RETAINING EXPERIENCED CRITICAL CARE NURSES: WHAT MATTERS MOST... TO YOU?

The following summary regarding factors that may affect retention of experienced nurses is drawn from a white paper recently published by the Robert Wood Johnson Foundation⁴ titled Wisdom at Work: The Importance of the Older and Experienced Nurse in the Workplace. In this descriptive study, a team of 6 nurses operationally defined the term older nurse as a nurse 45 years and older.⁴ The “wisdom” accumulated and shared in the report was derived from 4 primary sources: an extensive review of current literature, the perspective offered by a panel of designated experts, a survey of practicing nurses, and a selection of best practices targeted to older nurses.

The literature review incorporated searching a number of well-known databases (Academic Search Premier, CINAHL, Medline, PubMed) for peer-reviewed research on factors contributing to the recruitment and retention of older nurses as well as inclusion of several published bibliographies related to relevant aspects (eg, nursing workforce, human resource development, facility design) of the topic.^5 –7 

Employment Benefits:

As expected, existing literature supports the notions that wages are a universally recognized factor in recruitment and retention of nurses and that persons in different age groups assign different values to various employment benefits. For example, just as younger nurses with children would be expected to highly value an employer’s provision of child care, older nurses with dependent parents might place an equivalent value on provision of elder care. This section will first summarize findings pertaining more specifically to nurses and then more generally to all workers 50 years and older.

The Wisdom at Work report included findings from 2 unpublished papers (J. Spetz and S. Adams, unpublished data, 2005) related to employment benefits that might help reverse the nursing shortage. Overall, these benefits were found to be more important for nurse retention rather than recruitment. Some benefits favored by older nurses included the following:

• Retention bonuses

• Flexible shift scheduling

• Employer-sponsored retirement plan

• Employer-sponsored health insurance

• Allowing nurse retirees to work part-time without adversely affecting their pension

• Gradual retirement from work

• Maximal flexibility in work scheduling

The American Association of Retired Persons (AARP)⁸ admonishes employers that workers 50 years and older represent a heterogenous group of individuals with different earnings potential, financial security, retirement interests, health needs, career goals, education, and family and social structures that will likely direct their needs for benefits in varying directions. According to AARP,⁸ an employment benefits program tailored to mature workers comprises the following 4 categories of benefits important for recruiting and retaining older workers: fundamental, core, significant value, and extras.

Fundamental Benefits:

• Full-time workers: health benefits that include reasonable coverage of diagnostic tests, disability with some rehabilitation coverage, basic pension program

• Part-time workers: flexible work options

Core Benefits:

• Alternative roles such as special projects, redesigned jobs, or working a variety of jobs

• Training that leads to multiple career options

• Pairing of experienced and new employees who work together so that knowledge is preserved, newer employee has expanded capabilities, and experienced workers are offered an important role

• Phased retirement

• Rehiring after retirement

• Health benefits for part-time employees

• Injury prevention programs that include conditioning of workers to reduce worker injury

• Tailored rehabilitation programs to support position requirements and return to work

• On-site physical therapy

Significant Value Benefits:

• Counseling and support for career placement

• Informal programs targeted to mature part-time workers

• Special hiring programs for “semivolunteers,” who may be compensated with meals or educational opportunities but who are not paid employees

• Service awards that include something of monetary value

• Rehiring programs for retirees

• Programs for workplace mentoring to integrate workers from all organizational sectors

• Paid time off (beyond what is legally required by Family Medical Leave Act) for caregiving

• Elder care options with company financial support

• Employee leave banks

• Retiree health benefits

• On-site fitness facility or access to wellness and prevention programs (eg, health screenings, immunization clinics)

• Long-term care insurance with employer subsidy or group purchase option

• Employer-provided pension benefits that exceed market norms

• Employer-provided catch-up contributions to 401(k) or other retirement plans

• Personalized retirement preparation programs

Scaled-Down Extra Benefits:

• Service awards without monetary value

• Assistance with placement as a community volunteer

• Elder-care referrals

• Unpaid leave for caregiving

• Long-term care insurance availability for voluntary purchase without group discount or employer subsidy

• Information on available prevention, wellness, and rehabilitation programs

• Retiree clubs, newsletters, and periodic social events

A substantial number of findings relate to the importance of a variety of aspects of nurses’ work environment that may influence experienced nurses’ decision to remain or leave practice. One overriding observation mentioned in the report was Neuhauser’s⁹ conclusion that nurses like working for and will choose to remain with healthcare employers who enable them to feel respected and proud of their work.

