write an essaybase on the attached file 7 paragraphs. Each paragraph needs to be 5 to 6 sentences in APA formatPlease provide references. Thanks

Downloaded on 07 07 2018. Single-user license only. Copyright 2018 by the Oncology Nursing Society. For permission to post online, reprint, adapt, or reuse, please email [email protected] “Change your thoughts and you change your world.” ––Norman Vincent Peale F or decades, efforts to maintain adequate levels of RNs in the healthcare workforce have centered on re- cruitment. The current workforce challenges and opportunities related to the national shortage of RNs in health care are outlined in chapter 9. This chapter will focus on creating a culture of retention as one key strategy to decrease nurse turnover and cost.

Surely the answer to RN vacancies lies in a strong and solid recruitment effort; however, once recruited, greater emphasis must be placed on retention. Consider that for every two nurses recruited, one or more could leave. Tens of thousands of dollars are spent each year on nurse advertising and recruit- ment strategies to hire RNs at all levels and across multiple specialties. Turnover comes at a high price to the organization and to the staff left behind who just spent weeks, physically and emotionally, precepting and acculturating the new hire in orientation and to the work environment. Nurse managers ﬁ nd themselves facing an ever-challenging global nursing short- age. The current shortage of registered nurses in the United States is expected to intensify as baby boomers age and the need for health care grows (American Asso- ciation of Colleges of Nursing, 2003). This shortage, to rival none in history, is sparked by a multitude of factors: aging nursing pool, fewer women choosing nursing as a career, and others outlined in chapter 9. To meet this challenge, healthcare employers have initiated multiple strategies, from for- eign nurse recruitment and sign-on bonuses to creative beneﬁ t packages, such as maid service, dry cleaning pick-up and delivery, and car washing. Although these tangible CJON B OOK E XCERPT SERIES amenities are nice, they seldom result, alone, in retaining a satisﬁ ed employee (Ropp, 2003). Recruitment bonuses serve the purpose of alluring the nurse to the or- ganization, but it is often a quick ﬁ x. Once the bonus is received, the employee, if pri- marily motivated by money, is out looking for the next big payday. Often these grand sign-on bonuses serve to devalue the cur- rent workforce and could have a negative effect on staff retention. At best, the sign- on bonus is a short-term ﬁ x. Nevidjon and Erickson (2001) stated that past solutions to the shortage (e.g., cash bonuses, relocation incentives) only served to redistribute the supply of nurses, not increase it. How to increase the supply of RNs will be reviewed later in this chapter.

High Cost of Turnover In November 2003, the Institute of Medi- cine of the National Academies reported that nursing staff make up the largest segment of healthcare workers in the United States, accounting for 2.2 million RNs, 700,000 licensed practical or vocational nurses, and 2.3 million assistive personnel, which con- stitutes 54% of all healthcare providers. The national unemployment rate for RNs is at its lowest level in more than a decade, declining from 1.5% in 1997 to 1.0% in 2000 (U.S.

General Accounting Ofﬁ ce, 2001). This re- ﬂ ects the limited pool of experienced nurses available for employment. A survey by the Advisory Board Com- pany (2000b) reported that the national Mary Magee Gullatte, RN, MN, ANP, AOCN ®, FAAMA, and Evelyn Q. Jirasakhiran, MSN, RN Retention and Recruitment: Reversing the Order Th is excerpt, chapter 12 from the book Nursing Manage- ment: Principles and Practice, edited by Mary Magee Gullatte, RN, MN, ANP, AOCN ®, FAAMA, is part of a ser ies of cl in ically relevant repr ints that appear per iod ically in the Clinical Journal of Oncology Nursing. From Nursing Management: Pr inc iples and Pract ice (pp. 217–233), edited by Mary Ma- gee Gullatte, RN, MN, ANP, AOCN®, FAAMA, 2005, Pittsburgh, PA: Oncology Nursing Society. Reprinted with permission.

Digital Object Identiﬁ er: 10.1188/05.CJON.597-604 turnover rate among hospital staff nurses was 15%, up from 12% in 1996. A more recent re- port by the HSM Group (2002) indicated a nurse turnover rate in the United States of 21%.

The national average salary for a medical-surgical nurse is re- portedly $46,832; turnover costs are up to two times a nurse’s salary (Atencio, Cohen, & Gorenberg, 2003). Inherent in nurse turn- over are costs associated with separation, replacement, and development of the nurse.

Turnover costs include many variables:

direct salary of the new hire and preceptor, education and development cost, marketing and recruitment costs, loss of productivity during orientation, and intangible cost of turnover on current staff. The American Nurses Association staff- ing survey (2001) reported that 75% of nurses felt that the quality of patient care had decreased over the past two years, and 56% felt that they did not have adequate time to perform patient care. Aside from the ﬁ nan- cial impact of nurse staff turnover, there is the negative effect on the staff that has been involved in the orientation of the new mem- ber and potential adverse patient outcomes.

Staff left behind may be working longer hours and take on increased patient assign- ments to ﬁ ll the vacancy. Agency nurses may be employed as a quick ﬁ x. These tempo- rary nurses are seldom as familiar with the patient population and may not possess the same level of skill as the organization staff.

