Retaining Clinical Nurses at the Bedside Dorothy M
Retaining Clinical Nurses at the Bedside Dorothy M. Beke MS, RN, CPNP-PC/AC, FAAN Nurse Practice Specialist Mechanical Circulatory Support Resource Cardiac Intensive Care Unit Bereavement Coordinator Cardiovascular Program Nurse Practitioner Cardiology Preoperative Clinic Boston Children’s Hospital
• I have no conflicts of interest • I have no financial disclosures
Objectives • Describe nursing characteristics and vulnerabilities associated with nurse staffing models and the impact on patient outcomes • Describe solutions for improving organizational and unit level culture • Discuss strategies to develop, empower, and engage staff
A Profile of Staffing Excellence: What Significantly Matters to Patient Outcomes? • Nursing Education 1 p<0. 05 • Nursing Experience 1, 2 Associated with Lower Mortality p<0. 05 • CCRN Certification 3 p=0. 02 • Nursing Education 2, 3 Associated with Fewer Complications p<0. 04 1 Pediatric Health Information Systems (PHIS) Database. Hickey P, et al. The Effect of Critical Care Nursing and Organizational Characteristics on Pediatric Cardiac Surgery Mortality in the US. J Nurs Adm 2013; 43(12): 637 -644 2 Society of Thoracic Surgeons (STS) Congenital Database for children undergoing cardiac surgery. Hickey P, et al. Critical Care Nursing’s Impact on Pediatric Patient Outcomes. Ann Thorac Surg 2016; 102: 1375 -80. 3 PHIS Database. Hickey P, et al. The Impact of Critical Care Nursing Certification on Pediatric Patient Outcomes. PCCM 2018; 19(8): 718 -724.
Understanding the Factors Which Promote Registered Nurses’ Intent to Stay in Emergency and Critical Care Areas • Feeling valued, respected, and acknowledged • Four key themes – Leadership – Inter-professional relationships – Job fit – Practice environment • Positive factors – Effective leadership – Inter-professional teamwork – Mentorship Van Osch M, et al. (2018). J Clin Nurs, 27(5 -6): 1209 -1215.
Identifying the Key Predictors for Retention in Critical Care Nurses • 24% with intent to leave job in next year • Key factors identified – Professional practice – Management – Interdisciplinary collaboration – Competence – Autonomy Sawatzky JA, et al. (2015). J Adv Nurs, 71(10). 2315 -2325.
Factors Negatively Associated with Nurse Recruitment and Retention • High intensity environment, heavy workloads, inadequate staffing • Distraught families, patient suffering and dying • Decreased well-being of nurses – Post-traumatic stress – Moral, emotional, spiritual distress • Salary, benefits, scheduling • Lack of autonomy, professional practice issues • Inter-staff conflict, poor communication, bullying, decreased collaboration • Organizational culture • Inadequate appreciation, lack of effective nursing leadership**
Implications of Lost Knowledge and Experience • Impacts – Staff performance levels – Nurses’ development of clinical competence – Patient quality and safety – Quality of work environment – Hiring and orientation costs Van Osch M, et al. (2018). J Clin Nurs, 27(5 -6): 1209 -1215.
Improving Nurse Retention
Magnet® Designation • Key components* – Transformational leadership – Structural empowerment – Exemplary professional practice – New knowledge, innovations, improvements – Empirical outcomes • Impact of Magnet® designation** – Lower levels of emotional exhaustion – Higher job satisfaction – Higher intent to stay *Salmond, SW, et al. (2009). JBI Libr Syst Rev, 7(26): 1119 -1178. **ANCC (ANA). (2019). https: //www. nursingworld. org/ana-enterprise/
Impact of Magnet® Hospital Designation on Nursing Culture: An Integrative Review • 29 studies, international • Magnet designation enhances organizational culture for nurses • Framework used to introduce Magnet® helps empower nurses to direct organizational culture Anderson VL, et al. (2018). Contemporary Nurse, 54(4 -5): 483 -510.
American Association of Critical Care Nurses (AACN) Beacon Award for Excellence • Recognizes caregivers in stellar units whose consistent and systematic approach to evidence-based care optimizes patient outcomes • Indicates: – Excellence in patient care environments through the utilization of evidence-based information – Positive and supportive work environment with greater collaboration between colleagues and leaders, higher morale and lower turnover AACN. https: //www. aacn. org/nursing-excellence/beacon-awards.
