Karen S. Hill, RN, DNP, NEA-BC, FACHE
Michigan Organization of Nurse Executives:
The Future of Nursing
November 12, 2010
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Objectives:
◦ Discuss the concept of innovation and the
application of innovation to today’s
healthcare system and leaders
◦ Identify trends and issues within the nursing
workforce
◦ Describe suggestions for workplace
innovation
Central Baptist
Hospital
383-bed acute care hospital
Lexington, Kentucky
Recognized for:
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Nursing Care
Stroke Services
Total Joint Replacements
Cardiac Care
Maternal Care
Cancer Services
Magnet designation in
2005; re-designated in
2010
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What is innovation?
◦ Innovation is a change in the thought process for
doing something, or the useful application of new
inventions or discoveries. Innovation may refer to
incremental, emergent or radical and
revolutionary changes in thinking, products,
processes, or organizations.
Wikipedia, 10/17/2010
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Why do healthcare leaders need to be innovative?
◦ “Much of the current work of health care leaders
involves deconstructing health services as they are
today” (O’Grady, Malloch, 2007)
◦ Pressure will increase on hospitals to decrease cost,
increase efficiency and provide more services focused on
wellness.
◦ Definition of what is considered “core” for practice of all
healthcare professions will be altered.
◦ Users of healthcare will be forced to be more
accountable for their health.
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Why do nurses need to be innovative?
◦ Nursing is recognized as having a critical role in
keeping patients safe (Dunton, 2007; IOM, 2004)
◦ The presence of an experienced, educated nursing
workforce is key to quality and creativity.
Relationships have been found between
characteristics of the nursing workforce and
improved patient outcomes
 Years of experience
 Education levels
 Staffing ratios
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The outcomes from Magnet organizations supporting
structure and process innovation is compelling:
◦ Transformational Leadership (team building, collaboration)
◦ Structural Empowerment (building and supporting staff
engagement)
◦ Exemplary Professional Practice (Decreased mortality rates,
decreased pressure ulcers, decreased falls)
◦ New Knowledge, Innovations and Improvements (creating a
culture of inquiry and scholarship)
Magnet Recognition Program (2009)®
Overall job satisfaction is increased where:
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The organization prioritizes patient care
Management recognizes the importance of personal and family
life/responsibilities
Satisfaction with salary and benefits are high
Perception of job security
Positive relationships exist (peers, management)
Coping mechanisms are available to address stress management
and hardiness
Workload is perceived as fair
Rewards/recognition are present
Opportunities for input into environment are present
Each of these areas present opportunities for
innovation!
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In addition, satisfaction with your career and role
contributes to a desire to stay within the workforce
o Four themes having significant influence on the decision of a nurse to
leave the workforce:
 Lack of educational support- the changing acuity of our patient
population and increasing complexity demand an educated workforce
 Concerns regarding pay/financial security- the end of a career can
mean diminishing financial resources
 The stress inherent in the work of nursing- stress and poor ergonomics
may lead to injuries and increase in the probability of early retirement
 Ineffective leadership
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What does the evidence say about role
satisfaction/intent to stay in the profession for nurses?
◦ Nurses leaving the profession contribute to loss of knowledge
(DeLong, 2007)
◦ Nurses leave the profession because they are unhappy with their
work (Weisman, Alexander & Chase, 1981)
◦ Role satisfaction and intent to stay are multi-dimensional
concepts (McCarthy, Tyrrell & Lehane, 2007)
◦ The workforce can be restless! 22.5% of RNs expressed intent to
leave existing roles and 37.1% were unsure about their plans
(Larrabee, et al. 2003)
◦ 96% of nurses surveyed anticipated no difficulty finding other
jobs (McCarthy, et al 2007)
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Recruitment Trends regarding new graduates
◦ Shift in nursing education preparation from 1980 to 2008
Diploma prepared RNs- 63.7% to 20.4%
ADN prepared RNs- 18.7% to 45.4%
BSN prepared RNs- 17.6% to 34.2%
◦ Less jobs are available for new grads:
 unsure economic health of organizations thus, less available jobs
 less baby boomers planning early retirement
◦ Schools have increased enrollments however in 2009, 54,000
applicants were turned away
◦ Alternative paths are being developed ie. Accelerated
programs ( 230 in U.S); BSN to DNP
◦ New graduates are being hired into almost every area of
nursing practice.