In a workforce survey commissioned by the C LINICAL JOURNAL OF ONCOLOGY NURSING • V OLUME 9, N UMBER 5 • R ETENTION AND RECRUITMENT : REVERSING THE ORDER 597 jm Book Excerpt.indd 597jm Book Excerpt.indd 597 9/19/2005 2:41:58 PM9/19/2005 2:41:58 PM This material is protected by U.S. copyright law. Unauthorized reproduction is prohibited. To purchase quantity reprints, please e-mail [email protected] or to request permission to reproduce multiple copies, please e-mail [email protected]. Oncology Nursing Society, nearly 80% of the RNs surveyed cited difﬁ culty retaining experienced nurses (Buerhaus, Donelan, DesRoches, Lamkin, & Mallory, 2001).

Creating an organizational culture of nurse retention is crucial to reducing vacan- cies in healthcare organizations. High nurs- ing staff turnover and low entry of nurses into the workplace adversely affect both the healthcare organizations and patient outcomes.

Job Satisfaction A key factor, lack of job satisfaction, is the most cited reason for staff turnover. Job satisfaction is multidimensional. In a study by Bratt, Broome, Kelber, and Lostocco (2000), two key factors surfaced related to job satisfaction: stress and nursing leader- ship. Job stress and workplace tension are inherent in healthcare. The key is how they are managed. The nurse manager should be engaged in the human relations variables of the workplace. Any nurse manager with the responsibility of hiring, ﬁ ring, and giv- ing performance evaluations should have taken at least one basic human resources class (Cline, Reilly, & Moore, 2003). How is the staff relating to each other? Is there collaboration and cooperation among the nurses and other members of the team? If the answer to these questions is no, then what does the manager need to do to facilitate the communication among a diverse group of nursing staff? It is not enough to continue to relay the dire predictions of a catastrophic nursing shortage facing health care in the next decade. As nurse managers and leaders, there must be continual proactive steps to enact a culture of retention while leveraging the vision of being an employer of choice and a healing organization, which places the value and worth of an individual as prime mission-sensitive goals.

Sengin (2003) identified 10 attributes that contribute to job satisfaction in acute care hospitals based on frequency and con- sistency of appearance in the literature. The attributes include (a) autonomy related to independence within professional prac- tice, (b) interpersonal communication and collaboration within the workplace with supervisors, subordinates, and members of the healthcare team, (c) professional practice—the opportunity for specialization and professional care delivery modes, (d) administrative/management practices—this attribute relates to organizational structure and culture, (e) status/recognition—the value of nursing within the organization; (f) job/task requirements—meaningful- ness and variety of work, (g) opportunity for advancement/promotion, (h) working conditions/physical environment—includes stafﬁ ng and scheduling, workload/patient assignment, equipment, and resources, (i) pay—competitive salary and beneﬁ t pack- age, and (j) fairness—centered around treat- ment related to employment decisions in the workplace.

Fundamentally, individuals choose a ca- reer in health care to make a difference in the lives of others. When the organization fails to meet employee expectations because of hectic and often failed organizational systems, the employee is left unsatisﬁ ed and unfulﬁ lled. Figure 12-1 compares the percentage of employees in health care versus the general population whose expec- tations are not being met. Often cited in the literature is the notion that nurses perceive being involved in decision making as a very signiﬁ cant variable in job satisfaction (Gleason-Scott, Sochalski, & Aiken, 1999).

This involves decisions impacting clinical practice as well as personal decisions related to stafﬁ ng and scheduling. Involving staff at a high level in policy and procedure develop- ment as well as in self-scheduling will score high on the retention scale. Culture of Retention The human relations efforts of managers toward staff are key to cohesion and com- mitment and creating a culture of reten- tion in the workplace (Wagner & Huber, 2003). Health systems also must pay at- tention to the retention of nurse managers.

The ﬁ rst-line managers are often the glue that holds the hospital together (Parsons & Stonestreet, 2003). Gone are the days of the head nurse or nurse manager respon- sible for a small nursing unit and a core group of staff. Over the past decade, the scope and breadth of the nurse manager’s responsibilities have spanned multiple units and, in some cases, across multiple hospital networks, with an increased number of cul- turally diverse employees. There have been human resource issues and increased de- mands from upper level management to re- cruit and retain a viable nursing workforce amid mounting national and international nursing shortages. First-line managers are assuming greater work responsibility often without formalized support or develop- ment for the expanded roles. Although there are reports of nurse managers being the reason for staff turnover, they are also the reason for staff retention. Leadership of strong nurse managers is the key to staff satisfaction and retention (Cullen, 1999).

Thorpe and Loo (2003) reported that the retention of ﬁ rst-line nurse managers re- quires top level organizational attention to providing adequate resources, training, and development as well as a supportive work environment.

When a nursing unit has a high retention rate, one would wonder, “What is the secret?” There is not one answer to this question. As shown in literature and research studies, a combination of retention strategies may work for a unit depending on the areas needing short- and long-term solutions, which could be any of the following: autonomy, salaries, schedules, credibility gap, and professional respect (Nevidjon & Erickson, 2001). Some general retention strategies used at healthcare organizations were compiled under “Best Practices in Retention” (Advisory Board FIGURE 12-1. P ERCENTAGE OF EMPLOYEES WHOSE EXPECTATIONS ARE NOT BEING MET Note.FromIn Our Hands: How Hospital Leaders Can Build a Thriving Workforce (p. 28), by American Hospital Association, Commission on Workforce for Hospitals and Health Systems, 2002, retrieved February 7, 2004, from http://www.aha.org/aha/key_issues/workforce/commission/InOurHands.html.