AACN Healthy Work Environment Framework • Skilled communication • True collaboration • Effective decision making • Appropriate staffing • Meaningful recognition • Authentic leadership AACN. (2019). https: //www. aacn. org/
Critical Care Nurse Work Environments 2018: Findings and Implications • On-line survey, n=8080 • Areas of concern – Absence of appropriate staffing (60%) – Physical & mental well-being issues (>198 K incidents in >6 K) – Intent to leave current position in 12 months (33%) • Improvement in all items of AACN healthy work environment scale (p <0. 05) – Positive correlation between implementation of initiatives and patient outcomes – Improved health of critical care environment – Improved job satisfaction – Increased nurse retention intent Ulrich B, et al. (2019). Crit Care Nurse, 39(5). e 1 -e 18.
Strategies to Reduce Turnover
Strategies to Reduce Turnover • Implement data-driven staffing • Decrease overtime • Practice shared governance • Develop quality of life initiatives AACN. (2016). Bold Voices, 8(11): 19.
Effective Leadership is Key! Perceived and Experienced Role of the Nurse Unit Manager in Supporting the Wellbeing of Intensive Care Unit Nurses: An Integrative Literature Review • 19 studies, international • Major themes – Building professional relationships – “Leading the way” – “Satisfying the needs of the ICU nurse” • Establishing trusting relationships was most significant • Nurse manager behaviors “clearly affect the wellbeing of ICU nurses” Adams AMN, et al. (2019). Aust Crit Care, 32(4): 319 -329.
Factors Contributing to Nursing Leadership: A Systematic Review • Development of leadership – Educational development programs – Role Modelling/demonstrating leadership skills – Experience • Effective leadership traits – Extroversion, being present – Openness – Motivation to manage Cummings G, et al. (2008). J Health Serv Res Policy, 13(4): 240 -248.
Complexity Assessment and Monitoring to Ensure Optimal Outcomes (CAMEO©) Acuity Tool • Pediatric-based acuity tool that includes both direct and indirect care • Measures cognitive workload: – Intellectual processing of patient information that drives performance and decision making • Quantifies the complexity of pediatric nursing care: – Skill, concentration, and level of surveillance required to provide care Connor J, et al. (2015). Am J Crit Care, 24(4): 297 -308.
Effectiveness and Best Practice of Nurse Residency Programs: A Literature Review • Implications – Cost savings – Increase in retention – Expand knowledge base, critical thinking and leadership skills • Common findings – Crisis point ~ 6 months, decreasing by 12 months – Increased confidence by 12 months – Most effective programs at least 12 months long Cochran C. (2017). Med. Surg Nurs, 26(1): 53 -57, 63.
Essential Elements Nurse Residency Programs Institution-based orientation program Skilled preceptors and mentors Successful Programs Delegation and prioritization Conflict resolution and communication Leadership Critical thinking skills Socialization Skill Development Didactic sessions Case studies Role play Simulation
Building a Culture of Clinical Inquiry • Clinical inquiry is considered essential to the delivery of quality nursing – Requires a commitment to resources and infrastructure • In 2011, the Nursing Science Fellowship at Boston Children’s was formed – Linking nurse scientists and bedside nurses to advance clinical questions through committed mentorship • Important strategy to advance professional development, advance science and engaged staff
Nursing Education & Support Team (NEST) Goals: • To support and build moral resiliency among critical care nurses • To positively impact staff morale and overall stability of the nursing workforce Experienced RN coaches with dedicated hours provide: • “Just in time” response to bedside RNs experiencing challenges • Timely support to bedside nurses by someone who has “walked in their shoes” • Support for challenging end-of-life care, withdrawal of support, complex psychosocial issues
Quality of Life Initiatives • Mindfulness initiatives – “Healthy CICU” initiatives – Alternative therapies • Socialization and team support – Sunshine fund – Committees and meetings § “Monthly mingles” § Community outreach § Healthy work environment § Level I nursing staff • Individual support – Office of clinician support – Managers – Mentorship program – NEST coaches • Staff debriefing – Bereavement rounds – Ethics rounds – Critical events – Clinician support initiative (CSI) rounds
Summary • Critical care nurse staffing models and patient assignments are best developed when informed by evidence • Solutions for organizational- and unit-level culture are key to recruitment and retention • Strategies to develop, empower and engage staff advance the nursing profession and impact patient outcomes
Thank You! “Yesterday I was clever, so I wanted to change the world. Today I am wise, so I am changing myself. ” Rumi Poet, Scholar, Theologian
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