pathways, standardized care processes and order sets, and improved communications as keys to success. All of these require physician leadership. At a cultural level, though, the keys are to drive out blame and to empower the person closest to the patient to make decisions based on the standardized protocols. This is the place for the physician to exert leadership.

            When I became medical director for the dialysis unit, I was taking over from a physician who maintained a fairly traditional doctor-nurse interaction.  He gave orders and they did them. I was convinced that it was crucial for nurses to be watching the patient, not watching the machine, and so I needed to create new protocols for them to use in caring for our patients. This turned out to be more challenging than I had originally imagined. I naively assumed this would make the nurse’s job more interesting, and therefore something she was more likely to keep doing. But many of the nurses did not want to assume responsibility for making decisions. Initially this was based on uncertainty as to how I would react when a “mistake” occurred.

            I was able to overcome the first hurdle rather by accident. I was making rounds on the patients one day and was, as usual, in a hurry. One of the LPN’s stopped me and told me about a problem one of our patients was having. Being in a hurry, I gave a quick “prescription.” She said in a clear, but not aggressive way, “I don’t agree.” I felt and saw all the other nurses in the unit take a deep breath and freeze. Fortunately, I was having a good day, so I simply said, “So what do you think?” She told me what she though ought to be done and why, and I agreed to go with her plan. But it became clear that many nurses simply could not bring themselves to take on the responsibility. As they left I accumulated a cadre of nurses willing to do so. (The LPN who challenged me that day stayed until her retirement some 15 years later.)

            In all fairness I have to say that some of my dialysis nurses, even though they have been with me for some time, are reluctant to talk to me. Perhaps I appear “too busy” to be bothered, even though I think I would probably stop and listen. Perhaps it is a doctor-nurse relationship brought in from other healthcare environments. Maybe it is because I am old enough to be the nurse’s grandfather. At any rate, this is an area that requires constant work, even after more than 25 years. But I also think it is the area that doctors have to take the lead. If the nurse is supported in her decision-making, she becomes a more valuable member of the team, both in fact and in her perception. In turn this will lead to development and better performance in areas of her own expertise, or what I like to call nurse craftsmanship.

            Ideally, this method would percolate down to the way the nurse managers lead their units, but I have not found this to be universally true, despite many efforts to make it happen over the years. In the small universe of the dialysis unit, I can reach past the nurse manager, but in a hospital environment this would be difficult.

            The other area where physicians can play a key leadership role is setting the clinical goals.  We all know the frustration of being graded on the various scorecards for something we have no ability to control. This happens to nurses all the time. Let me give a couple of examples.

            I am aware of a large dialysis organization that decided to make nurses responsible for the number of gauze pads used during the dialysis treatment. This was done because the price of the pads had gone up and some accountant had noted a simultaneous increase in consumption. From the nurse’s perspective, this meant she had a choice to let the patient bleed or get blamed for using too many pads. The proper goal, though, is to maintain the patient at a goal hemoglobin of 11 without using more (expensive) drugs than necessary. This does depend to some extent on things the nurse can control such as good needle stick technique, proper management of heparin during dialysis, good rinse back technique, and having enough staff time to hold pressure on the access after the needles are withdrawn, particularly for those patients who are cognitively impaired. The LDO did reverse its policy.

            Another example, this time from the administrative realm is budgeting. In any healthcare organization revenue is critically dependent upon payer mix. But the nurse has absolutely no ability to impact the payer mix of her patients. Yet when budgets are reviewed, budget shortfalls are scrutinized and resources may be reassigned as a result. On the other hand, the nurse can be responsible for wastage of supplies. How often is the IV started with the first IV setup?  How often does an IV have to be restarted sooner than protocol requires? Tracking these items costs money, but they are indicators the nurse can own. Improvement in performance would directly benefit patients, who don’t want needle sticks any more than absolutely necessary, either.

            Good choices for goals can also help with the problem of burnout and compassion fatigue. When I started the CQI program, I thought the fact that dialysis patients have an average annual mortality of 22% was a direct cause of burnout. Although our mortality rates are publicly reported, I wanted staff to focus on the things they could control, like good access technique, avoiding symptoms during dialysis and so forth. All of these steps were important to patients even though they probably do not reduce mortality significantly. (We do have data suggesting they reduce morbidity in the form of hospitalizations.) By emphasizing nursing craftsmanship, we have been able to keep turnover manageable, improve the longevity of the staff, and create resilience in dealing with the stressors that lead to burnout.

            Finally, as suggested elsewhere, only physicians can model how to balance technical and compassionate, patient centered care. This, combined with establishing standard procedures and protocols, driving out blame, and clinical goal setting are things physicians can do to build stable clinical teams.

 Administrators and Physicians Working Together

            Building teams requires doctors, administrators, and senior nurse leaders working together. Despite the obvious truth of this statement, it turns out to be remarkably difficult to achieve in practice.  Why?

            In medical organizations, administrators are responsible for hiring, paying, firing and retaining employees. Traditionally, taking care of patients was left to the doctors and the nurses. It should be abundantly clear, though, that modern hospitals contain numerous systems that determine the outcome at least as much, if not more, than individual doctors and nurses. Moving ahead requires a new mental model of what each group does.