Copyright 2002 by American Hospital Association. Reprinted with permission. Work-Life HarmonyGrowth Afﬁ liation Rewards Safety/ Security 60% 50% 40% 30% 20% 10% 10%Health Care Employers Employers in General The Performance Pyramid™ Component Expectations Not Met 598 OCTOBER 2005 • V OLUME 9, N UMBER 5 • C LINICAL JOURNAL OF ONCOLOGY NURSING jm Book Excerpt.indd 598jm Book Excerpt.indd 598 9/19/2005 2:41:59 PM9/19/2005 2:41:59 PM Company, 2000a). The following strategies may be familiar to you or might help strength- en a system you already have in place.

1. Cultivate an interesting and accepting culture. This comes from the top lead- ership of the organization and trickles down to the manager. A manager who understands diversity and promotes an atmosphere where everyone can be en- gaged in working together in harmony will get a lot of mileage from staff. Nurse managers who are seen by their staff as always displaying a positive attitude, no matter how stressful and challenging a day can be, will ﬁ nd that it rubs off on staff when positive comments are heard from patients and staff from other departments. Retention is maintained in a culture where nurses feel they make a difference, their talents are tapped, and their contributions are acknowledged. To make the work environment interesting, staff can be competitive and join hospital- sponsored contests, such as holiday deco- rating contests, which promote teamwork and bolster morale. They also can submit entries to contests by nursing magazines such as “The Best Nursing Team Con- test” sponsored by Advance for Nurses.

Activities that bring pride to a unit foster teamwork and, most of all, retention.

2. Implement professional clinical/career ladders.This opportunity gives the nurse autonomy and a sense of accomplishment and value, as well as a way to impact per- sonal earnings based on the level achieved in the clinical/career ladder.

3. Develop ﬂ exible work arrangements.

Empower staff to participate in self- scheduling; make the full-time beneﬁ ted positions less than 40 hours a week (32 or 36 hours). Staff is able to schedule around work and personal activities to af- ford them ﬂ exibility to balance work and home. With guidance and directions from the nurse manager, this is a major gain for the staff to feel empowered to have some control over their work schedule. For this to work, it requires some give and take on the part of the staff.

4. Offer encouragement, praise, and rec- ognition.Making employees feel that they are valued by the organization often is revealed as one of the highest reasons for retention. A manager who gives im- mediate recognition for a job well done often will ﬁ nd the employee striving to do better and better. A pat on the back always works, as it makes the employee know that you care and that you are paying at- tention. Depending on the situation, some praise is better given on a one-to-one basis and other times in front of an audience. Sharing letters of compliments written to senior administrators from patients and family and posting thank you cards from patients and their families are examples of recognizing staff for quality care.

Another form of recognition comes from staff themselves sharing praises giv- en by employees from other departments or from patients. Hospitals have their own programs for recognizing employees who go the extra mile. At Emory Healthcare, a program called “I just noticed you do- ing something special” allows patients, visitors, and employees to write on a card any exceptional action that an employee did. The card is faxed to the patient re- lations ofﬁ ce, and a quarterly drawing for a customer service award gives the employee a chance to win a cash prize.

Individual organizations will have ways of recognizing and rewarding employees to express value and appreciation. These activities should be encouraged. Every unit has its own way of recognizing staff:

an employee of the month/quarter award, a casual dress day, and celebrating various holidays and staff special occasions. A good idea is to engage the physicians of a unit to donate prizes for employees of the month/quarter and for the staff to do special things for other members of the healthcare team, including physicians, so- cial workers, and pharmacists. Branham (2001) reported that many managers be- lieve that employee retention is primarily tied to money, but in survey after survey, financial compensation is only one of many factors employees cite as a reason to seek or leave an employer.

5. Encourage direct manager-to-employee communication. According to Ribelin (2003), nurses do not leave hospitals, they leave managers. In an interview conducted by a manager of her own unit, staff nurses were asked what they like in a manager.

Being approachable came to their minds right away. A manager with an open door policy who allows them the opportunity to voice concerns or express apprecia- tion is another characteristic they liked.

Getting back with employees and follow- ing up on their concerns shows that the manager listens. Often a manager can be overwhelmed with paperwork, deadlines, or meetings and is unable to meet with staff on a regular basis. Meeting with staff face-to-face at least every month allows them to ask questions about new policies or changes in practice that may come to them in memos or announcements. You can tell the difference with a staff who is well informed and those who are not by looking at compliance on different audits done either by their own unit or by other departments.

A staff that is well informed will most likely work to show ﬁ duciary responsibil- ity when it comes to the unit budget re- lated to supplies or stafﬁ ng. Making time to meet with staff is something that must be emphasized with managers. One staff meeting a month that covers only a certain shift will not do. Expecting the staff to come in on their days off to attend staff meetings has not worked. The manager must be ﬂ exible to meet the needs of the staff and schedule several meetings that will cover all shifts, including weekends.

A manager who has frequent face-to-face communication with staff will reap the rewards of a high-performing unit.

6. Competitive compensation and bene- ﬁ ts. Even though salary is not the number one reason for retention, it does come up somewhere along the line. Most young nurses are lured by higher paying institu- tions or those who offer sign-on bonuses.