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Newly hired RNs changed jobs during the first year 13% of
the time and 37% reported they felt ready to change (Kovner, et
al., 2007)
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The presence of a post-licensure nurse transition programs
(Nursing residency programs) is reported to result in
significantly less errors (43% vs. 56% p=.004)
New graduates who participated in transition programs report
being better able to make decisions, supervise others, make
calls to physicians and document care (NCNSB, 2010)
The ROI for a nurse residency program is calculated to be 8.8
months (Pine & Tart, 2007)
Preceptor programs for new graduates result in increases in
job satisfaction, retention and socialization (Phillips, 2006)
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The problem with transition of new grads:
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Complex healthcare system
Inconsistency in readiness to practice among graduates
Variability in transition/orientation models
High risk for errors/patient safety
Turnover higher for new grads
 35-60% turnover in first year ($46,000 - $64,000).Some studies
calculate cost at125% of RN salary
 Expertise gap will result in novice nurses depending on inexperienced
nurses for support (Orsolini-Hain & Malone, 2007)
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Retention among experienced nurses
Factors which contribute to decreased organizational
turnover
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Less job stress
Higher group cohesion
Stable work schedule
Minimal overtime (Shader et al., 2001)
Ability to accommodate outside obligations (Family)
Adequate salary
Open communication
Opportunity for learning and self-growth (Hsu, 2006)
Career opportunities for aging nurses
Sound familiar?
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Aging nurses
◦ Predicted shortage of 260,000 RNs by 2025
*Only 9% of the nursing population is under 30 years of age
(Bernard Hodes Group, 2009)
*Nurses tend to leave the profession earlier than the average
retirement age (55 yrs vs. 62 yrs.)
*55% of surveyed nurses report intent to retire between 2011
and 2020 (Bernard Hodes Group, 2009)
* Faculty
shortages may be the tipping point for the nursing
workforce
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Magnet culture:
1. Transformational Leadership- incorporates traits including
broadening and elevating the interests of the followers,
enabling them to transcend their own self interest for the
team. Inspires and facilitates.
o “Dynamic, transformational leadership engenders motivation”.
(Coomber & Barriball, 2007)
 How is transformational leadership reflected?
CNE- Self reflection
High performing leaders and leadership teams with
great outcomes
Mentoring at all levels
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Monitoring employee engagement and not just
satisfaction. Being “engaged” means the employee
utilizes discretionary energy towards the workplace.
What supports nurse engagement?
◦ RNs want input into practice environment
◦ Relationships matter; it is reported that satisfaction
with relationships are the strongest predictor of job
satisfaction for the nurse
◦ Nurses want decreased stress in the environment
including support services and co-workers that are
responsive
◦ Hardiness contributes to job satisfaction; balance
 Nurses want career options
(Larrabee et al., 2003)
2. Structural Empowerment
◦ Shared governance
Redesign recruitment and retention
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Early career phase- Onboarding programs; nursing residency
initiatives; mentorship
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Mid-career phase- career coaching; development of a career
portfolio; leadership development programs
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Late career phase- flexible roles; career coaching; phased
retirement; re-entry programs; generational socialization
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“Healthy aging” is suggested as a strategy to decrease the
physical and mental deterioration associated with aging (Thornton,
2002) .
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Levels of physical and mental decline appear to have a high
level of variability (Rowe and Kahn, 1987).
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Social networks, including work relationships, are clearly
linked to healthy aging (Michael, et al., 1999).
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Accommodations to keep nurses in nursing include:
◦ Ergonomic changes
◦ Use of clinical technology
◦ Changes in human resources/benefits area (The Lewin Group, 2009)
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Mid-career nursing workforce
◦ Shifts in the nursing workforce are dramatic; Significant
increases are evident in the numbers of nurses over 50
years of age (Hart, 2007)
◦ Expertise is related to provision of optimal nursing care
 For each increase of a year in average RN experience
in a study of nurses with more than 10 years
experience, the patient fall rate was 1% lower and the
hospital acquired pressure ulcer rate was 1.9% lower”
(Dunton, 2007, p.8)
◦ Satisfaction in the workplace contributes to quality care
(Coomber & Barriball, 2007)
 Remember, only 9% of the nursing population is under 30 years
of age!
