✯
✯
2003 National Health Policy ✯Conference
January 22-23, 2003
J.W. Marriott
Washington, D.C.
2003 National Health Policy Conference
Reinventing the Health Care Workplace
January 22, 2003
Massachusetts General Hospital
Jeanette Ives Erickson, RN
MGH - ORIGINAL CAMPUS
„ Third oldest hospital in America - Chartered in 1811
by an act of the state legislature.
MGH
„ A premier center of patient care, teaching and research.
„ Occupying 66 buildings, over 25 acres.
MGH - EMPLOYEES
MGH - EMPLOYEES - 2002
MGH WORKFORCE
„16,980 Employees
„ Largest Private
Employer in
Boston
Management
4.2%
GeneralSupport
MDs
12.7%
9.5%
PhDs
2%
Clerical
21.4%
Trainees
12.1%
Nurses
17.5%
Technicians
9.5%
Other Professionals
11.1%
PATIENT CARE ACTIVITY
‹
Despite predictions that volume would fall due to
market pressures, inpatient volume grew an average of
4.2% per year
‹
Length of stay has declined 12% from 6.65 days in
FY96 to 5.86 days in FY02
‹
Average daily census has increased 13% from 616 in
FY 96 to 695 in FY02
‹
Outpatient visits grew an average of 4% per year
‹
Emergency Department activity risen to 76,000 visits
per year.
LENGTH OF STAY DECLINED IN THE FACE OF
INCREASING PATIENT ACUITY
7.50
• 12% LOS decline came in spite of a 20% increase in acuity
• Patient care staff from all disciplines rose to the challenge of this
additional workload
7.00
1.90
1.85
1.80
1.75
6.50
1.65
6.00
1.60
1.55
5.50
1.50
1.45
ALOS
ACUITY
Linear (ALOS)
FY
'0
2
FY
'0
1
FY
'0
0
FY
99
FY
98
1.40
FY
97
FY
96
5.00
Linear (ACUITY)
ACUITY 1
ALOS 1
1.70
NURSING
‹
‹
‹
‹
‹
Challenged by 30% growth in patient volume and a 20%
increase in acuity
Succeeded in adding over 600 nursing positions
Despite this growth, the nursing vacancy rate has stayed
relatively constant at just under 5% compared to a 10%
statewide vacancy rate and a 13% national vacancy rate.
Many programs instituted to recognize nursing
professionalism as key to patient care, such as the
clinical recognition program.
Turnover averages 5% annually.
PROFESSIONAL PRACTICE MODEL
Values
Collaborative
Decision-Making
Privileges
Credentialing
Peer Review
Philosophy
Professional
Development
Research
Standards
Of Practice
Patient Care
Delivery Model
Descriptive
Theory Models
RETENTION & RECRUITMENT OF REGISTERED NURSES
HIGH LEVERAGE STRATEGIES
X
Attracting Today & Tomorrow’s Nurses
¾
Marketing
• Establishing a World-Wide Identity for the MGH Nurse
• Aligning with Human Resources
¾
Focus on New Hires
• Creating Professional and Specialty Expertise
• Securing New Hire Loyalty
• Developing Tomorrow’s Nurses
RETENTION & RECRUITMENT OF REGISTERED NURSES
HIGH LEVERAGE STRATEGIES
(CONTINUED)
X
Retention of Talent
¾
Nurse Executive Role
•
•
•
•
•
•
•
¾
Creating a Multidisciplinary Professional Practice Model
Providing Competitive Compensation
Customizing Staff Scheduling
Enabling Hours Through Technology
Continuing to Improve Systems
Building Relationships
Developing a Robust Quality and Safety Program
Retention at the Front Line
• Instilling Manager Accountability
• Recognizing and Developing Nurses
• Developing a Speakers’ Bureau
CREATING A LEARNING ORGANIZATION
One out of three RNs that we hire today is a new graduate!