Unlike their more experienced coun- terparts, beneﬁ ts do not seem to retain younger nurses. Nurses with less than one year in the profession are more likely to quit their jobs (Reilly, 2003). The future is too far for them to imagine, and they do not want to think of retirement money or beneﬁ ts such as tuition reimbursement.

They want to see the money that comes in their paychecks now, either because they have a student loan to repay, a new apart- ment to furnish, or a new car payment.

Hospitals, therefore, have to compete with salaries within the metro area. It then be- comes imperative that hospitals conduct an ongoing market survey of compensa- tion. It is also important for compensa- tion specialists to make sure that nurses with longevity are not paid less than new hires. On exit interviews of operating room nurses (Nissen, 2003), a nurse was humiliated when she found out she was training someone who was making $2 more an hour. This could be vital in reten- tion. Nurses should be paid for the profes- sional service that they provide (Holcomb & Kornman, 2002). Most nurses who try to balance their professional and personal lives will stay with hospitals that offer services such as child care, dry cleaning, car washing, housekeeping, and banking (Neuhauser, 2002).

7. Develop mentoring and preceptorship programs. Nurses with less than one year in the profession are most likely to quit their job, making it critical that veteran nurses lend support to their rookie colleagues (Reilly, 2003). Emory Hospitals in Atlanta take pride in their C LINICAL JOURNAL OF ONCOLOGY NURSING • V OLUME 9, N UMBER 5 • R ETENTION AND RECRUITMENT : REVERSING THE ORDER 599 jm Book Excerpt.indd 599jm Book Excerpt.indd 599 9/19/2005 2:41:59 PM9/19/2005 2:41:59 PM residency programs for new graduates in the oncology, operating room, critical care, emergency room, and medical-sur- gical ﬁ elds. The residency programs vary in length from six months to a year. The specialty residency combines classroom learning with precepted skills and leader- ship development. New graduate nurses as well as novice specialty nurses are transitioned to their role as professional or specialty nurse with conﬁ dence and less anxiety.

8. Streamline paperwork. Nurses are re- portedly spending more and more time documenting/charting and cite this as a dissatisﬁ er. Nurse executives should ﬁ nd ways and resources to support computer- ized/electronic documentation.

Retention Reﬂ ects Leadership Style The management skills and attributes of the nurse manager enhance job satisfaction, sustain organizational commitment, and encourage retention (Boyle, Bott, Hansen, Woods, & Taunton, 1999). Managers are critical components in building a strong workforce (Ribelin, 2003). It is essential that the nurse manager be fully engaged with staff. The manager is the key player in advocating and implementing a culture of workplace retention. Managers often struggle with accomplishing all the goals set by the organization while wearing mul- tiple hats and trying to maintain balance and energy. Grove (1995) wrote that the single most important aspect of managerial output is the organizational unit under the supervision or inﬂ uence of the manager.

Output is more than the sum of daily activi- ties around achieving objectives; it is actual outcomes achieved based on project goals.

These outcomes are not achieved by “I” but through a “TogetherEveryone Achieves More” attitude, headed by a dynamic and visionary leader who can get things done through and with others.

One strategy to assist the manager in achieving the desired organizational goals is to leverage the activities needed to achieve the outcome. Leverage is the measure of in- creased power of purposeful action to achieve movement (Barnhart & Barnhart, 1991, p.

1204). Leverage can be positive or nega- tive. An example of positive leverage is the manager who delegates (an essential aspect of a successful manager) with clear direction and effectively communicates expectations, timelines, and outcomes. On the other hand, an example of negative leverage is a manager who pretends to delegate but continues to mi- cromanage the delegated tasks. This negative leverage stiﬂ es employee growth potential, which leads to underdevelopment and dissat- isfaction of the employee and does not bode well for the organization under the leadership of such a manager. The leadership style of the nurse manager should reﬂ ect ﬂ exibility, responsibility, efﬁ ciency, customer-focused innovation, and proﬁ tability (Ribelin, 2003).

The nurse manager should strive for con- sistency and regularity in management style and approach, manage and disseminate information, and facilitate communication and collaboration through consultation and consensus with subordinates and se- nior management. Keep your pulse on the activities within the organization through personal contact with employees. Man- age by walking around. Do not get caught up day-after-day laboring over countless e-mails and telephone conversations and neglect contact with grassroots staff. Do not underestimate the value of physical pres- ence to the frontline staff. Leverage your actions to achieve desired organizational outcomes. Remember to take care of the people who take care of the patients. Nurse Manager Retention As a nurse leader and manager, ask for what you need in terms of formal develop- ment and education to maximize effective- ness in your role. It is recognized, although not often acknowledged, that the ﬁ rst-line manager provides the glue that holds the hospital together. The question that is often not asked is where is or who provides the glue that holds the nurse manager together?

