AORN JOURNAL JANUARY 1991, VOL. 53, NO I

Recruitment and Retention STRATEGIES FOR KEEPING GOOD NURSES

Marguerite Birkenstock, RN

o effectively compete for nurses during the present nursing shortage, hospitals must use T effective recruitment techniques and take

steps to reduce their turnover rates. A stable nursing staff is essential to both effectiveness and efficiency. This article presents strategies to improve nurse recruitment and retention.

Success in reducing turnover depends on creating a “whatever it takes” attitude. Senior management, including the governing board of the hospital, must be totally committed to the priority of nurse recruitment and retention.’ The team at the top sets the tone.

Successful Hospitals

ospital executives must have a bias for action. They must cut through stifling red H tape that paralyzes many health care

organizations. They must stay close to the needs of their customers (ie, patients and their families, community members, physicians). Quality must be the tradition at the hospital. Executives must encourage autonomy and innovation. They must increase the self-esteem of all employees. They must generate enthusiasm for their values. They can offer inspiration through strong leadership. Belonging to such a hospital makes employees feel fortunate.2

Great value continues to be placed on innovation, creativity, education, research, and scholarship and clinical competence. A recent follow-up study of 16 magnet hospitals identified the most frequently named new activities.3 These include

redesigning or developing new nursing care

designing, expanding, or differentiating roles, delivery systems,

Nursing and Rehabilitation Center, Alexandrk Va She was an assktant professor in the nursing administration specialization graduate program at the University of Pittsburgh School of Nursing when this article was written She received her nursing diploma from the Ann May School of Nursing, Jersey Shore Medical Center, Neptune, N& both her bachelor of science degree in nursing education, prespecialuation and her master of a m degree in nursing education, adminkpation of hospital nursing from the Teachers College, Columbia University, New York City: and her doctorate in higher education from the University of Pittsburgh

Marguerite Birkenstock, RN, PhL? CNAA, is director of nursing and education at Woodbine

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setting up programs and activities to enable

strengthening collaborative nurse/doctor

strengthening computer programs, particu-

Administrators can not do this alone. Nurse managers have a great deal of influence on recruiting and retaining good nurses.

or empower staff,

practice, and

larly for documentation.

Retaining Nurses

etaining nurses involves encouraging autonomy, involvement, and innovation. R Nurses are energized by the freedom to

act on what they know, and for which they accept accountability. Nurses at hospitals with low turnover rates

are involved in forming the hospitals’ mission and values, devise their own shift rotations and wage differentials, can concentrate on patient care because ancillary services are well staffed, view themselves as patient advocates and collaborate with physicians, and are rewarded for performing quality service.“

When nurses’ work is valued as the major product of the hospital, the quality of patient care takes on great luster and importance. Nurses must feel important, cared for, and in control of their practice of nursing. Providing excellent patient care satisfies nurses.

Recruitment

ecruitment is a daily activity, and it requires creative strategies. To attract R nurses to your hospital, evaluate how you

welcome nursing students. Recruiting activities explain how nurses fit into the pecking order in your organization. Do you extend every amenity to nursing students and faculty? The climate for learning is an essential factor. Do you offer scholarships and student loan forgiveness? Do you have an externship program? Is preceptorship rewarded in salary and prestige? Can you offer college instruction in a classroom at your hospital,

either by telecommunications or by faculty members who are willing to travel? This may be a long-term strategy, but it will pay dividends in the long run.

Advertising in newspapers is costly but essential. Be creative in your placement and copy. A hospital in a Florida fisherman’s paradise placed a small advertisement in BmsMmter, a magazine for fishing enthusiasts, hoping that fishermen would be married to nurses? Four full-time RNs were hired as a result of the advertisement. Be creative to overcome boring, nonproductive advertise- ments. Featuring a different nursing specialty or a different employee benefit can make your advertisement more interesting. One creative advertisement featured family-sued frozen entrees priced at cost plus 10% as an employee benefit. This benefit recognized that most nurses also are homemakers. Advertisements often mention day care for children. Day care for dependent elders is another benefit that may become important as the number of nurses with dependent parents increases.