X
Needs of new graduates at the MGH:
¾
¾
¾
Responsive systems that are easy and intuitive so that
new staff can provide safe and efficient care
Understanding of intergenerational issues
A Learning Organization
ORIENTATION CHALLENGES
NEW GRADUATE VS EXPERIENCED NURSES
Baseline
Orientation
Cost
(1)
Overall
Productivity 1st Year of Hire
Critical Care Units
Experienced
New Graduate
$14,233
$30,556
81%
50%
Routine Units
Experienced
New Graduate
$8,796
$24,244
88%
53%
(1)
Orientee and preceptor salary expense
IMAGE CAMPAIGN STUDY
X
Make nursing visible
X
Promote the rewards of nursing
¾
generate loyalty to profession and organization
¾
stimulate interest and appreciation for nursing
• potential nurses
• general public
FACTORS AFFECTING CURRENT NURSING SHORTAGE
X
Image
X
Working conditions
X
Salary
X
Many competing career options
X
Low enrolment in nursing schools
X
Unhappy nurses who don’t recommend nursing
OBJECTIVES
We Wanted to Understand . . .
X
Mindset around choosing a career
X
Interests, values, behaviors
X
Influences
X
Images and perceptions of nursing
X
Benefits and barriers to nursing
RESEARCH METHODOLOGY
X
Qualitative (January/February 2002)
¾
5 focus groups
• Nursing Students (1st & 2nd year)
• Urban teens grade 7 - 11
• Suburban teens grade 7 - 11
• Parents of youth grades 7 - 11
• Potential career switchers
X
Quantitative (April/May 2002)
¾
400 Telephone surveys
• Junior high/high school students (Grade 7-11)
• Career switchers (adults 18-49)
CONCLUSIONS: FOCUS GROUP RESULTS
Big challenges and
promising opportunities
WE HEARD LOUD AND CLEAR...
“We don’t know what
nurses do”.
Source: Partners Healthcare nursing as a career focus groups
IMAGE
“Supply of nurses is negatively influenced by the
inaccurate media images of nursing, decreasing the
selection of nursing career options by young
people.”
William Mercer, Inc. 1999
NEARLY ALL PARTICIPANTS HAD AN IDENTICAL
STEREOTYPE
X
White hat
X
Short white skirt
X
Blond
X
Sexy
X
Young, attractive, cheerful…
When asked to picture a nurse, without exception, everyone
saw nurses in a white hat, short skirt, young, and sexy often
with zippers half way down their chests or very old and
serious like school nurses.
NEGATIVE IMPRESSIONS OF NURSING
X
20% of teens believe nurses perform menial clean-up
tasks
X
Only 39% of teens believe nurses are critical
thinkers, capable intelligent problem solvers
X
Do not believe that nursing pays well (less than 20%
believe that nurses earn $45,000)
X
Few believe that nursing offers:
¾
Career advancement
¾
Flexible schedule
¾
Happiness at work
Source: Partners HealthCare nursing as a career telephone survey
DOCTORS ARE IT
X
They saw nurses as less than doctors, second best.
X
Doctors are smarter, more respected, paid more,
and, in short, it is a better career.
X
Nurses are second class citizens, it’s all about the
doctors.
X
This sentiment was even expressed by the student
nurses. Many wanted to do better than nurse
relatives and become doctors.
SALARY
X
X
X
Although many felt nurses are finally being paid
adequately…
they underestimated today’s salary by half
Potential career switchers estimated today’s
nurse salary by half
WHAT YOUNG PEOPLE LOOK FOR IN A CAREER
‹
Make a difference
‹
Be passionate about their job
‹
Be somebody
‹
Have a flexible schedule
‹
Make money
‹
Have stability in their job
‹
Be intellectually stimulated
‹
Be needed
CHALLENGES OF NURSING
X
Long hours (mandatory overtime)
X
Early mornings, late nights, they want a life
X
Stress
X
Workload
X
Unpleasant working conditions
X
Education is challenging
X
Lack of respect
X
Low pay
X
Not all viewed nursing as a career or profession
WHO INFLUENCES CAREER DECISIONS
X
Teachers, especially science teachers
X
Visitors to schools talking about their careers or the
opportunity to shadow nurses
X
Science club, community service, relatives
X
Pushed by a boss who was a nurse
X
Relative or parent of friend speaking about nursing as
a career
X
Many began thinking about a career as early as age
seven.