In a study by Parsons and Stonestreet (2003), six themes were recorded in interviews with nurse managers related to factors that contribute to their retention: (a) communi- cation—ability of their boss to listen and provide guidance, effective communication, clear expectations, and feedback, (b) admin- istrative management philosophy—included an opportunity to participate in decision making and empowerment to manage, (c) effective administrative systems—avail- ability of and access to resource manage- ment systems, meaningful orientation and professional development systems, and manager compensation systems, (d) suc- cessful personal practices—balance in life and work, (e) quality of care—the ability to support systems and processes to deliver quality patient care and safety, and (f) reten- tion—79% of the nurse managers participat- ing in the study verbalized plans to remain in their roles. However, they reported that they would leave their job when they could no longer ensure quality of care because of stafﬁ ng shortages. With these factors in mind, it is important for the ﬁ rst-line manager as well as the se- nior administrative manager to mentor and develop staff at all levels. The job satisﬁ ers and motivators are often the same regardless of job title. Employer of Choice If the revolving door of recruitment and turnover could be stopped or slowed down, the vacancy rate for a given institution would be signiﬁ cantly curtailed. So what is this retention culture anyway? Retain- ing highly skilled staff in the workplace is coveted as silver and gold. The goal in the workplace for the managers and leaders is to become known in the healthcare and business sector as the healthcare employer of choice. That is to say, the institution is the one magnet workplace that people in the local area and people looking to work in the area want to seek employment. The respon- sibility for creating that environment of job satisfaction and sense of value, worth, and family lies, in large part, with the manager, backed by the senior level management.

The healthcare leadership is responsible for creating an organizational culture and must adopt a “culture of caring.” Within this culture of caring are employee expecta- tions coupled with commitment to integrity, value, compassion, respect, recognition, and truth. Kouzes and Posner (1999) wrote on the principles and practices that support the basic human need to be appreciated and valued for contributions.

Recruitment Word of the seriousness of this current and future nursing shortage has reached a large audience outside of the nursing profession. This interest has brought new stakeholders into the mix to partner with professional nursing organizations to pre- serve the health care of Americans. Be- cause of the magnitude and complexity of the nursing shortage, there has been an outpouring of interest and support from the private sector and corporate and gov- ernmental agencies offering to partner with professional nursing organizations by employing short- and long-term strategies to eliminate the nursing shortage. Recruit- ment into the nursing profession brings a quagmire of issues, challenges, and oppor- tunities unlike any other.

There is also heightened awareness that strategies and solutions of the past will not meet with past successes. A key rea- son for this revelation is that the changing demographics such as age distribution and 600 OCTOBER 2005 • V OLUME 9, N UMBER 5 • C LINICAL JOURNAL OF ONCOLOGY NURSING jm Book Excerpt.indd 600jm Book Excerpt.indd 600 9/19/2005 2:42:00 PM9/19/2005 2:42:00 PM multigenerational issues are impacting re- tention of nurses as well as recruitment into the nursing profession. In a report by Kim- ball and O’Neil (2002), a key recruitment strategy should be to focus on recruiting a more diverse nursing workforce, with both ethnic and racial minorities as well as men.

In 2000, men constituted 5.4% of the RN pool in the United States, up from 2.7% in 1980 (Sagon, 2003). Figure 12-2 depicts the percent of women in healthcare careers and shows an actual decline between 1989 and 1999—an opportunity to recruit more men into nursing. Figures from the U.S. Census Bureau (2000) and Health Resources and Services Administration (HRSA) (2001), outlined in Figure 12-3, show the racial composition (African American, Hispanic, and American Indian/Alaskan Native) of the U.S. population versus the percentage that are RNs. This ﬁ gure illustrates a need to recruit a more diverse RN workforce and to meet the changing demographics of a more diverse patient population. The new nurse workforce will need to be recruited from the population who is younger than 30, which is more diverse and will create an even greater dislocation, in the future, if nurses from this current generation are not successfully recruited into the profession (Kimball & O’Neil, 2002). Other recruitment challenges lie in the plethora of labor force options for women and the multigenerational issues of the generation X employee. A more detailed discussion of the multigenerational issues can be found in Chapter 2. Some of the multiple negative indicators affecting retention also impact recruitment (see Figures 12-4 and 12-5). It is important to offer long-term retention incentives for the applicant seeking employment within your organization as well as current em- ployees you desire to retain. Specialty Nurse Recruitment The past two decades have witnessed an erosion of specialty, disease, or symptom- based nursing units and, in some cases, services. These units or services often were small and were sacriﬁ ced to the administra- tive budgets as administrators struggled with balancing healthcare revenues and expenses. The philosophy of “no margin, no mission” was likely in the forefront of decision making to downsize and, in some cases, eliminate specialty units such as on- cology in areas across the country.

As patient care services for some diag- noses shifted to ambulatory services, the demand for the oncology beds in com- munity hospitals felt the decline in census and inpatient revenue, forcing tough deci- sions. The units were reconﬁ gured usually for medical-surgical beds, and staff that remained gave up their specialty identity.

Another cost-cutting measure across many hospitals, academic and community, was to downsize master’s prepared advanced practice nurses (nurse practitioners as well as clinical nurse specialists). The loss of these experts along with the dissolving of the specialty unit had the potential to im- pact quality cancer care (Lamkin, Rosiak, Buerhaus, Mallory, & Williams, 2001; Satryan, 2001).

Recruitment and education of specialty nurses is often more challenging and expen- sive than recruiting for generalist nurses.