Paycheck stuffers, encouraging staff to help recruit nurses who “are just like you” may be effective. A recent study found that the three most important reasons nurses applied to the hospitals in which they work are 1) location (ie, close to home), 2) available shifts, and 3) type of hospital.‘j Some hospitals offer a “finders fee” of $50 to $500 for each referred nurse who is hired and some even pay $100 just for attending their open houses. Many hospitals offer sign-up bonuses of $1,000 to $5,000.7 It is important to recruit sufficient applicants so you can be selective in hiring. Being chosen from a group of applicants is important in fostering high self-esteem and pride in the organization.

Effective Hiring Strategies

iscuss hiring requirements with your human resources staff before beginning. D These employees are trained to conduct

effective hiring programs. They can help you use time efficiently and hire the right person.

Interviewing. Effective interviewing requires careful planning. There are seven distinct parts

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Creative Interview Questions

The answers to these questions can bring out the personality and character traits of a potential employee.

“Tell me about yourself in two minutes or less.” You will see how the applicant can organize and prioritize thoughts. “What were you criticized for during your last job?“ “Please describe the ideal working environment.” Thh will provide insight into your environmental fit. “What would your former boss say were your weaknesses ?” “What questions would you like to ask me ?” “We only have a few more minutes so please tell me anything you think I need to know about you before we end the interview.” Thk gives a clue that it is time to close the interview.

to a good interview. They are greeting, overview of the structure of the interview, candidate’s educational history, work history, career plans, information about your hospital, accurate and realistic information about the position, opportunity for questions and answers, and closing.

The job description must include what the applicant will be expected to do. Every detail of the job does not need to be included, but the major job requirements must be reviewed. The job specifications should be determined before placing a recruitment advertisement. This includes the minimum education and skills required. Consider what personality traits are essential. List the characteristics that you believe are necessary to be successful in this job. These could include ability to pay attention to detail; to thrive in a high-tension atmosphere; to work in close confines; to work with little supervision; to do repetitive

functions; to be team oriented; and to exhibit honesty, initiative, and creativity.

Give this information to human resources staff members so they can evaluate these characteristics during an interview. Be certain to stay within the law. You may ask and measure job-related characteristics. You may not ask about or make a hiring decision based upon race, age, sex, sexual orientation, religion, national origin, or other characteristics. A helpful rule of thumb is “if in doubt, don’t ask.”

Screening. After obtaining a signed, standard employment application from the applicant, human resources staff members can follow your guide to screen out those unsuited for the position. You should make an applicant evaluation checklist for each job title so that the same information will be gathered from each applicant. First, identify four or five essential performance factors and personality factors required for the position. Across from these factors, leave space for human resources staff members to note their appraisal of these characteristics. They can summarize their overall impressions and rate the applicant immediately following the interview (Fig 1). You can scan several checklists in a matter of minutes and select the applicants you wish to interview.

The second interview. You will want to become personally involved in the process after the preliminary screening. Remember that an excellent interviewee is not necessarily an excellent employee. Prepare yourself for the interview by clearing your mind and preventing interruptions. Be aware of the image you project. Concentrate on projecting a positive attitude, competence, total expectation of quality nursing care, self- confidence, interest, and friendliness.

Prepare an interview outline to follow. Remember that questions regarding bona fide occupational qualifications are legal. Listen actively to the applicants responses. (See “Creative Interview Questions” for ideas.)

Reserve a few minutes immediately after the interview to record your reaction. Note your thoughts about the applicant’s presentation compared to your requirements?

Selection. Do not delay. Evaluate all applicants on one criterion only-their ability to be successful

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Fig 1 Applicant Evaluation Checklist, Staff Nurse, OR

Name Address Interviewer Phone Date available Shift preference

I. Performance factors: (Related experience; jobs; reason for changing jobs; skills, absence, etc.) Performance factors: Appraisal:

#1 Education related to job #2 Related experience, skills #3 Dependability, attendance #4 Attention to detail #5 Organizational skills

11. Personality factors: (Ada tability, leadership, reaction to change, conflict management, etc.) Personalty factors: Appralsal:

#1 Ability to accept changes #2 Crisis management #3 General attitude, cooperation #4 Emotional reaction to stress #5 Interpersonal skills

Other: (Why do you want to work here? What else should we know about you?) 111. What are your major strengths?

