Nursing Workforce

Issues and Initiatives Retention Initiatives Always a part of the dialogue surrounding nurse shortage and staffing issues is retention of the nursing workforce. Hospitals and other employers are consistently looking for ways to keep good nurses. Over the years many ideas have been generated by staff nurses and nurse leaders for making the work of nurses more satisfying and rewarding. Some of our members’ initiatives have been highlighted in the ICNR quarterly Retention Newsletter. Other hospitals have sought and received Magnet status. Further initiatives are being “tested” through the Department of Commerce and Economic Opportunity’s Critical Skill Shortages Initiative. Some of these initiatives are described here.

Magnet Award for Nursing Excellence - Twelve Illinois hospitals have received the American Nurses Credentialing Center’s Magnet Award for Nursing Excellence, the highest award a hospital can receive for outstanding achievement in nursing services. While about 3% of the nation's hospitals achieve Magnet status, Illinois hospitals are at 6%. Congratulations to the following hospitals:

• Advocate Christ Medical Center, Oak Lawn
• Advocate Lutheran General Hospital, Park Ridge
• Children’s Memorial Hospital, Chicago
• Delnor-Community Hospital, Geneva
• Edward Hospital, Naperville
• Methodist Medical Center of Illinois, Peoria
• Northwest Community Hospital, Arlington Heights
• Northwestern Memorial HealthCare, Chicago
• OSF St. Anthony Medical Center, Rockford
• OSF St. Francis Medical Center, Peoria
• Rehabilitation Institute of Chicago
• Rush University Medical Center, Chicago ¹⁵

Additionally Northwest Community Hospital was the only healthcare employer in Illinois named to the Fortune “100 Best Companies to Work For List” and Centegra Health System is the only healthcare employer in Illinois to be named to AARPs Best Employers for Workers over 50 list.

Nurses’ Week Activities
Although employers need to recognize and reward nurses for quality patient care all of the time, Nurses’ Week has become a special “holiday” for recognition of nurses. It is usually the first full week in May, with Monday of that week being designated Nurses’ Day in hospitals and other provider settings across Illinois. Hallmark and American Greetings have also gotten into the Act and Nurses’ Day cards can be found “anywhere cards are sold”.

The ICNR Retention Committee has published in its June Newsletter for the past two years some of the activities ICNR members have enjoyed during Nurses’ Week. A summary list of ideas and celebration activities is presented here:
Written thanks and PR
Letter to the editor of the local newspaper from the CEO about the dedication of the nurses to the community.
Notes/ individualized cards from the CEO, the physicians, the CNE and/or nurse managers to each nurse thanking her/him.
Unit /department gifts (don’t forget off-site/ remote-site nurses):
Basket of popcorn, chips, Twizzlers, M&Ms, and Crystal Light packets.

• Goody bags and personalized cookie from Mrs. Fields Cookie's. The goody bags consisted of lots of chocolate, hard candy, fruit, chips, popcorn, trail mix and other edible goodies. We decorated each bag and attached a note saying thank you. The goody bags and cookies were delivered to each unit by the entire Nurses Week committee. This year we delivered the goody bags with a cheer "2-4-6-8- who do we appreciate?" "Nurses!" The staff enjoyed the pleasant interruption in their day!
• Cake distribution to nurses by senior leadership on the PM and night shifts.
• Hand massages delivered to the nursing units by Mary Kay.

Gifts to each nurse:

License plate frame with the Hospital and Nurse Week logo
“Bath and Body Work” items
Logo drinking bottles
10% discount at bookstore or gift shop to all nurses.