The specialty nursing expertise is generally obtained on the job, all the more reason to make every effort to retain the experienced specialty nurses, whether oncology, critical care, emergency department, or operating room. Offering internship and residency pro- grams in areas of specialty nursing will serve to attract generalist nurses and new graduate nurses to the specialty. Partner with local specialty nursing organizations as a means to offer networking opportunities to the new specialty nurse. Professional, Public, and Private Partnerships The U.S. Department of Labor (2004) pro- jected a 27% increase in the need for nurses nationwide from 2002–2012. There have been a number of initiatives launched over the past ﬁ ve years that have focused on reversing the nursing shortage. Groups that participate with partnering professional nursing orga- nizations include the Robert Wood Johnson Foundation, Johnson & Johnson (Campaign for Nursing’s Future), American Hospital Association, federal government (Nurse Re- investment Act Legislation), and HRSA, just to name a few. These multifaceted initiatives have begun to make an impact. In June 2003, the U.S. Department of Health and Human Services announced awards of $3.5 million in grants to promote diversity in the nursing workforce. These funds are earmarked to support disadvantaged students, including those from racial and ethnic minorities who are underrepresented among RNs.

Remember the projection is that there will be in excess of a million nurses needed within the next seven years. The work is not ﬁ nished. Look within your community for opportunities to bolster the image of nurses and promote nursing to all as an honorable and sustaining profession.

Reach out to youth in schools and youth organizations to promote nursing as a career choice. Offer to mentor a young student who expresses interest in the profession.

Bring them into your work setting for a day.

Share with them the rewards of a career in nursing.

Recruiting Internationally When American healthcare organizations recruit internationally, it impacts the nursing FIGURE 12-2. P ERCENTAGE OF WOMEN IN HEALTH CAREERS Note.FromIn Our Hands: How Hospital Leaders Can Build a Thriving Workforce (p. 48), by American Hospital Association, Commission on Workforce for Hospitals and Health Systems, 2002, retrieved February 7, 2004, from http://www.aha.org/aha/key_issues/workforce/commission/InOurHands.html.

Clinical laboratory technolo- gists and technicians Dieticians Occupational therapists Radiologic technicians Registered nurses Social workers Speech therapists Nursing aides, orderlies, and attendants Physical therapists Licensed practical nurses 0% 20% 40% 60% 80% 100%1989 1999 CLINICAL JOURNAL OF ONCOLOGY NURSING • V OLUME 9, N UMBER 5 • R ETENTION AND RECRUITMENT : REVERSING THE ORDER 601 jm Book Excerpt.indd 601jm Book Excerpt.indd 601 9/19/2005 2:42:00 PM9/19/2005 2:42:00 PM shortage in a global way. Foreign nurses often are attracted to the higher standard of living, earnings potential, and many other benefits of working in America, leaving their home healthcare system with fewer nurses. However, Christmas (2002) pointed out those organizations investigating foreign nurse recruitment should ﬁ rst focus inter- nally on retention initiatives prior to making a commitment to recruit from abroad. There are numerous strategies involved in planning to recruit an international nursing pool.

The manager must be attuned to the needs of the foreign nurse prior to and after recruitment. These needs include ﬁ t within the culture of the organization, language, social- ization, support structures, licensure, work- ing or permanent resident visa, and ﬁ nancial resources. When a hospital decides to recruit foreign nurses, a designated person from nursing administration may be assigned as the point person to work hand in hand with human resources. The hospital may choose to send a nurse manager and a nurse recruiter from human resources to go to the foreign country or countries of choice to personally interview applicants. Applicants can come from an agency in that country or an agency based in the United States that has its pool of applicants in that foreign country. A contract between the hospital and the agency of choice must be signed before the process begins.

A hospital also may choose to interview by phone the applicants chosen by the agency, provided a resume is on hand. Once the interview is done, a contract is offered to the foreign nurse by the hospital representative or the designated agency. Necessary paper- work must be submitted by the applicant to process the visa application. Paperwork must include copies of passing TOEFL (Test of English as a Foreign Language) results, a passing CGFNS (Commission on Graduates of Foreign Nursing Schools) certiﬁ cate or result, or a passing NCLEX–RN (National Council Licensure Examination for Regis- tered Nurses) result, transcript of records, let- ters of recommendation, and a contract with the sponsoring hospital. An application to the Bureau of Citizenship and Immigration Ser- vices together with the application for Alien Employment Certiﬁ cation must be ﬁ lled out by the hospital designee. An approval or denial letter will be sent to the hospital of- ﬁ cial who signed the petition. If the petition is approved, paperwork will be forwarded to the U.S. embassy where the applicant resides. The embassy will notify the nurse of the approval and a list of requirements prior to the interview date, when the appropriate visa is given. Once the nurse receives the visa, ﬂ ight schedules can be arranged by the recruitment agency or a travel agency chosen by the hospital. Depending on the type of visa applied for, the process can take from several months (for working visas) to two years (for permanent resident visas). Prior to the nurse arriving in the United States, someone from the hospital (usually human resources) will be responsible for arranging housing. It is a good idea to identify nurses in the organization to serve as their adoptive sisters to orient them to the country and show them around their new environment. Transportation to and from the hospital must be arranged if their hous- ing is not within walking distance. A good thorough orientation will be key to successful integration into the system. A warm welcome from the nurses and other employees within the hospital will help early adaptation to the new workplace. Foreign nurses have been known to stay with the hospital that recruited them as a sign of gratitude and loyalty. The FIGURE 12-4. N URSE RECRUITMENT STRATEGIES • Sell the organization and unit (do not make false promises or paint a false picture).

• Create a shared vision.

• Market the image of nursing.

• Improve the work environment.

• Offer nurse internship and residency programs for novice nurses into a specialty.