IV. What areas would you like to improve?

V. Describe the person you work best for.

VI. When I check your references, what will they be apt to tell me you were praised for?

VII. When I check your references, what will they be apt to tell me you were criticized for?

VIII. What are your career goals?

Any reasons why you would not consistently arrive for work on time and work according to the schedule ? How do you rate these general factors? Punctuality - Attendance - Cooperation -

Overall Rating: O=Low 3=Minimal 5=Competent 8=Excellent 10=0utstanding Communication skills 0 3 5 8 10 Adaptability 0 3 5 8 1 0 Initiative 0 3 5 8 10 Planning 0 3 5 8 1 0 Related work experience 0 3 5 8 10 Appearance 0 3 5 8 1 0 Team worker 0 3 5 8 10 Enthusiasm 0 3 5 8 1 0 Personality 0 3 5 8 10 Interest in this job 0 3 5 8 10 Comments: Action: Rating: ~ (Add all scores and divide by 10)

(Adapted from and used with permission of Employee Management Services, Erie, Penn) Recommend 0 Do not recommend 0 For further interview 0

AORN JOURNAL JANUARY 1991, VOL. 53, NO 1

Every interaction with new employees should maintain and increase their self-esteem and

their commitment to your hospital.

employees. Limit the number of decision makers because it wastes time. Hire the best people even if they were the first ones interviewed. Make job offers that contain a complete compensation package.

Now that you have made your selections, you want those applicants to accept your offers of employment. Emphasize and itemize benefits carefully. Employee benefits typically cost hospitals 20% to 40% more than salary. Do not overlook emotional benefits (eg, less stress, proximity to home) and monetary benefits (eg, pension plans, discounts, group life insurance, free parking) when offering a position to an applicant.

Start the new employees as soon as possible. If the positions are competitive, do not notify the losers until after the winners actually start their positions.

Evaluate hiring practices. Identify successful and unsuccessful employees. Review their application files and note what worked well so you can revise your procedures annually.

Orientation

S tart the orientation as soon as an applicant accepts your offer of employment. Send a personalized welcome letter signed by you

or the person’s immediate supervisor. If you provide a preemployment physical examination, make it a surprisingly positive experience. Consider using a nurse practitioner as your employee health service primary health care provider. Nurse practitioners are competent, compassionate, and cost-effective. You also will reinforce the importance of nurses at your hospital. The positive environment you create at the preemployment physical will pay dividends later.

It is essential to get the orientation process off to a good start. This creates a sense of belonging in the organization. Build pride and identification with the hospital. Be informal, individualistic,

I

positive, and participative. Teach healthy decision making (eg, offer fruit juice and yogurt along with coffee and donuts). Provide a brief history of the hospital’s service to the people in the community. Use slides or a videotape for visual emphasis. Give an overview of the philosophy of the organization, its mission, and its goals. Some hospitals include all employees in a reorientation process to be certain that all employees share the attitudes, habits, values, and norms that the hospital wishes to emphasize? Involve enthusiastic staff in the orientation process. The purpose of every interaction with the new recruits should be to maintain and increase their self-esteem and their commitment to your hospital. Emphasize to each that only the best are invited to join your group of expert professionals.

Use the employee handbook as a reference guide. Encourage the orientees to make notes in it. Review the positives (eg, employee benefits) before the negatives (eg, progressive discipline). Maintain a positive attitude throughout the orientation. When possible, have the chief nurse executive of the hospital present each employee’s name pin with a brief welcome message. Photograph the employee receiving the name pin, a smile, and a handshake. Put the photo into an inexpensive frame and give it to the employee before he or she goes home. This creates a positive beginning and helps recruiting efforts in the employee’s circle of friends.

A videotape showing all levels of employees is a good way to demonstrate the need for teamwork by all employees. It is good practice to recognize the importance of all employees to the overall work of the hospital.

Feature each new nurse in your hospital newsletter and ask, “What would you like your new coworkers to know about you?” This will help your new nurse gain a sense of belonging.

Introduce the orientee personally to coworkers and supervisors. Reduce tension with a positive

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Flexible Scheduling Choices

Full-time options-40 hours per week, 80 per pay period. 4-40,7-on, 7-0e Baylor Plan. Either dayevening or day-night rotation. Permanent evenings or nights. Shifts of eight, 10, or 12 hours. Only calk no call; only weekend calk no

weekend call.

Part-time option.-20 hours per week (earns prorated part-time benefits). Shifts of five, eight, 10, or 12 hours. Promise of permanent assignment on

Every weekend off; only work weekends. requested unit at first opening.

