Examining Challenges Hospitals face due to Nursing shortage

High nursing turnover rates and the nursing shortage in the United States are creating major challenges for hospital administrators (Chan, McBey, Basset, O’Donnell, & Winter, 2004). Like many hospitals, the University of Arkansas for Medical Sciences (UAMS) in Arkansas has recently had a surge in nursing turnover rates that has caused an overall nursing shortage in the organization. The high nursing turnover has had several negative influences on the remaining staff. The high turnover has decreased cohesiveness of the units, increased burdens placed on the staff, decreased work satisfaction, and reduced quality of patient care. The high turnover rates have also affected the organization by causing additional cost for recruiting, selecting, and training new personnel (Chiu, Chung, Wu, & Ho, 2008). This paper aims to plan a solution for the high nursing turnover rate at UAMS using Maslow’s hierarchy of needs theory. First, a review of literature regarding nursing turnover will be reviewed. Maslow’s hierarchy of needs theory will then be utilized to understand the needs of the employees and a plan will be formulated to solve the problem. Lastly, a plan will be presented to evaluate the methods and outcomes.

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Literature Review

Nursing turnover is defined as the process where nursing staff either transfer within the healthcare environment or leave the professional all together. Turnover can be either voluntary or involuntary. Voluntary turnover occurs when the employee chooses to leave, whereas involuntary turnover occurs when the organization dismisses the employee or when other factors cause an employee to leave (i.e. death). The organization has little control over involuntary turnover but can have great control over voluntary turnover. Staff retention programs should focus on ways to prevent voluntary turnover (Finkler, Kovner, & Jones, 2007).

There are multiple factors that contribute to nursing turnover. The top factors for turnover include: (a) work-related stress, (b) staffing level, (c) leadership skills of direct manager, (d) schedule flexibility, (e) competence of clinical staff, and (f) recognition (Unruh, 2008; Chan, Mcbey, Basset, O’Donnell, & Winter, 2004). Nursing turnover can be a vicious circle with the stress put on remaining nurses leading to those nurses also leaving the organization (Hart, 2003). The nursing shortage caused by nursing turnover leads to reduced job performance and nurse satisfaction. Registered nurses with more years of experience tend to have a higher job satisfaction, a lower burnout rate, and lower turnover rate (Cameron, Horsburgh, Armstrong-Stassen, 1994). The turnover rate tends to be higher during the nurses first and second year of employment (Gray & Phillips, 1994). Some hospitals have reported that over 50% of the organizations turnover rate consists of new graduates (Zucker et al., 2006).

High nursing turnover rates can have detrimental effects on the organization, staff and patients. Organizations can experience an increase in contingent staff costs. Nursing turnover can cost 1.2 to 1.3 times the salary of the nurse or $22,000 to $64,000 per nurse turnover (Jones, 2008). Turnover costs for the organization can be related either to direct or indirect costs. Direct costs include hiring, orientation and training, and termination of employees. Indirect costs may include decreased productivity, decreased work environment, decreased quality of care, and additional staff turnover. (Brooks, 2007; Jones & Gates, 2007). Turnover costs represent an expenditure of around 5% of the annual operating budget (Waldman, Kelly, Arora, & Smith, 2004). Many healthcare organizations must rely on contract, agency, and travel nurses to fill positions left by nurses who have left. These positions often cost more than a staff nurse

The shortage of nursing staff due to turnover also adversely affects patient outcomes and satisfaction (Unruh, 2008; Needleman et al., 2011; Jones, 2008). Patients who had nurses who found work meaningful were more satisfied with their care than those who had nurses who felt exhausted or expressed concern to quit (Leiter, Harvie, & Frizzell,1998).A study conducted by Needleman et al. (2011) found that increase turnover rates were associated with increased patient mortality. Hospitals that have adequate staff experience fewer adverse patience outcomes including pneumonia, urinary tract infections, falls, restraint use, medication errors, post-operative complications, pressure ulcers, and death (Unruh, 2008). A study by Zimmerman et al. (2002) found that patient infection rates increased by almost 30% with each loss of a nurse.


Discuss management and leadership theory and methods that will be used to solve prob.

In order to determine why the organization is experiencing a high turnover rate management will need to look for an underlying cause. A cause and effect analysis will be performed to determine what is creating the high turnover rate and the effect that it is having on the organization. The identified effect (high nursing turnover rate) was determined by examining the current turnover rate of the organization and comparing the results to those of surrounding organizations. To determine the causes that contribute to the effect an investigation would be performed on the reasons why employees have left the organization. Upon employee termination the employee completes a post-employment questionnaire and exit interview with a human resources personnel member. These both allow the organization to examine the reasons why staff members are leaving and allow for planning to prevent further avoidable staff turnover. Also an employee climate survey will be conducted on current staff members to assess their perceptions and perspectives of the organization.