Among the most notable literature in the area of healthy work environments for nurses are the well-established principles related to the Magnet Hospital Recognition Program from the American Nurses Association Credentialing Center¹⁰ and, more specifically, to the American Association of Critical-Care Nurse’s¹¹ 6 guiding principles contained in the Standards for Establishing & Sustaining Healthy Work Environment:

• Skilled communication

• True collaboration

• Effective decision making with nurses as central participants

• Appropriate staffing that matches patient needs and nurse competencies

• Meaningful recognition

• Authentic leadership that fully embraces the imperative of a healthy work environment

Other strategies that may enhance older nurses’ work environment include offering the following^12 –14:

• Time off while on-the-job for renewal and reflection

• Services that enhance time off (eg, elder care, laundry services)

• More principle-centered (versus rigid) personnel policies and procedures

• Opportunities for nurses to work in new service areas or in newly structured positions

• Managerial respect for workers that includes openness to inclusive decision making and sharing credit where due

• Managers who are passionate and compassionate, competent, honest, and ethical

• Physicians who are passionate and compassionate, competent, honest, and ethical

• Emphasizing healthcare as a cause rather than a business

• Honoring the spiritual aspects of healthcare work and workers

• Promotion of all dimensions of staff development

• Promotion of new technologies that ease work burdens

Manipulation of “Push Factors” Versus “Pull Factors” Related to Retirement¹⁵:

• Diminish influence of negative factors such as injury or poor health that tend to push workers into retirement

• While workers are still on the job, provide some of the positive factors such as more free time or reduced stress that tend to pull workers into retirement

Another area often targeted for improving the working condition of nurses relates to the more physically taxing attributes of the workplace. Ergonomic enhancements cited in the report that may benefit nurses as they get older include suggestions for the following:

• Reducing the amount of walking that nurses need to do

• Locating supplies and equipment closer to where nurses need them

• Decentralizing nursing stations to bring patients closer to the nurse

• Installing overbed lifts to easily care for large or immobile patients

• Locating monitoring equipment to maximize visibility

• Removing clutter

• Securing wires, cords, and dangling equipment

• Installing lighting adjustable to the nurse’s needs

• Locating restrooms close to the unit

• Ensuring adequate space for equipment necessary in patient care

• Creating a visually pleasant work environment

• Standardizing rooms whenever possible

• Minimizing noise by optimizing unit acoustics

Thirteen persons who team members considered as experts in hospital nurse retention, retention of older workers in other occupations, or in the use of technology for providing or improving patient care were interviewed via telephone regarding barriers to and opportunities for extending the career of older nurses. All 13 individuals said senior nurses could continue contributing to direct patient care if healthcare facilities were willing to welcome, accommodate, appreciate, and efficiently use these nurses. Suggestions for these modifications could be sorted into the following categories:

Human Resources:

• Increased flexibility with work schedules to include considerations such as enabling senior nurses to engage in activities outside of the facility

• Enabling senior nurses to project their weekends and holidays off from work, to bid on unpopular shifts

• Take advantage of the value of their wisdom and experience by creating expanded, innovative roles such as that of team builder, new staff mentor, best practices coach, meal and break relief nurse, senior consultant, staff preceptor, quality coach, family advocate, safety officer, and research analyst

Ergonomics and Healthcare Design:

• Patient lift and ambulation devices

• Decentralized location of all necessary patient care devices and supplies at the bedside

• Allowance for patient privacy

• Lighting that better illuminates nurse’s work area while shielding patients

Technology:

• Ensure that nurses older than 50 years participate in evaluating new technology before it is introduced so any visual, auditory, or other sensory aspects can be adequately addressed

