"I've always loved being a nurse here, but if things don't get better, I don't know if I'm going to be able to stay."
Five years ago, all 3,000 nurses at the University of Michigan (UM) hospitals received the above message in their e-mail inboxes. It came from Juanita Parry, the hospital's manager of nurse retention, and it was both an acknowledgment of a problem and a plea for help in finding a solution. "I knew I had to be realistic. I couldn't just be rosy about the situation," says Parry, who now also oversees recruitment at the institution. "People were doing an amazing job in some really tough circumstances. Something had to change."
Parry wasn't just reacting to conditions at the Ann Arbor hospital—she and her counterparts across the country saw a serious struggle looming. Health care is the nation's largest industry, employing 13.5 million people in 2004, according to the Bureau of Labor Statistics. It's also the fastest growing—it is anticipated that health care will account for 19 percent of new jobs created between 2004 and 2014. That growth in demand, however, is not spurring a growth in supply. South Bend, Ind.–based health care consultancy Press-Ganey forecasts that by 2010 the vacancy rate for registered nurses (RNs) will grow from its current 14 percent up to 20 percent.
If those numbers make you a little nervous at the prospect of being admitted to a hospital in the next decade, consider the fear they strike in the hearts of hospital administrators.
"The challenge is just huge to find those qualified people," says Steve Mordecai, director of human resources for Griffin Hospital in Derby, Conn. But hospitals aren't just competing on a local level, and Mordecai knows this: "College grads are much more mobile today than they were five, 10 years ago. And they aren't looking to stay in a place for a long period of time. Sometimes we joke that [young nurses] are just coming in to get their signing bonuses and move on."
Mordecai can afford to joke a little—Griffin's turnover rate is 8 percent, well below an industry average that, according to the American Hospital Association, hovers around 20 percent. Nursing has a high burnout factor, due to long shifts, missed holidays with family and the odd hours, few of which are spent sitting down. And caring for seriously ill patients and their families is emotionally taxing.
Hospitals are responding with a proactive approach to recruitment and retention. The ones that do best rely on a mix of flexible work arrangements, employee recognition programs, rewards tied to performance and an overall cultural commitment to creating a great patient experience. "Our members are trying to create much more employee-friendly environments lately," says Becky Frederick, executive director of the American Society for Healthcare Human Resources Administration in Chicago.
Just (Let Me) Do It
Toward the end of her recently completed 27-month nurse anesthetist program, Julie Bergenser says that she received recruitment letters in the mail daily, and when she went to conferences, people were "falling over themselves" to talk to her about their hospitals. She eventually decided to take a job at a large teaching hospital in Portland, Ore.
The reasons she chose the hospital are simple: "The head doctor was doctor of the year. Everyone's so friendly there. And when I went to interview, they were the most organized of the places I visited." Bergenser's choice reflects the prevailing attitude among nurses—their first priority is usually to work somewhere that enables them to deliver stellar care.
"Most health care workers are in these professions because they have a belief system; they want to do good for people," says Bill Powanda, vice president at Griffin and a 31-year veteran of the hospital. "They want to leave their jobs at the end of the day feeling that they had the opportunity to provide the best care for people."
The most basic, but far from simple, component of helping nurses serve customers better is getting shifts covered in a way that prevents burnout and allows them to have a life outside of work. Short-staffed hospitals can find this hard to do. Nurse Sherri Powers* recalls her experience at a Connecticut hospital a few years ago. The standard patient load was six, but by the end of many of her shifts that number had burgeoned to eight or 10, keeping her at work four hours late. She's since moved to a hospital in another state, where she says the work is still demanding, but scheduling is better managed. And that allows her not only to leave on time, but also to feel more fulfilled. "It's very rewarding to have people happy with the care they receive," she says.
Employees in many industries seek flexible work arrangements, but nursing appears on the cutting edge of some creative approaches. One is shift bidding, available from companies like San Diego–based BidShift, in which qualified nurses go online to bid for available shifts; these systems can also be used without the auction function, as an avenue for nurses and managers to communicate about scheduling. Some hospitals also employ "floating" nurses, who fill gaps in several units. And companies like Professional Placement Resources in Jacksonville Beach, Fla., employ "travel nurses," hired out to hospitals around the country on a temporary basis.
Happy Patients, Happy Nurses
When health care experts talk about the connection between happy nurses and satisfied patients, it doesn't take long for them to fall into a chicken-and-egg cliché. Hospitals that score in Press-Ganey's 90th percentile for medical staff satisfaction see a 24 percent increase in patient volume. But while the results demonstrate the connection, they don't answer the question of which comes first—happy nurses or happy patients.
Whatever the answer, it seems hospitals have a labor pool that, for the most part, is hardwired to understand the value of customer service. But far from assuming that nurses automatically understand customer service, smart administrators work hard to keep service top of mind. At Griffin, every employee learns about patient care on a retreat to a convent on Long Island Sound. They bunk up together and spend two days doing exercises simulating the hospital experience through the patient's eyes.
"We sometimes have to drag people there kicking and shouting, but they come back with a much different appreciation for how intimidating and scary the hospital experience can be," Powanda says. "We think that has contributed the most to changing the culture of the organization."
This winter, Fortune magazine ranked Griffin fourth on its "Best Places to Work" list, the highest ranking ever for a hospital and the seventh time it has made the list. After about 20 years of involving all employees in a patient-centered approach to care, Griffin has instituted a number of interesting practices: Patients are encouraged, not just allowed, to view their charts; they can research their conditions in Griffin's library, which counts 8,000 community members as cardholders; an arts and entertainment program brings musicians in to perform in the lobby area; volunteers bring patients cookies baked in the hospital's family kitchens (pictured, left); and the child-birthing center features hotel-like rooms with double beds for new parents.