Events:

• Style show. Use local businesses for apparel, nurses as models.
• Raffles for Nurse Week prizes. (donated by local businesses).
• Daily Drawings – We purchased 50 copies of the book Chicken Soup for the Nurses Soul with a label placed inside commemorating the week. Ten winners were posted daily throughout the week.
• Godiva Coffee Break open to all employees.
• Speakers and special programs- (Art of Storytelling)
• Picnic celebration during work hours in honor of “Nurse’s Day” for $3.00, open to all employees.
• Nurses’ tea. Leadership bakes the goodies and hosts the tea for our staff. Our CEO Visits with staff during this event. Additionally, one of our staff created a music video featuring pictures of many of our nurses at work (and at play) in our hospital.
• Night shift "Pot Luck" Main courses provided with specialty dishes brought by staff to share in celebration of one another recognizing the off shift RN. Open to all employees.
• Nursing Clinical Governance Fair. Each nursing council --practice, education, research, leadership, advanced practice, quality, clinical progression, and staffing/scheduling-- present posters on nursing accomplishments from the past year. The fair markets the work of the nursing department and is an excellent networking opportunity for nurses. Professional Networking is enhanced by food and the distribution of a nurse’s week gift during the fair. Nurses may participate in a game by identifying fun facts about the clinical governance councils. Those who complete the game enter a drawing for special prizes.
• Educational Forum open to all employees hosted by Surgery. Power point presentation and equipment demonstration featuring heart lung machine put on by CV perfusionists. Physician, staff and Vendor supported.
• Poster board presentation recognizing the efforts of the role of the RN in operations improvement. Special projects featuring unit specific pilots such as the CAA, admission process, and discharge process.
• Breakfast the Nurse Managers make for the staff.
• Nondenominational blessing of the nursing staff. Three different sessions were conducted by the chaplains in order to accommodate nurses on all shifts.
• Vendor fair with lunch. Nurses enjoyed talking with representatives and learning more about the products that we use.
• Annual staff meeting and open forum with the CEO and VP of nursing. This included lunch and our semiannual presentation of the "Charting the Course" magnet awards.
• Speakers Day. We had three different sessions addressing ethics, hospice, or aromatherapy.
• "Cookie drop" where the shared governance officers personally delivered cookies to all nursing units on the night shift.

Clinical Nurse Excellence Awards and events:

Nominees received a certificate, fleece imprinted blanket and a personalized note pad. Winners received a traveling plaque, gift certificates to local restaurant and a book. Appetizers and cake served by R&R members. Event held to celebrate nurses who have been nominated by their peers for excellence in the role of: acute setting, non-acute setting, mentor ship, advanced role categories. Educational $50.00 certificates and excellence pins to nominees. Crystal award to winner.

• We had a recognition program to allow staff from each unit to nominate the RN, LPN, or CNA for a nursing excellence award. The criteria focused on the employee’s performance and support of Passavant area hospital's mission and professional nursing practice. A committee reviewed the nominations and selected the person from each unit that should be recognized. They received a certificate, flowers, and their name to be posted in each unit as receiving the award.
• Nursing Recognition Video "Many Roles, One Profession". Played for staff throughout the week recognizing the role of the RN.
• Awards banquet attended by recipients and nominees (and their guests) for the departmental awards for leadership and mentoring. This is an elegant formal dinner, but also a fun and uplifting event.

This year we hosted a coffee as a thank you for the entire hospital for their support of nursing and had an educational session for the staff with an open house from the OR that demonstrated a variety of procedures and equipment.
Fundraiser to obtain supplies for nurses serving in Iraq. We also made a video that captured nurses in their varied roles and set it to music for display at a variety of activities.

• Raffle for IRAQ RN's which raised money for families with relatives in IRAQ or Armed Forces. Raffle prizes gathered by the R&R members from local community and distributed during Nurses Week.

I received a lot of positive comments over the green water bottles with the Rush logo on thAuthor: Diana Halfer, RN, MSN, Children’s Memorial Hospital – dhalfer@childrensmemorial.org

Introduction
It is often a distressing time for the graduate nurse when making the transition from the role of a student in a protected academic environment to the reality of becoming an independent competent RN. At Children’s Memorial Hospital, an American Nurses Credentialing Center designated Magnet hospital; the RN Internship Program was implemented to transition the graduate nurse into a confident and proficient pediatric nurse. The RN Internship Program is based on the Benner’s novice-expert framework and Malcolm Knowles Adult Learning Theory. The program’s purpose is to bridge the gap between school and the clinical arena of pediatric nursing and prepare nurses that think critically and have the ability to manage acutely ill pediatric patients. New graduate nurses are transitioned into the nursing department at Children’s Memorial Hospital by participating in the RN Internship Program. The RN Internship Program has been partially funded through a Department of Health Human Services, Health Resources and Services Administration (HRSA) three-year award (9/03-6/06) for $640,000.