Recommendation: Consider the career phase and not
just the age of the nurse in developing retention and
satisfaction.
3. Exemplary Professional Practice
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Clinical advancement models integrated with performance
management and job expectations
Roles for APRNs; Nurse Navigators; Extended role nurses
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Ensure adequate staffing and support resources
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Staff nurses perceive low staffing levels as a lack of “support”
Develop leadership capacity among staff including additional
staffing resources
Ensure presence of flex staffing
Provide response teams for support (rapid response, stroke,
code white)
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4. New Knowledge; Innovations and Improvements
o Introducing research and the language of inquiry into the
culture
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Bedside report
Hardwiring handoffs
Clinical automated documentation
Overhead ceiling lifts
Integrated clinical systems
Patient falls research
Pressure ulcer prevention
Breast feeding rates
Psychosocial distress among newly diagnosed cancer patients
Where do we go from here?
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Suggestion #1: Job Sculpting: Identification of
individuals within workforce that are key to
success and continually recruiting them
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Informal and formal
Performance reviews; coaching
Organizational awareness for talent management
Key persons who contribute to success
Demonstrated initiative including leadership development
curriculum
◦ Educational opportunities; tuition reimbursement
 Suggestion #2: Know the definition of flexibility
for your workforce and where they see
themselves on their career trajectory
Age and Flexibility Study: (CBH Data, 2008)
“When work works: a project on workplace effectiveness and flexibility”.
Employee perceptions (CBH Data, 2008)
o Employee rating themselves as “mid-life” ranged from 25-65
yrs of age; Employees rating themselves “older” ranged from 48
yrs to 74 yrs
o Employees rating themselves in “early career” ranged from 20’s
to early 40’s, mid-career from late 20’s to early 60’s and late
career from early 40’s to late 60’s.
o 91% of CBH respondents agree that having flexible work
options contributes to their quality of life
 Suggestion #3: Develop strategies to retain
knowledge among the nursing workforce
“Mitigating Knowledge Loss; A Strategic Imperative for Nurse Leaders”
Bleich, M, et al. JONA, (2009)
◦ What happens when the current workforce of registered nurses, 50 years
and over, exit the workforce?
◦ Will the loss of knowledge be devastating to organizational performance
and productivity?
◦ What are the implications for quality and patient safety?
Suggestions:
-Simulation
-Mentoring
-Phased Retirement
-New Roles
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Suggestion #4: Address stereotypes of aging
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What are the issues and stereotypes of age?
Employers perspective
◦ Myth: Older workers are unwilling to try newthings; younger workers are
open to new ideas
◦ Myth: Older workers are unwilling to learn new technology; younger
workers are generally good at technology
◦ Myth: Older workers are more expensive to employ; younger workers are
less expensive
◦ Myth: Older workers are either disabled or out sick more often
◦ Myth: Older workers best days are behind them
Wisdom at Work, Hatcher et al., 2006
Suggestion:
-Multigenerational hiring and team composition
-Assess workforce demographics
-Include age diversity in strategy
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Suggestion #5: Develop a highly informed
nursing workforce through education and
increased understanding regarding benefits and
compensation
◦ Pay and benefits have been cited frequently as a reason for
less “invested” nurses to leave jobs.
◦ Educate nursing staff to understand concept of benefit
package as an asset versus hourly salary mentality.
◦ Provide opportunities for compensation for additional
responsibilities (i.e. clinical ladders; differentials)
◦ Evaluate market for comparison at regular intervals and let
staff know you do this.
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Suggestions #6: Assure an environment of
shared empowerment
Benefits:
o Decrease obstacles that impede healthy work environments
o Decreases stress for caregivers
o Improves outcomes for both patients and nurses
o Demonstrates caring “The caring they want us to give patients
is not given to employees”
Suggestions:
-Unit-based shared governance
-Open meetings; communication
-Staff committees and teams with
intention
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Suggestion #7: Implement strategies to support
development of relationships
Benefits:
o Demonstrate caring “The caring they want us to give patients is not given
to employees” (Erenstein, R., McCaffrey, R., 2007).
o Implement socialization strategies from the onset of employment
(orientation, introductions, networking)
o Suggestions:
o Encourage social support structure among co-worker which has
been demonstrated to decrease stress (Erenstein, R., McCaffrey, R., 2007).