There are many factors that could be found to cause nursing turnover in the organization. The top factors that affect nursing turnover include (a) work-related stress, (b) understaffing, (c) leadership skills of direct manager, (d) schedule flexibility, (e) competence of clinical staff, and (f) recognition. This paper will focus on only one of the factors, competence of staff, and a plan will be developed utilizing Maslow’s theory.

In order to increase job satisfaction and decrease nursing turnover management must understand what motivates employees. Maslow’s hierarchy of needs theory provides a process to understand and influence employee motivation. Maslow’s theory consists of five stages listed in order of hierarchy from lowest to highest: (a) physiological, (b) safety and security, (c) social activity, (d) ego, and (e) self-actualization. It is important to note that the lower needs must first be met before a higher need can be satisfied. Maslow modified the definitions of the stages in order for them to be applied in a management setting. Competence of staff members was identified as one factor that could cause nursing turnover. By creating a plan that involves increased education of staff during initial hiring and throughout the employment, turnover rates will hopefully be decreased. Maslow’s theory suggests that if the needs of the employee are adequately met that the employee will be more satisfied working with the organization. Satisfied employees are less likely to leave an organization. The first level consists of wages. If adequate wages are not provided, the employee will focus on the issue and higher levels will not gain any focus. The wages employees earn provide basic needs such as water, food, and shelter. If adequate wages are provided the employee moves to the second level, safety and security. This does not seem to be a concern in the organization thus the higher needs will be the focus.

A safe work environment consists not only of physical but also mental safety. Safety needs can be provided by ensuring adequate training. Workers often relate training to safety. Once the employee feels safe and secure they move on to the third level, social activity. The employee seeks pleasant working relationships. Training provides employees with additional opportunities to meet other employees in the organization. Employees have additional opportunities to meet other co-workers with similar interests or job responsibilities and allow the employee to establish new lines of communication within the organization.

The fourth level, ego, consists of the need for a positive self-confidence.. As the individual obtains training, it presents an opportunity to feel and actually become more productive and confident in the work environment. As the employees confidence level grows there is a greater opportunity to obtain rewards, recognition, and positive performance appraisals. The final need is self-actualization. The employee attempts to develop their full potential, learn new things, and take risks. Training allows the individual to move toward self-actualization; to develop one’s potential, to learn new things, to take risks, and to feel more confident in what one does.

An extensive orientation program for new nursing graduates at UAMS will be developed in order to decrease nursing turnover. A study conducted by Bowles and Candela (2005) found that 30% of new nursing graduates left their first nursing job within the first year and 57% left before their second year. New graduates often feel overwhelmed when transitioning from an educational setting to a clinical setting. When new nurses are not trained sufficiently, their stress level increases and job satisfaction decreases leading to the nurse leaving the organization or even possibly leaving the profession altogether (Christmas, 2008). Although orientation programs add costs, the resultant savings from decreased turnover would be worth it.

A committee will be formed to develop the orientation program. The committee will consist of nursing executives, nurse managers, human resource staff, and staff nurses. The committee will design the program, obtain a budget, select applicants, and monitor the program. A program will be designed to fit the organization’s needs. A survey of previously hired new nursing graduates will be performed. The survey will help to gain insight into new nurses need and want in an orientation program. Also, a study of orientation programs that other similar organizations have implemented to decrease turnover rates may be beneficial.

Once the program is designed, applicants will be selected and interviewed by members of the committee. A clinical coach program will be developed. The program will train seasoned staff on how to become an effective preceptor for the orientees. Orientees will be matched with clinical coaches based on fit. Orientees will also get the chance to select which clinical area they are interested in. The program will be six months in length opposed to the three month orientation standard to most organizations. The participants will rotate through multiple units in their selected clinical area. Each participant will also attend classes, complete case studies, and attend reflective learning sessions.

(1) collaborate and develop partnerships with key stakeholders, (2) identify and develop tools for measuring the outcomes, (3) develop a national transition to practice web site, (4) develop model rules for transition to practice and (5) identify funding sources.

These included: serving as a role model, integrating the new graduate nurse into the unit culture, advocating for the new nurse graduate, encouraging and evaluating performance, debriefing after critical situations, offering support and helping adjust to the profession, fostering the development of relationships on the unit, serving as a resource, and teaching clinical skills

The findings of this study provide information on the effect of orientation programs on new RNs’ confidence, competency, and retention. The reviewed studies suggest that the orientation programs are successful in improving new RNs’ confidence in caring for patient and in enhancing their competencies such as knowledge and critical-thinking skills in the clinical environment. By doing so, these programs may encourage new graduates to stay and to participate in a supportive system. Furthermore, as Benner’s (1984) model would suggest, this review shows that an orientation program with certain characteristics-that is, structured teaching methods, clinical experiences with qualified preceptors, and support systems-fosters the transition of new RNs from novices to advanced beginners.

Plan for Evaluation