WHO DOES NOT INFLUENCE THE CAREER DECISION
X
Guidance counselors were not helpful; they only
helped schedule and select classes, not make career
decisions.
X
Parents do not push children into any field or
discourage any field.
So… where do we go from here?
NURSING PROVIDES BENEFITS THEY WANT,
THEY JUST DON’T ALWAYS KNOW IT
Career Motivators
Perceptions of the Benefits
of Nursing
Students
Adults
Students
Adults
Enjoyment
88%
81%
35%
33%
Making a difference
57%
56%
78%
78%
Importance
50%
52%
63%
72%
Money
43%
50%
26%
29%
Flexible schedule
38%
61%
16%
28%
Learning opportunities/
growth
25%
54%
31%
40%
Teamwork
31%
40%
46%
55%
Working with people
you like
44%
47%
57%
62%
Source: Partners HealthCare nursing as a career telephone survey
HOW TO REACH YOUNG PEOPLE
X
They listen to the radio constantly
X
They are on the internet daily
¾
35% of teens
¾
30% career switchers
Source: Partners HealthCare nursing as a career telephone survey
INFLUENCES
Students who spoke to someone
about nursing, and have heard or seen something
in the news or entertainment,
are three times more likely
to choose nursing as a career.
Source: Partners HealthCare nursing as a career telephone survey
HOW CAN WE ENCOURAGE YOUNG PEOPLE
TO CHOOSE NURSING?
X
There is no substitute for first-hand experience and
knowledge.
¾
¾
¾
X
X
Relatives
Job shadow, career days
Volunteer opportunities
Science teachers, mentors
Tutoring, environmental, organizations serving
youths
Source: Partners HealthCare nursing as a career telephone survey
EXISTING OPPORTUNITIES
X
Classroom visits to schools by nurse ambassadors
¾
¾
¾
X
X
X
X
X
X
X
Elementary, middle and high school
Entrée through science and / or health curriculum
Multiple visits to build relationships and deepen content
Arrange job shadow opportunities
Baby sitting classes at hospital
Student volunteers for community service projects
Student internships
Student part-time employment
Clubs and organizations (scouts, science club)
Health fairs with a career component
FEDERAL LEGISLATION
NURSE REINVESTMENT ACT
X
August 2, 2002: signed into law
X
Authorizes loan repayments and scholarship
programs for nurses; public service announcements
re: nursing profession: career ladder programs; best
practice grants; and Long Term Care training grants
X
$250 million requested for funding; however, no
funding was allocated this fiscal year
X
American Organization of Nurse Executives (AONE)
requesting all members to contact their Senators and
Representatives to allocate funds
Symptomatic Solutions
Demand & Supply: Driving Factors
Society’s Increased Need for Nurses
• Population growth
• Baby Boomers aging
• Growing immigrant population
• Increased life expectancy
• Increased survival from severe illnesses
• Improved diagnostics and more treatment
options
• Less-invasive therapies
• Less restrictive insurance policies
• Heightened consumer expectations
• More liberal employer health benefits
Increased Demand for Patient Care
• Patient acuity & workload
• Fast pace & complexity of care delivery
• Shorter length of stay
• Increasingly specialized care beyond what is
taught in basic education
Composition of Nursing Workforce
• Aging workforce
• Current workers staying longer
• Increased number of new graduate nurses
• Number retiring greater than number entering
• Growth and demand has increased number of
job opportunities
• Approximately 50% of staff nurses work parttime
• Workforce does not match diversity in US
Nursing School Enrollment
• Although 30% decline in nursing enrollment over
last 5 years; enrollment in nursing programs is
now increasing
• Aging of nursing faculty
• Racial/Ethnic group under-representation
• High Cost of education; lack of scholarships and
loans
•
•
•
•
•
•
Mandatory overtime
Hiring bonuses
Mandated ratios
Advertising (in absence of image campaign & supportive
practice environment)
Escalating wages (in absence of image campaign &
supportive practice environment)
Heavy reliance on agency staff
Demand-Driven
Nursing Shortage
Fundamental Solutions
Professional Practice environment that influences
recruitment & retention
• Nurses sense of control over their practice
• Collaborative nurse-physician relationships
• Administrative support
• Staffing adequacy, quality