• Ensure that in-service efforts related to new technology meet the needs of all staff

• Ensure that technology facilitates effective and efficient approaches to care by all staff

Organizational Culture:

• Maintain an organizational culture that acknowledges, values, and respects the contributions that nurses make

• Maintain an organizational culture that values and respects a nurse’s work experience

Training and Continuing Education:

• Provide continuing education opportunities for senior nurses to maintain current skills

• Provide continuing education for senior nurses to expand skill sets for new positions

• Afford learning opportunities at times and via formats that appeal to older nurses

The project team developed and pilot-tested a survey with items developed from the project objectives and preliminary literature review findings. The intent of the survey was to elicit opinions regarding factors in the work environment that affect intent to remain employed in nursing at that institution. These items were then refined as a Web-based survey administered to a convenience sample of more than 2000 nurses employed by the Presbyterian Health System in 6 cities in New Mexico. Of that group, 377 nurses (19%) completed the survey of both fixed-response and open-ended questions. Few findings from this survey were reported and only a single finding reflected information related to older nurses. Although 99% of respondents indicated they were satisfied or very satisfied with their job, 33% of nurses younger than 40 years of age said they were likely to stay at their current workplace compared to only 12% of nurses 40 years and older. The top 3 factors that would influence the intent to remain in nursing for the duration of career were pay, benefits, and flexible scheduling.

For this project, the term best practice was operationally defined as a practice “that expands employment opportunities for older nurses; addresses their particular concerns, needs and interests; and generally makes work more rewarding.”⁴ The 12 best practices appearing in this report were drawn from a number of notable sources, including suggestions by the sages, findings from review of literature, Magnet Hospitals principles, Advisory Board Company, Centers for Disease Control and Prevention, and Center for Substance Abuse Prevention. Criteria used by the team to identify these 12 practices were taken from the “AARP Best Employers for Workers Over 50” selection process¹⁶ and include, in descending order of importance, the following:

1. Staff (employee) development opportunities

2. Health benefits for employees and retirees

3. Age of employer’s workforce

4. Alternative work arrangements and time off

5. Retirement benefits and pensions

The Wisdom at Work team⁴ selected 12 best practices that they believed would contribute the most to retention of the older nurse (their report includes the names and locations of healthcare institutions where examples of these practices are already in place); these best practices are presented below.

At various healthcare facilities, this practice includes the employer providing the following:

• Financial education programs

• Automatic enrollment instead of offering the choice of “opting in” to 401(k) plans

• “Catch-up contributions” to pension plans for staff age 50 and older

• Defined contribution pension plans that allow after-tax contributions so staff can straddle retirement and employment

• Tax-free health savings account so retirees may save toward additional medical expenses

This practice encompasses employer-provided assistance in caring for a spouse, parent, or other family member, including the following:

• Fifty percent subsidy for elder care or sick-child care

• Assistance with home-healthcare services for dependents for up to 10 days per year

• Subsidized child care for grandchildren

• Life-cycle employment program to assist workers in planning for their personal needs at every stage of life, including caring for parents and protecting assets

This best practice views mature employees as “resources to be cherished” and manifests as the following:

• Including the director of senior services on its diversity team

• Training managers on the motivators, demotivators, communication preferences, and strategies for working with various age groups, including mature workers

• Providing mature workers an opportunity to offer feedback

These options include the following:

• Worksites

• Job structures

• Work assignments

• Job sharing

• Compressed work schedules

• Seasonal months-off program up to 6 months per year while maintaining their health and life insurance at the same rate

• Seasonal worker program via short-term contracts

This practice means employees who are about to retire will train their replacements and enable transfer of their accumulated knowledge and skills to the replacements.