-Healing Community
-Activities relating back to rationale
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Suggestion #8: Implement strategies to decrease
stress
◦ Nurse huddles
◦ Manager rounding and visibility
◦ Observe for signs and symptoms of stress and
turmoil
◦ Track employee engagement scores
◦ Ensure adequate staffing including support staff
◦ Support interdisciplinary teams to address areas
of concern
Suggestion
#9: Support programs and service
that encourage development of traits of
hardiness
o Offer scheduling flexibility through self-scheduling
o Utilize resources including pastoral care staff to support
coping mechanisms.
o Ensure adequate and timely communication to promote
trust
o Support opportunities for transfers within the organization
o Directly address negative behaviors/attitudes
o Employee Support - Pastoral Care, Employee Assistance,
Social Services
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Suggestion #10: Develop role for career coach
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Career Coach Process at CBH:
◦ Staff nurse participants discuss career goals with coach
◦ Participants give coach information re clinical ladder
experiences
◦ Within one month coach formulates a plan
◦ Coach meets with participant to discuss plan, identify
mentor
◦ Coach meets with participants to discuss movement toward
goals
◦ Coach reports to administration annually regarding activities
to date
*Selection of coach was essential. Retired seasoned nurse leader was
contracted.
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Suggestion #11: Support development of
education targeted towards and including
experienced nursing population
o Assess educational needs and interest of nursing population within this
cohort
o Offer a variety of teaching methodologies including self-study,
Simulation, classroom, role playing and one-on-one
o Engage experienced nurses in program planning and execution
o Create roles for experienced nurses to support education
o Encourage managers to explore their own beliefs regarding age
stereotypes and other generations
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Suggestion #12: Develop programs of phased
retirement for targeted positions/skills
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Identify organizational definition of phased retirement
Evaluate organizational readiness for concept
Identify skills/positions for trial and targeted outcomes
Identify available options
Develop business case for phased retirement
Create communication plan for stakeholders
“Development of a Business Case for
Phased Retirement in Nursing” Hill, K., JONA;
40(7/8).
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Suggestion #13: Implement workplace
accommodations
o Assess physical and adaptive needs of workforce
o Identify available options for adaptations through consultation
with experts
o Identify outcomes and baseline data prior to interventions of
ergonomic adaptations
o Ensure fair hiring principles and policies against age
discrimination
Innovative Adaptations:
o Intuitive nurse call systems including integration with cell
phones
o Integrated equipment with electronic charting
o Overhead ceiling lifts with remote control
o Portable lap top computers and other IT devices for
documentation
o Integrated systems to decrease re-work and additional calls
and stress including bed placement and ancillary support
department requests
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Suggestion #14: Create socialization experiences
for senior nurses
o Assemble meetings for senior nurses throughout the year to
have educational topics presented and network
o Offer non-biased counseling for employees to develop
retirement plans including projections of income needed in
latter part of career
o Provide opportunities for senior nurses to be recognized for
contributions/expertise
o Create opportunities for senior nurses to mentor novice
nurses
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Conclusions
o The nursing workforce is experiencing shifts in age,
composition, education and roles
o Significant changes are occurring within society which
include increasing numbers of older citizens to support and
care for. This presents opportunities for nurses in the
creation of new roles as well as in the ability to contribute
income back into the system by working longer.
o Strategies in the future must address phases of careers and
not use age as the defining factor
o Nursing satisfaction is multi-dimensional and must be
recognized as such in planning and implementation
o Relationships matter in supporting recruitment, retention
and satisfaction
o Interventions and tactics to address retention but must be
integrated through strategic planning with measurement
criteria and baseline data for evaluation
o Innovation must occur at all levels within an organization as
well as care settings where nurses practice
o One responsibility of leaders is to help others mourn the loss
of what is passing and then let it go! (O’Grady, Malloch, 2007).
A refusal or reluctance to innovate does not diminish
the demand for change, it just makes the adjustment to
the change more difficult! (O’Grady, Malloch, 2007).
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khill@bhsi.com