• Develop institutional nurse reentry education and training programs.

• Recruit retired nurses to form the basis for a professional mentoring corps.

• Make the interview work for you.

• Develop an in-depth orientation program to attract new graduate nurses.

• Form some community alliances with local schools; visit on career days; give interact ive health presen- tations; sell nursing to the next generation; talk about the rewards of nursing, service, and healing.

• Foster relationships with nursing students and faculty.

• Create a learning and mentoring environment for nursing students.

• Go to local nursing schools and provide a pizza luncheon to students during ﬁ nal examination week.

• Offer an educational program and skills fair for faculty at local schools of nursing.

• Offer recruitment fairs on-site and offer tours of specialty areas.

• Offer an on-site National Council Licensure Examination review course for new graduates waiting to take the State Board Examination.

• Offer recruitment incentives to new hires and current staff.

• Offer service cancelable student loan repayment packages.

• Conduct prompt follow-up with applicants to schedule interviews and facility tours.

• Add a personal touch when calls come in from prospective applicants; put the “human” back in human resources.

• Find a way to personally respond to inquiries of available positions, especially if there is an online application process.

• Provide a hassle-free interview encounter; facilitate parking; and avoid applicant waits and delays when it is a scheduled interview.

• Value workplace diversity.

• Partner wi th local specialty and diverse nursing organizations.

• Offer competitive salary and beneﬁ t packages. FIGURE 12-3. R ACIAL COMPOSITION OF U.S. P OPULATION AND RN S, 2000 Note.From In Our Hands: How Hospital Leaders Can Build a Thriving Workforce (p. 47), by American Hospital Association, Commission on Workforce for Hospitals and Health Systems, 2002, retrieved February 7, 2004, from http://www.aha.org/aha/key_issues/workforce/commission/InOurHands.html.

Copyright 2002 by American Hospital Association. Reprinted with permission. U.S. Population RN Supply 13% 16% 19% 12% 15% 10% African AmericanHispanic American Indian Alaskan Native 602 OCTOBER 2005 • V OLUME 9, N UMBER 5 • C LINICAL JOURNAL OF ONCOLOGY NURSING jm Book Excerpt.indd 602jm Book Excerpt.indd 602 9/19/2005 2:42:00 PM9/19/2005 2:42:00 PM majority of foreign nurses have become very successful in their careers and have proven to be great assets to their adoptive healthcare institution.

The advent of the nursing shortage ex- tends beyond the borders of the United States. In a recent publication on ethical issues in the recruitment and retention of graduate nurses, Johnstone and Stewart (2003) reported on mounting concerns in Australia that by the year 2010, Australia will face a shortage of 40,000 nurses. As a consequence of this concern, one Aus- tralian state has given rise to a computer match service. This service, a recruitment strategy aimed at matching new gradu- ate nurses across participating healthcare organizations, is challenged to distribute the nurses equitably within this Australian state. Reports of unethical recruiting strat- egies by healthcare facilities in the region has drawn criticism of the tactics used by some to entice nurses away from one em- ployer to another. Unfortunately, the new nurses are not ﬁ nding the promises being kept by the employer once they change from one job to another; hence, the nurses are left feeling unsupported, cheated, and disillusioned (Johnstone & Stewart).

The concerns of nurse leaders in Australia seem to mirror many of the same issues and challenges facing healthcare organizations and nurse leaders in America. Recruiting and retaining new and experienced nurses is critical to the survival of the healthcare system, patient care, and safety. Conclusion Adopting a culture of retention is key to organizations maintaining adequate staff- ing levels to meet the complex care needs of patients. It is imperative that employees feel empowered, in control of their own performance, and willing to help move the organization to achieve its strategic goals (Troﬁ no, 2003). Nurse managers must be actively engaged in implementing strate- gies to promote job satisfaction and retain a viable workforce of RNs. Engage staff in assessing the work environment and culture of retention. Work within your individual circle of inﬂ uence to make a difference in reducing turnover and promote a culture of retention. The recruitment strategy should be one of bringing new people into the profession, not merely relocating nurses who are already employed. Ensure that your organization is committed to being an employer of choice for current and future nurses.

References Advisory Board Company. (2000a). Best prac- tices in retention. Executive summary. Wash- ington, DC: Author.

Advisory Board Company. (2000b). The nurse executive center. The nurse perspective: Nurse job satisfaction and turnover. Washington, DC: Author.

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Buerhaus, P., Donelan, K., DesRoches, C., Lamkin, FIGURE 12-5. N URSE RETENTION STRATEGIES Value and respect staff.

• Break down any caste system.

• Empower staff to be involved in decision making that directly affects their work and practice.

• Support shared governance within the workplace.

• Provide timely coaching and counseling.

• Recognize and reward high performers.

• Use progressive discipline to remove poor performers who consume too much time and have a nega- tive effect on overall staff morale.

• Work with staff to create unity and harmony and promote a sense of teamwork.

• Treat staff like adults; they do not need a mother or father.

• Establish open and honest communication.

• Treat staff fairly.

• Embrace and teach corporate values.

• Offer educational development.

• Conduct a skills fair annually for all clinical staff.

• Provide pai d time off for continuing education.

• Offer residency or internship programs in specialty areas.

• Offer scholarships or percent reimbursement for formal career education.

• Develop leadership opportunities for staff.

• Be a mentor.