• There are no formal rules or guidelines about what to share or how

• Retiring and replacement employees have considerable freedom to arrange schedules

Healthcare institutions that have been designated as Magnet hospitals are also noteworthy for additional benefits they offer to retain their most experienced nurses. Some of these benefits include the following:

• Seasonal flex scheduling that allows experienced critical care nurses the opportunity to work for 9 months and take 3 months off during the summer

• Work schedules tailored to fit individual and family needs

• On-site shoe repair, dry cleaning, and hair salon

• Elder-care resources

• Pastoral care

• Retirement plan and matching contributions

• Paid time off cash-outs on an elective or emergency basis for medical expenses or other personal or family catastrophes or natural disasters, legal expenses

• Interest-free loans for financial difficulties

These programs enable health-care organizations to facilitate transfer of workplace knowledge and operations from the most experienced staff to newer employees, thereby benefiting not only the new employee but the organization itself. Some of these programs offer benefits including the following:

• Publicly recognizing and financially rewarding seasoned nurses who agree to serve as preceptors to younger, less experienced colleagues

• Clinical mentorship program in which 65 clinical nurse mentors who meet stringent competence and personality requirements are able to work in less physically demanding positions where they work shorter, more flexible shifts in order to serve as resources for both experienced and inexperienced staff on units.

Phased retirement enables workers approaching retirement to leave the workforce gradually while continuing to accrue retirement benefits; other employers can rehire retirees without affecting their retirement benefits.

• Allowing long-time employees the ability to collect full retirement benefits while continuing to work part time or at reduced hours

• Staff with a decade or longer work history at the facility can work less than full time and still receive full healthcare coverage

• Pension plan changes enacted to allow employees to draw on these funds for certain types of expenses while still working.

This category of practices affords instruction on planning for retirement.

• Provision of quarterly information sessions on topics such as financial planning for retirement, transitioning from work to retirement, and estate planning.

This strategic planning practice involves an employer’s analysis of its workforce relative to projected demographic and labor market trends to track key factors such as age, careers, and necessary skills and to determine future needs. Such systems are being used for employee referral, career development, succession planning, performance appraisal, and learning management.

This practice category designs instructional programs specifically for the older worker.

• Career enhancement programs offered by academic facilities where staff who are 60 years and older may audit classes free of charge

• Bridge programs that help older staff transition into college

• Healthcare facilities partnering with nearby schools of nursing to offer on-site classes for staff pursuing basic and advanced degrees in nursing

Ergonomic improvements in the physical workspace contribute considerably to making a mature nurse’s work environment more safe and productive. The number of improvements identified is nearly endless; some of the more notable refinements include the following:

• Purchasing new beds throughout the hospital to reduce nurses’ strains in lifting and moving patients

• Installing patient care areas with enhanced natural-light, improved airflow, home-like rooms

• Installing ceiling lifts and booms in intensive care units and neurology patient rooms to curtail patient handling injuries

• Reducing noise levels by carpeting hallways, putting acoustical tiles on walls and ceilings, and relocating machinery and charts away from patients

• Adding private patient rooms to decreased transfers due to conflicts among patients

• Issuing each nurse a noncellular phone to obtain shift report, patient history, recent clinical information, to call the rapid response team, or to use with hospital voice mail/message system

• If a nurse judges that the unit is too busy because of patient or emergency situations, the nurse can pull a chain that notifies others and delays arrival of new admissions for 30 to 60 minutes.

At Critical Care Nurse, our interest in these issues centers around what all this information related to retention of our most experienced critical care nurses means to you, personally. In keeping with that focus, we invite and strongly encourage you to take a few minutes to complete a brief online survey so we hear your voice in this discussion and learn what your priorities are.

Please go to ccn.aacnjournals.org and click on the red Retention Survey link to take the survey. This online survey must be completed by July 15, 2007.

The aggregated pricetag of nurse turnover is truly astounding. A conservative estimate for most industries that tabulates just hiring, training, and productivity costs averages about 25% of the employee’s salary.¹⁷ A recently reported survey of turnover in acute care facilities found that replacement costs for nurses were often equal to or greater than twice that nurse’s regular salary.¹⁸ Using a common rate of nurse turnover of 21.3% with a national average salary for a medical-surgical nurse of $46832, the cost of replacing just one nurse was $92442, whereas replacing a specialty area nurse escalated that cost to $145000.¹⁸ You are indeed a precious commodity, so let us hear from you.