Casual flexible pool Limited assignments to the perioperative

Must work 16 hours per month. Must work one Saturday or Sunday per

Must work one holiday a year. Hours selected by the nurse.

unit so skills stay expert.

month.

comment about a personal attribute or accom- plishment of the new employee. Explain how long the orientation will continue and that skills inventories, safety instructions, and return demonstrations will keep the new employee quite busy.

Be sure that a preceptor is identified, and assign another employee to accompany the orientee to breaks and meals for the first week or more. Distribute orientation evaluation forms weekly for the first few weeks. Listen to your new employees and use the information to guide you in improving your future employment planning and development.

Continue the orientation of each new employee untiI he or she demonstrates both competence and self-confidence. You already have a vested financial interest in the success of each recruit. Make sure that he or she is a success.

Policies Affect Turnover

he five most important policies that affect turnover are: time off, scheduling, fair T treatment, wages and benefits, and hiring

the right people in the first place. A 1988 American Hospital Association report, “Responding to the Nursing Shortage,” has six appendixes that present an excellent summary of flexible, innovative policies aimed at retaining nurses.10 A policy is a recommended course of action for carrying out an organizational goal. It is intended to convey the thinking of management as a guide to action. Each policy should begin with a clearly stated purpose. Readability should be geared to an eighth- grade level, becaw clarity requires the use of basic English.

The following policies affect recruitment and retention of professional staff.

Time oflfrom duty. Traditionally, personnel policies regarding holiday, vacation, and sick time accrual reward behaviors that undermine honesty. The “use it or lose it” policy is costly. Alternative methods of handling sick and vacation time (eg, paid personal time incentive program) have been successful and can save money. One hospital‘s program reduced its absentee rate from 3.9% to 2.1%, and saved about $34,000 in one year.11 This plan combines holiday, vacation, and sick

time. A certain minimum of days must be “banked,” after which employees may start to use their credited days. Scheduled paid leave becomes available for use after six months of employment and enables employees to selectively choose how and when they redeem their benefit days. Emphasize that paid personal time requires advanced scheduling, but that employees may request unscheduled time off that will either be approved or denied depending on the work load.

Flexible scheduling. Flexible scheduling requires working individual nums into your master staffing plan. It requires new and creative personnel policies. Work with your human resources staff to offer some of the options listed in “Flexible Scheduling Choices” and “Creative Incentive Programs.” Be willing to implement pilot programs for a three-month trial.

Fair treatment policy. Communication lies at

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the heart of successful management. Communi- cation may seem to be common sense, but the essentials of communication may get lost in the pressure of operating room schedules. Ask yourself how new policies or changes will affect those involved. Be certain that you and all managers practice consistent management skills and that you remain visible and accessible to the perioperative staff. Staff members react to every change with the immediate question, “What does this mean to me?’

There is no ideal fair treatment policy, but that is no reason for having no policy at all. Identify acceptable means for employees to communicate their views of a problem to top administration. If freedom to question a decision is lacking, employees could look to collective bargaining units to speak for them.

Avoid the term “grievance” and use “fair treatment policy” instead. The purpose of that policy is to provide a mechanism for resolving problems and misunderstandings between man- agement and employees in a fair and equitable manner. Who could argue with that?

When a problem is identified, the policy follows certain steps, and the final decision is made by the fair treatment committee. The committee is composed of one board member, one employee representative selected by employees, one person selected by the person presenting the problem, and one department head selected by the department head involved.’Z Problems rarely should reach this point.

Ongoing management education for supervisors is one important way to ensure fair treatment of all employees. Consistency in policy interpretation is critical.

Wages and benefits. Money is not the primary draw to a career in nursing, yet the total compensation that society affords a group is a measure of the group’s value. High pay should not hold someone in an unsatisfactory work situation; low pay rarely causes a satisfied employee to leave. Nursing salaries are improving, but the increases in starting salaries caused by competitive bidding to recruit new nurses seem unrelated to compensation for experienced nurses’ increased skills, judgment, competence, and

Creative Incentive Programs

Incentive programs should be designed to entice part-time employees to increase

maintain ties with recently resigned

offer “golden handcuffs” of vested

their hours,

nurses, and

benefits.

Examples of some creative incentives include

?Frequent Fker’’ programs. The employee accumulates points for hours worked over a year and cash in the points for awards or bonuses.