Program Impact
The impact of the RN internship program on both the recruitment and retention of graduate nurses has been dramatic. The hospital has experienced a 39% increase in the hiring of graduate nurses and a 50% reduction in turnover in the first year of employment. The success of this program has supported the hospital’s expansion of inpatient services. Graduate nurses learn about the internship program during their nursing student clinical rotation at Children’s Memorial, by attending the annual student nurse conference, and through viewing career development opportunities on the nursing web page at www.childrensmemorial.org.

Program Design
The length of orientation for the graduate nurse was increased to one year to incorporate enriched learning and mentoring experience. The RN Internship Program consists of five areas to transition graduate nurses to becoming confident competent pediatric nurses in a tertiary care setting.

Pediatric Nursing Classes
The RN Internship Program provides extensive classroom and skills lab experiences throughout the RN intern’s first year of employment. Classes focus on pediatric nursing assessment and skill development. The goal is to advance the RN intern’s clinical practice experience and build on the knowledge that they have obtained from their nursing courses and from preparing for the NCLEX exam.
The core curriculum is approximately 80 hours of classroom content and includes topics such as pediatric physical assessment, pediatric pain management, child abuse and neglect, and car seat safety. Specialty curriculums for the inpatient units and critical care areas vary ranging from 32 hours to 72 hours. Interns have the flexibility of completing pediatric courses such as age specific care through an online educational program. Emergency management skills are developed through pediatric advanced life support and/or neonatal resuscitation classes. The RN Interns are required to attend PALS (Pediatric Advance Life Support) classes within their first year of employment. Depending on the nurses’ pediatric sub-specialty area other courses are required such as NRP (Neonatal Resuscitation Program), S.T.A.B.L.E. (Sugar, Temperature, Artificial Breathing, Lab, Emotional Support), NCAST (National Child Assessment Satellite Training), and ENPC (Emergency Nursing Pediatric Course).

Clinical Mentor
The nurses that participate in the Mentor Program are experienced RN’s that are committed to the development of the RN intern. The mentor guides the RN intern’s integration into his or her first professional nursing position. The mentor shares career stories and gives insights for balancing work/life priorities. The coordinator for the Mentoring Program presents the Mentoring Program to RN Interns during their fist week of orientation. Mentors complete a mentor profile and the mentee completes a biosketch, which highlights personal and career information, which the coordinator of the mentoring program uses for mentor/mentee matches. Matches are made by the program coordinator based on preferences of mentee. Mentors are given the mentee biosketch and information to contact the mentee. A Mentoring Agreement is signed by both the mentor and the mentee. Meetings between the mentor/mentee occur in several different venues such as meeting for lunch or for coffee, email, phone conversations, and off site social activities. The goals of the Mentoring Program are to increase confidence to adjust to the demands of the staff nurse position; foster positive work attitudes and give insights for balancing work/life priorities; and guide the nurses’ assimilation into the nursing profession and organization.

RN Transitioning Sessions
The RN Transitioning group discussions offer the RN intern a safe, confidential environment in which experiences are shared. By meeting with peers in a small group setting the RN intern learns coping skills in adjusting to their new role as a RN. The RN intern can also learn skills to balance work/life stress. The transition sessions are for 1½ hour(s) and are linked to class days. The transition groups meet six times during the first year of employment. Each transition session is lead by two facilitators a nurse and either a social worker or chaplain. The experience facilitators are trained to lead groups and work with new graduates nurses. The following comments about transition sessions were made by the interns:

Clinical Exchange
The clinical exchange gives the RN intern the opportunity to develop a holistic approach to pediatric nursing care. The RN intern rotates to multiple patient care areas specific to their patient population, enabling the RN intern to learn the patient experiences first hand and build working relationships throughout Children’s Memorial Hospital. The clinical exchange builds relationships for future encounters that the RN intern will have with staff in various departments.