Such efforts have a domino effect: "When you have a culture of service and all employees are empowered to deliver excellent care, the patient feels it," says Robert Wolosin, a research director with Press-Ganey. "The physicians feel it too. They know when people are being treated properly."
Carolyn Cruz started working at Washington Adventist Hospital in Takoma Park, Md., in 1998, when the demand for nurses was much lower. She's remained there largely because of the work environment and the way it enables her to care for patients. "I get a lot of support," she says. The hospital offers mediation sessions at the beginning of each shift, but adequate staffing plays an equal role in limiting Cruz's on-the-job stress. "They make sure the nurse-to-patient ratio is safe, which is huge."
When hospitals seek to shore up elements like patient satisfaction, retention or recruitment, they typically turn to teams of volunteers to direct change. At UM, Parry invited nurses to a brainstorming session on how to fix retention in 2002. About 100 showed up, and she pared that group down to 18 nurses who meet every two weeks to refine initiatives to improve the work environment.
At Griffin, the major improvement efforts that began in the 1980s were guided by a combination of customer research and employee brainstorming. And management's open attitude allows employees to make major improvements that affect their peers. A pet therapy program launched for patients by nurse receptionist Ruth Turrico has benefits for workers as well. And Dare to Care, a yearlong program of personal improvement seminars available to all staff, lets employees raise their profile with coworkers by becoming instructors. Both programs rely on volunteers, and exist only because management encourages employees to come forward with their ideas.
At Norman Regional Hospital in Norman, Okla., open communication between different levels and departments has led to irrefutable bottom-line benefits. In 2000, its first Press-Ganey employee survey put it in the 14th percentile nationally. The hospital asked each survey participant what it would take to turn the environment around. Managers implemented suggestions in their departments, and the hospital took a more formal approach to recognition. Six months later Norman had climbed to the 68th percentile. Within a year, Norman had reached 92. Improved morale quickly paid dividends: "As our employees got more satisfied, we got more positive comments from patients," says Carolyn Shockey, director of human resources at Norman. Net operating margin went from $2 million in 2000 to $9 million last year. Turnover went from 28 percent to 16 percent. Thanks to that, plus a better image in the community, Norman was able to cut its advertising cost for new employees in half from 2003 to 2005.
What to Reward
Most hospitals that have formal reward and recognition programs employ three elements: some kind of bonus system, spot recognition and an employee-of-the-month competition.
Bonuses or incentives can be tied to revenue, clinical outcomes or patient satisfaction metrics. For Griffin's Success Rewards program, departments submit three measurable goals each quarter. If they hit their targets, everyone in the group gets a $25 bonus. If the whole hospital meets its goals, employees get another $25. And management places framed posters around the hospital with the names of departments that reach their goals. Patient satisfaction scores are posted prominently online, an accountability measure not lost on employees or members of the community.
Organizations should introduce outcome-based rewards gradually, says Laura Vercler, a knowledge manager at Press-Ganey. "You have to start by making patient satisfaction a part of their vocabulary, and show them how it relates to their day-to-day work," she says. "Otherwise, it's just, 'Sometimes I get a bonus, sometimes I don't.' The financial reward just becomes something that they have no control over."
To determine where to focus efforts, Vercler suggests managers ask nurses to choose improvement goals from a list of specific problems, gleaned from patient and employee surveys. "If you give them a choice in how they improve their scores, they're more likely to take responsibility," Vercler says. Once a few units start to progress, recognize them in front of peers.
"Then when you decide to take it to the next level [with rewards], people are already familiar with the language of patient satisfaction," Vercler explains. She adds that any outcome-based reward program has to include all staff; Press-Ganey research shows hospitals that reward only managers perform below the national average on patient satisfaction.
Top hospitals even include interns in their efforts. In a break room at Griffin Hospital not long ago, nursing student Joe Welsh pondered his future. "I might stay here, but I'm not sure," he said of the place where he's been working as he finishes his degree at the University of Connecticut. "Other places are offering more money, but this has become like my family." By creating a great place to work, Griffin just might have edged out deeper-pocketed competitors for Welsh's loyalty.
Better work environments alone can't save nursing. Health care as an industry has some serious problems contributing to the shortage, and the education pipeline that creates RNs also could use some work. But as hospitals compete for market share and try to create the kind of community relations that attract top physicians and generate charitable giving, the ones that empower and recognize employees and customers have the best chance at a healthy future.
A Revolution in Space
Initial impressions of Griffin Hospital in Derby, Conn., hint at an unusual approach to running a hospital. Pull up to the front entrance and a valet takes your car keys, no charge. Inside, panoramic windows let light in wherever possible, and art decorates the softly lit walls. Management has nearly eliminated signage, instead encouraging workers to seek out and escort confused customers.
"As health care becomes a more competitive industry, more hospitals are really taking design into consideration," says Sara Mayberry, director of communications for the Center for Health Design, based in Concord, Calif. Research from the center shows that improvements in ventilation, ergonomics and lighting can reduce infection rates and accidents and improve patient satisfaction and employee motivation.
Hospitals have unique issues as a work environment. Walking distances are one important consideration. Nurses waste a lot of time and energy just getting from room to room. Noise is another. The cacophony of pages, ice machines and humming monitors has been shown to elevate blood pressure, increase heart rate and interfere with sleep—for workers as well as patients. Institutions like Florida Hospital Waterman in Tavares, place patient rooms in clusters surrounding nurse stations. These pods allow better patient access, cutting down on both walking and noise.