Lifetime nurse membersh@s. This keep nurses aligned with the hospital by providing full credit for length of service, priority consideration for rehire, health insurance coverage, and notification of and inclusion in staff meetings and educational programs. In addition, keep in contact with mailed newsletters and invitations to all unit activities, both professional and social.

“Of7 shut programs. These are designed to encourage nurses to work the less desirable shifts. Monetary bonuses (eg, vacation time) over and above the salary differential are paid when a certain percentage of work is on the “off’ shift.

confidence. This aggravates the problem of salary compression between new recruits and expe- rienced nurses. The long-range cure for the shortage of nurses must address appropriate salary levels for experienced nurses.

To devise a budget-neutral model of nursing care delivery (ie, one that does not add to the cost of current services), hospitals must experiment with systems that make the best use of nurses’ time and expertise, freeing them from duties not requiring their specialized skills.

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Conclusion

ncreased competition among hospitals is mirrored in employee turnover. To keep good I nurses, employers must have

renewed emphasis on retention strategies, improved recruitment efforts, improved orientation programs, flexible personnel policies, and superior management skills.

These ideas can increase successful nurse 0 recruitment and retain good employees.

Notes 1. G K Gordon, “Developing a motivating

environment,” Journal of Nursing Administration 12 (December 1982) 11-16.

2. M Kramer, C Schmalenberg, “Magnet hospitals: Part 11: Institutions of excellence,” Journal of Nursing Administration 18 (February 1988) 11-19.

3. M Kramer, “Trends to watch at the magnet hospitals,” Nursing90 20 (June 1990) 74.

4. Hospital Trustee Association of Pennsylvania, “Nursing issues,” Trustee Folio 29 (March 1989) 5.

5. A Miller, “Seeking an Rx for nurses: As shortages grow, hospitals recruit harder,” Newsweek (July 10, 1989) 32.

6. C C Olsen, “Staff retention in the O R A job satisfaction study,” AORN Journal 47 (May 1988)

7. C J Huston, B L Marquis, Retention and Productivity Strategies for Nurse Managers (Philadel- phia: J B Lippincott Co, 1989) 9.

8. S Bruce, Face-to-Face: Every Manager’s Guide to Benerlnterviewing (Madison, Conn: Business & Legal Reports, 1984).

9. M 0 Bice, “Employee orientations should stress core values,” Hospitals 64 (March 20, 1990) 72.

10. AHA Special Committee on Nursing, AHA Repow Responding to the Nursing Shortage (Chicago: American Hospital Association, 1988) 22-40.

11. R Stryker, How to Reduce Employee Turnover in Nursing Homes and Other Health Care Organizations (Springfield, Ilk Charles C. Thomas, 1981) 113.

1271-128 1.

12. Zbid 119.

Suggested reading Birkenstock, M. “OR nurse turnover: Collecting

pertinent data to analyze the problem.” AORN

Poteet, G W. “The employment interview: Avoiding discriminatory questioning.” Journal of Nursing Administration 14 (April 1984) 38-42.

Journal 52 (August 1990) 315-324.

Bubbles Assess Artery Bypass Grafts Surgeons at the University of Chicago are inject- ing tiny bubbles into patients’ bloodstreams to assess how well coronary artery bypass grafts are working intraoperatively . According to a news release from the American Society of Anesthesi- ologists, the surgeons can thus measure which areas of the heart muscle are not getting enough blood and immediately make corrections.

Coronary angiography does not provide infor- mation on the distribution of blood flow. The new technique, called contrast echocardiography, uses an ultrasound transducer placed at the patient’s esophagus with the beam aimed at the heart. This generates bubbles smaller than blood cells that flow along with the blood and reflect sound waves. This allows direct on-line visualiza- tion of regional blood flow changes in the heart before, during, and after surgery.

Tanning Pills Deemed Illegal The US Food and Drug Administration (FDA) has not approved canthaxanthin-the main ingredient in tanning pills-as safe for any cos- metic use. According to the Oct 1, 1990, issue of the FDA Talk Puper, such products are illegal.

According to the report, statements that claim the ingredient has been approved are misleading. It has only been approved, at very low levels, for coloring some foods and drugs, but not, at any level, for tanning purposes.

The FDA has an import detention alert on any tanning tablets containing canthaxanthin manufactured outside the United States and has refused many shipments since 1981. It also con- tinues to seize such tanning pills produced in the United States.

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