Individualized Preceptor Orientation
The unit based nursing preceptor assists the RN intern to learn clinical skills and develop team relationships. The preceptor guides the RN intern in learning nursing skills and responsibilities. Preceptors also play an important role in the socialization of the RN intern. The preceptor works with the intern to develop an individualized orientation and the intern has an active role in identifying their learning needs.

Program Outcomes
The internship program has become a magnet exemplar. For every graduate nurse accepted into the program, three others were considered. With multiple candidates for each position, nursing managers select exceptional graduate nurses into the program. Graduate nurses report that the internship was more important than pay in making their employment decision. A hospital nursing satisfaction longitudinal survey conducted at 3, 6, twelve, and eighteen months of tenure shows job satisfaction has become even higher since the introduction of the internship. This high satisfaction with the program has led to a 50% reduction in turnover. The newest nurses to the profession are finding that they want to build their pediatric nursing careers at Children’s Memorial Hospital.

“Precepting and Mentoring” - Passavant Area Hospital
Author: Cari Graham, RN, Staff Nurse

On March 23rd, 2005 I attended a seminar in Springfield, which was presented by the ILLINOIS COALITION FOR NURSING RESOURCES. It covered precepting orienting and mentoring practices that several hospitals in Illinois are currently utilizing. Nine hospitals were represented and shared specific tools that they use in their own program.

Blessing Hospital in Quincy gave a very thorough review of their Residency Program. They discussed how they collaborated with a Baccalaureate Nursing Program from a nearby college in order to recruit new employees. I was very impressed with their program. They saw their Residency Program as an investment to promote a partnership between hospitals and colleges. They shared with us how they believe the best way to bring in new employees is to “attract” them, thus they developed a magnet program. They decided to grow their own nurses so to speak. They shared several different ways that you can qualify to get state funded grants to initiate their programs. Blessing definitely did their homework before they developed their program. They are still in the transitional stage of the program, but feel very positive about the success of it. They shared with us that so far everything was progressing well.

Other various hospitals shared their own variation of their preceptor programs. Out of the nine hospitals and colleges involved, they had 5 testimonials of various people involved in this type of program. One was an RN from College of DuPage, who was involved in the mentoring process. They also had an RN from Blessing hospital who was involved in precepting students and new graduates. She was also involved in the developing of the Blessing Program as well. A new graduate from College of DuPage spoke and gave her view on the Preceptor Program she was currently enrolled in. They also had an L.P.N. who was a junior in a B.S.N. Program. A Professor from one of the colleges also discussed what role she played in a CO-OP MENTORING and PRECEPTORSHIP PROGRAM.

Overall, this seminar gave a broad perspective of how mentoring and precepting can be very successful and rewarding to all involved. They discussed how to increase job satisfaction, decrease turnover, improve competency and increase recruitment. They also shared the national scene statewide on ways to collaborate with other facilities to improve preceptor programs. It also looked at nursing in the future and how to lay the groundwork for nursing graduates in 2008. They discussed investing now in order to get good returns in the future.

Staffing
Staffing ratios have been a contentious issue for quite awhile. California passed its nurse staff ratio bill in 2001. Since then bills have been introduced at both the federal and other states levels to mandate nurse to patient ratios in acute care hospitals. The debates about this issue continue to this day in California and have spread across the nation as other nursing associations and unions in other areas of the country push for staffing ratio regulation.

Illinois has not been immune. For the past several years several nurse unions with a presence in Illinois have introduced and lobbied for Illinois Nurse Staff Ratios. The Illinois Hospital Association has been the primary opposing organization. We invite those two groups to write policy documents for this site to present their views on what would comprise an acceptable compromise.

For now though the IHA has developed a paper on the Impact of the Nurse Staff Ratio Bill. This is HB 2548 introduced by Representatives Mary Flowers (D), Karen May (D) and James Osmond (R). This particular iteration of the bill will “die” this veto session (Fall 2006) if it remains dormant but the IHA cautions that it will be “resurrected” in the session beginning in January 2007 under a new bill number.