            To use the dialysis unit again as the illustrative clinical microsystem, I want to consider how I interact with the administrator. She is responsible for the business of the clinic. Budgets, staffing, hiring, and disciplinary actions all belong in her domain. However, none of these decisions takes place in a vacuum, so it is important that we have a conversation and be in agreement as to what the impact of these decisions will be on our team. I am responsible for the clinical activities, including direct patient care, choice of supplies, and for insuring quality and safety of patient care. Again, none of these activities takes place in a vacuum, and so we must stay in contact and come to agreement if we are to arrive at the balance that supports the team.

            A major activity is our Annual Staff Meeting. (The staff call it Dr. Wright’s Annual Address to the Troops.) We get everyone together after hours, but on the clock, for a meal and a presentation. The administrator presents financial results in enough detail for the staff to understand how their actions affect them. We review clinical performance for each of our locations, and talk about significant group achievements. Individual staff members are recognized for milestones, both personal and professional. I conclude the meeting by talking about what is coming in the next year and what new goals the leadership team has set. Sometimes we talk about political developments and their potential for disruption in our usual way of doing business, and I always include a reminder that it is the patients who justify our operation. While the meeting has a substantive agenda, the real value of the meeting is for the team to see that the administrator and the medical director are involved and together on both clinical and financial performance and goals.

            This would be more difficult to achieve in a hospital setting given the need for 24 hour staffing, but the principles remain valid. Clinical performance and financial performance are two sides of the same coin. To adapt an old adage, it is the doctor’s responsibility to make sure the right thing is done, and the administrator’s job to make sure things are done right. But neither can be done without the other and both must be focused on making sure the team succeeds. Failure to recognize this fact will doom healthcare organizations to increasingly poor clinical and financial performance.

30 August 2014


[1]  Accessed 23 August 2014 at http://www.hopkinsmedicine.org/innovation_quality_patient_care/areas_expertise/improve_patient_safety/cusp/

[2] Timmel, J., Kent, P. S., Holzmueller, C. G., Paine, L., Schulick, R. D., Pronovost, P. J. Impact of the Comprehensive Unit-based Patient Safety Program (CUSP) on Safety Culture in a Surgical Unit. Jt Comm J Qual Patient Saf 2010;36(6):252-260.

[3] Colosi, Brian. NSI Nursing Solutions, Inc., 5th Annual National Healthcare and RN Retention Report. Accessed 16 August 2014 at http://www.nsinursingsolutions.com/Files/assets/library/retention-institute/NationalHealthcareRNRetentionReport2014.pdf

[4] Robert Wood Johnson Foundation “Wisdom at Work Initiative.” Accessed 16 August 2014 at http://www.rwjf.org/content/dam/files/legacy-files/article-files/2/revlewinevalrnturnover.pdf.

[5] Hunt, S. T. Nursing Turnover: Costs, Causes, and Solutions. Accessed 16 August 2014 at http://nmlegis.gov./lcs/handouts/LHHS081312NursingTurnover.pdf.

[6] Brown, D. S. and Wolosin, R. Safety Culture Relationships With Hospital Nursing Sensitive Metrics. J Healthc Qual 2013;35(4):61-74. doi: 10.1111/jhq.12016.

[7] Van Bogaert, P., Timmermans, O., Weeks, S. M., van Heusden, D., Wouters, K., Franck, E. Nursing Unit Team Matters: Impact of Unit-Level Nurse Practice Environment, Nurse Work Characteristics, and Burnout on Nurse Reported Job Outcomes, and Quality of Care, and Patient Adverse Events—a cross-sectional survey. Int J Nurs Stud 2014;51(8):1123-34. doi: 10.1016/j.ijnurstu.2013.12.009.

[8] Ibid.

[9] Hannah, K. L., Schade, C. P., Lomely, D. R., Ruddick, P., Bellamy, G. R. Hospital Administrative Staff vs. Nursing Staff Responses to the AHRQ Hospital Survey on Patient Safety Culture. In Henriksen K, Battles JB, Keyes MA, et al., editors. Advances in Patient Safety: New Directions and Alternative Approaches (Vol. 2: Culture and Redesign).

Rockville (MD): Agency for Healthcare Research and Quality (US); 2008 Aug. http://www.ncbi.nlm.nih.gov/books/NBK43704/pdf/advances-hannah_23.pdf

[10] McConnell, K. J., Chang, A. M., Maddox, T. M., Wholey, D. R, Lindrooth, R. C. An Exploration of Management Practices in Hospitals. Healthcare 2014;2:121-129. Downloaded 28 July 2014 from www.elsevier.com/locate/hjdsi.

Further Reading

Clinical Microsystems
Clinical microsystems are composed of front-line clinicians engaged in direct patient care.  Despite a lack of formal authority, they are the key to successful healthcare reform.

Physician Engagement
Is physician engagement a strategy to promote physician leadership, or a code word meaning how do we get the doctors to do what  we want?
  
Productivity in Healthcare Part 1
Many are focused on efficiency and productivity in healthcare without a clear understanding that the two are not interchangeable.  This article introduces the two concepts as they are commonly used. 

Productivity in Healthcare Part 2
The conflict between productivity and efficiency is examined from three perspectives using the care of dialysis patients as the case study.

Productivity in Healthcare Part 3
 The conflict between productivity and efficiency is contributing to widespread physician malaise, which has negative implications for health care improvement.
 
 Strategic Human Capital
Healthcare organizations need to realize the economic value of experienced teams of clinicians able to provide highly reliable care and to recognize the importance of maintaining team integrity in times of surges in patient volumes.          
Teams and Learning Organizations
A brief introduction to the concept of the learning organization for physicians.