• Assign a consistent preceptor to the new orientee.

• Adjust patient assignments of the preceptor to allow ample time for teaching.

• Create a learning organization.

• Implement RN clinical/career ladders.

• Maintain functional and state-of-the-art equipment for staff.

• Provide appropriate stafﬁ ng.

• Seek volunteers when overtime is needed.

• Listen and take immedi ate action regarding workplace concerns from staff.

• Offer self-scheduling.

• Offer ﬂ exible work hours and/or job sharing.

• Offer competitive compensation and beneﬁ ts.

• Offer a package that includes health, education, and retirement beneﬁ ts.

• Take ownership for retention in your area of responsibility.

• Engage staff in taking ownership for workplace retention.

• Encourage collaborative relationships between physicians and nurses.

• Provide challenging work opportunities for professional growth.

• Work with multigenerational issues.

• Inject some spontaneity in the staff work day with FUN. • Celebrate successes (e.g., high patient satisfaction scores) with simple things such as pizza or an ice cream treat, theater tickets, a spa day, or a ﬁ tness center membership.

• Decorate your unit during holidays and enter contests if sponsored by the institution.

• Enter your unit in contests such as “Best Nursing Team Contest” sponsored by a nursing magazine.

• Write articles about your unit for celebrations and recognitions received and publish it in your institu- tion’s newsletter.

• Conduct exit interviews and make personnel and/or environmental adjustments as needed. • CLINICAL JOURNAL OF ONCOLOGY NURSING • V OLUME 9, N UMBER 5 • R ETENTION AND RECRUITMENT : REVERSING THE ORDER 603 jm Book Excerpt.indd 603jm Book Excerpt.indd 603 9/19/2005 2:42:01 PM9/19/2005 2:42:01 PM L., & Mallory, G. (2001). State of the oncology nursing workforce: Problems and implications for strengthening the future. Nursing Econom- ics, 19(5), 1–11.

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Institute of Medicine. (2003). Substantial changes required in nurses’ work environ- ment to protect patients from health care errors. Retrieved February 7, 2004, from http://www4.nationalacademies.org/news .nsf/isbn/0309090679?OpenDocument Johnstone, M.J., & Stewart, M. (2003). Ethical issues in the recruitment and retention of gradu- ate nurses: A national concern. Contemporary Nurse, 14, 240 –247.

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Sagon, E. (2003). Nursing recruiters tailor pitch to men.Arizona Republic. Retrieved July 15, 2003, from http://www.azcentral.com/arizona republic/business/articles/0715nurses15 .html Satryan, M. (2001). The oncology nursing shortage and its impact on cancer care services. Oncology Issues, 16(1), 21–23.

Sengin, K. (2003). Work-related attributes of RN job satisfaction in acute care hospitals. Journal of Nursing Administration, 33, 317–320.

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Troﬁ no, J. (2003). Power sharing: A strategy for nurse retention. In H. Feldman (Ed.), The nurs- ing shortage: Strategies for recruitment and retention in clinical practice and education.

New York: Springer Publishing.

U.S. Census Bureau. (2000). Proﬁ les of general demographic characteristics, 2000. Washington, DC: Author.

U.S. Department of Labor. (2004). 2004 – 05 edi- tions of the Occupational Outlook Handbook and the Career Guide to Industries available on the Internet. Retrieved August 18, 2004, from http://www.bls.gov/news.release/pdf/ooh.pdf U.S. General Accounting Ofﬁ ce. (2001). Nursing workforce: Emerging nurse shortages due to multiple factors. Report to the chairman, Sub- committee on Health, Committee on Ways and Means, House of Representatives. Retrieved February 25, 2004, from http://www.gao.gov/ new.items/d01944.pdf Wagner, C.M., & Huber, D.L. (2003). Catastrophe and nursing turnover. Journal of Nursing Admin- istration, 33, 486 – 492. Recommended Web Sites to Visit American Hospital Association Commission on Workforce for Hospitals: www.aha.org/aha/ key_issues/workforce American Nurses Association: www.nursing world.org Bureau of Labor Statistics: www.bls.gov Forum on Healthcare Leadership: www.health careforum.org Historically Black Colleges and Universities:

www.doi.gov/hrm/black.html Johnson & Johnson’s Campaign for Nursing’s Future: www.discovernursing.com Leapfrog Group: www.leapfroggroup.org Male Nurse Magazine: www.malenursemagazine .com Minority Nursing Associations: http://ninr.nih .gov/ninr/research/diversity/minority_assoc .html National Alaska Native American Indian Nurses Association: www.nanaina.com National Association for Equal Opportunity in Higher Education: www.nafeo.org National Association of Hispanic Nurses: www .thehispanicnurses.org National Black Nurses Association: www.nbna .org National Coalition of Ethnic Minority Nurse As- sociations: www.ncemna.org National League for Nursing: www.nln.org Nurses for a Healthier Tomorrow: www.nurse source.org Oncology Nursing Society: www.ons.org Philippine Nurses Association of America, Inc.:

www.pnaa03.org Transcultural Nursing Society: www.tcns.org 604 OCTOBER 2005 • V OLUME 9, N UMBER 5 • C LINICAL JOURNAL OF ONCOLOGY NURSING jm Book Excerpt.indd 604jm Book Excerpt.indd 604 9/19/2005 2:42:01 PM9/19/2005 2:42:01 PM