The following are points excerpted from the IHA document entitled “Impact of Nurse Staffing Bill”. ¹⁶

• LPNs would not be counted in meeting ratios. They are not recognized as licensed nurses and would severely limit their utilization for patient care in hospitals.
• “Ratios must be provided 24/7”. The IHA says this means hospitals will have to hire additional staff to cover nurses when they take breaks or go to lunch. (In California some hospitals have the house supervisor and float staff spending their time just for this purpose.)
• In California 50% of hospital staffing is now supplied by agency staff or travelers. This is because the shortage has been exacerbated by the ratios. The demand has been substantially increased, competition has increased and many nurses saw opportunity for increased pay by leaving their home hospitals and going to agencies which can demand high pay for nurses to care for patients.
• In California support staff (CNAs, PCTs, LPNs, unit clerks and others) were laid off in order to shift wage dollars to RNs. RNs were then required to pick up the work usually performed by support staff. In some cases other departments were also decreased. RNs could be required to do the work of Lab, PT, OT, respiratory etc. if these ancillary departments can no longer hire the staff they need.
• One dire result of the staffing legislation in California has been decreased access to acute care services for patients. This occurred when nursing care units and hospitals closed due to inability to staff according to ratios because there aren’t enough nurses to meet the ratios. If it is against the law to perform patient care without the mandated number of nurses, hospitals will have to turn patients away when they cannot hire the nurses needed.

“Hospital administration, managers, staff and patients would welcome the ability to provide lower Nurse: Patient ratios especially if it provided a safer environment for our patients. Mandated ratios which do not take into consideration the acuity of the patient, however, make no sense and cause a financial hardship on the hospital. And in some cases, may actually create an environment that is less safe than the current system. The Hospital Report Card Act and the CMS Core Measures will provide a better measurement of quality in hospitals without mandating strict guidelines based on numbers alone.”

IHA is urging hospitals to talk with direct care staff about facts and experience (as in California) with this type of legislation. IHAs website provides a PowerPoint and a discussion guide to assist nurses with this education. They can be found at www.ihatoday.org. Click on Issues then Nursing for the tools.

The Hospital Report Card Act
Another requirement for hospitals which began as a contentious issue but has been resolved is that of requiring reports to consumers regarding “hospital’s staffing process and effectiveness as it relates to a critical public interest-patients\ outcomes.”¹⁷ The 93rd General Assembly passed the Hospital Report Card Act in 2003. The law became effective in 2004 and was amended last year in 2005.

SB 1862 (Enrolled) amended the Hospital Report Card Act changing the definition and requirements for the section on reporting “Infection-related measures” (was Nosocomial Infection Rates initially). The section now reads...

2) Infection-related measures for the facility for the specific clinical procedures and devices determined by the Department by rule under 2 or more of the following categories:
A. Surgical procedure outcome measures
B. Surgical procedure infection control process measures.
C. Outcome or process measures related to ventilator-associated pneumonia.
D. Central vascular catheter-related bloodstream infection rates in designated critical care units. The infection –related measures developed by the Department shall be based upon measures and methods developed by the Centers for Disease Control and Prevention, the Centers for Medicare and Medicaid Services, the Agency for Healthcare Research and Quality, the Joint Commission on Accreditation of Healthcare Organizations, or the National Quality Forum.

The Department (IDPH) shall include interpretive guidelines for Infection –related indicators and, when available, shall include relevant benchmark information published by national organizations.

Reports are to be made quarterly and include measures other than the infection-related indicators listed above. They are: 1)Nursing hours per patient day, average daily census, and average daily hours worked for each clinical service area and 2)Annual reports on vacancy and turnover rates for licensed nurses per clinical service area. There are safeguards regarding disclosure to the Public including a review and validation process in the law.
IHA has been the lead policy organization working on this legislation for several years. Updates are usually available at www.ihatoday.org. The entire law can be downloaded from the Illinois Legislature site: www.ilga.gov by clicking on public acts and typing in PA93-0563 in the search box.

¹⁵ www.ihatoday.org, July 2006
¹⁶ Illinois Hospital Association, Impact of Nurse staff Ratio Bill HB 2548(Summary from IHA meeting), November 1, 2006
Illinois Hospital Association, “Working Together Illinois Nurse Staffing Laws and You”, 2006