Turnover From the Perspective of the Departing
I had a conversation with the hospital’s COO one day about nursing staff turnover. As a nurse himself, he was also concerned about the issue, and reported the exit interviews conducted by HR showed that money was the most frequently cited concern. I told him I thought we might benefit if we heard that as “you can’t pay me enough to put up with…” as opposed to the need for a pay raise. Just today I heard a young RN, commenting about the difficulty of dealing with incontinent patients, “even for a $1000/hour I could not do that if I had to do that all day.” Recently, Travis Bradberry published an article on Forbes.com, entitled “9 Things That Make Good Employees Quit.” His key point: “Managers tend to blame their turnover problems on everything under the sun, while ignoring the crux of the matter: people don’t leave jobs; they leave managers.” He then listed the nine most common problems.
First, good employees tend to be overworked. “New research from
Stanford shows that productivity per hour declines sharply when the workweek exceeds 50 hours, and productivity drops off so much after 55 hours that you don’t get anything out of working more.” We were once trapped in a situation where we got behind on staffing at a time when workload was increasing, and employees were logging more than 10 hours of overtime. While there was some complaining at the time, most of the resignations came in when we finally got staffing up decent levels, and people could plan on their schedules being reasonably predictable. Once they got some sleep, they realized they could not go through that again.
The second and third points are similar: good work is not recognized and managers don’t care about their employees. In medical environments when tend to expect quality work from employees and are quick to notice (and complain about) failure, but slow to say thanks. And the focus on the patient can cause people to forget about the other team members, particularly when status issues are involved. I once heard a young team leader tell a new janitor (in the middle of the night) that he always wanted to make sure the rooms he cleaned were cleaned thoroughly, because if he did not, the next patient might get sick. I did report the young man to management for commendation, as he clearly understood his role, but how many others do the same thing and are never acknowledged?
His fourth and fifth points: they don’t honor their commitments and they hire and promote the wrong people. In some ways this is a corollary to not caring about employees, but represent personal failures on the part of the manager. I remember a vigorous discussion with some consultants, nursing leaders and myself, where I kept asking what I thought were probing questions. It soon became clear that some of the nursing leaders (but not the consultants) thought I was just being a nuisance and prolonging the meeting. They did not quite come out and say that, but I did get the message, when one of them said they would not hire me. How often do we want to move the employee who keeps asking why and retain the one that just says okay? In a learning organization environment, the first employee is likely to be more valuable.
The last four seem to me the biggest factor in the health care environment. (6) They don’t let people pursue their passions. (7) They fail to develop people’s skills. (8) They fail to engage their creativity. (9) They fail to challenge people intellectually. Since medical care involves a great number of highly educated and trained people, you would think these four factors would come naturally to managers and employees at all levels, yet they don’t.
Perhaps the biggest challenge is the current regulatory environment. All healthcare organizations are subject to repeated, often intrusive examination by various agencies of the state and private organizations. Each inspector has his/her own agenda, and is looking for the information that the organization is performing as required. Yet performance in medical care is, at best, a statistical proposition. Some proportion of our patients are going to die during the current admission, now matter how competent the medical care provided. Since we don’t really know how much of what we do is critical to achieving desired outcomes, the temptation is to go with rigid protocols and to define “the right thing to do” as following the protocols. It is easy to see why passion, creativity, inclusiveness and thinking could be seen as threats to following the protocol.
Lest this seem too farfetched, how many of you have worked with doctors whose anxiety caused them to become enmeshed in the small details of a patient’s care and badgered the nurses for more data? These anxious doctors may see themselves as more conscientious than their slovenly brethren who don’t chase after all the details, but it is fairly clear there results are not superior and they have more problems with the patients and the staff than their peers. Can you see how these behaviors create an environment where nurses decide to leave?
I was talking to a group of dialysis unit medical directors about staff turnover. I suggested this might be a more important metric to monitor in our QAPI program than some of the indicators mandated by CMS. One young doctor, though, demurred. “Turnover is not my responsibility.” Yet it is clear that physicians have a major impact on the working conditions of nursing staff—perhaps as much as HR practices and nursing leadership, which can be prone to all of the errors outlined by Bradberry. I suggest we all have a role to play in turnover, and organizations that find ways to give appropriate feedback will prosper, while those that do not will fail.
1 May 2016
quit/#cdd6b2b260b3. Accessed 23 Feb 2016.
Horizontal Violence and Nursing Staff Turnover
A recent study shows horizontal violence - conflict between nurses in a hospital - is common and a major cause of job dissatisfaction and intention to leave. What can be done about it?
Nursing Staff Turnover
If empowered teams of clinicians is the key to effective, efficient care, then staff turnover is Achilles' heel. Nationally, RN turnover exceeds the cap needed to maintain patient safety and quality of care. The problem and approaches to a solution are considered.
Teams and Learning Organizations
A brief introduction to the concept of the learning organization for physicians.