• Quality of nursing leadership
• Quality of care
• Professional advancement and recognition programs
• Internships & new graduate programs
• Work schedules, flexibility
• Competitive wages and benefits
• Enabling technology & support services
Strategies to grow tomorrow’s Nurses
• Image Campaign to change image portrayed in media
• Partnerships w/ youth-serving groups
• Classroom visits, Career fairs & Student shadowing
• Develop Web Site to stimulate interest in nursing &
facilitate enrollment
• Financial aid, (loans & scholarships)
® Clara Barton Bill (MA)
® Nurse Reinvestment Act (Federal)
• Increase number of faculty
• Shift attention from active to passive nursing market
• Reach out to students & new graduates
• Accelerated degree, new learning options using
technology
Develop long-term pipeline
• Create a state taskforce to assess, monitor & address
healthcare workforce requirements
• Minority recruitment
• Maintain image campaign and financial support
Contributing Factors
Difficulty attracting people into profession
• Image in media not attractive
• Public does not know what nurses really do
• More career options open, especially to
women
• Decreased enrollment in nursing programs
• Today’s workers want to balance life with
work
• Gen X & Y are smaller cohort of workers –
more competition for talent pool
Workplace conditions
• Inability to offer competitive wages
• Need for flexible hours
• Childcare
• Transportation and parking
• Stress of providing care for today’s patient
population (acuity, workload, physical
demands)
• Need for safe environment for practice
• Need for autonomy over practice
• Need for administrative support and control
over resources
• Need for collaborative and respectful
relationships with colleagues (esp MDs)
• Increased specialization, can’t move staff
between areas
• Increased use of technology
• Orientation & preceptors to transition from
student to clinician
Inadequate Reimbursement
• Does not cover actual cost of care
• Does not support training for specialty areas
and new graduate orientation provided by
institution
Copyright © Massachusetts General Hospital
Department of Nursing
May 2002
MGH: Retention & Recruitment Registered Nurses
A High Leverage Strategy to Maximize Nursing
Retention & Recruitment in an Era of an Impending World-Wide Shortage
Attracting Today & Tomorrow’s Nurses
Marketing
P
R
O
G
R
A
M
S
Focus on New Hires
Establishing a World-Wide
Identity for the MGH Nurse
Magnet Hospital application
Nursing Image Campaign
Increase advertising
Journal Publications
National conference
attendance and presentations
Narrative book
Annual report
Creating Professional & Specialty Expertise
Multidisciplinary Professional Practice Model
Continuum of care assignments
Inpatient Æ Outpatient Æ Retention
Culturally Competent Care Curriculum
Recruitment & Retention
Population specific patient care
Continuing education support
State of the art learning & simulation lab
Tuition Reimbursement
Human Resource Alignment
Align recruits with programs
Open Houses
Web site
Image
Relocation assistance
Referral program
Securing New Hire Loyalty
New hire coordinator
Competency based orientation
Preceptor and Mentor Programs
Pipeline programs with local schools of nursing
Unit-based CNS support
New graduate development programs (generic,
oncology and critical care)
Collaboration with nursing schools to create
certification programs for new grads in critical
care, and OR nursing.
Developing Tomorrow’s Nurses
Grammar school and high school
“Nurses of Tomorrow Programs” to
promote nursing as a career.
Web site orientation
Collaboration with youth-serving organizations
- Girl Scouts
- Big Sisters
Retention of Talent
The Nurse Executive Role
Multidisciplinary Professional Practice
Model
Career mobility
Advancement
Retention
Collaborative Governance
Providing Competitive Compensation
Salaries & benefits
Tuition reimbursement
Back-up child care
FMLA
Customized Scheduling
Flexible staff scheduling
Job sharing
Staffing to demand
Enabling Hours Through Technology
Narcotic dispensing
Electronic assessment tool
Electronic discharge planning
Electronic patient education material
Continuing to Improve Systems
Medication administration
Supply management
Food service
Transcription Support
Relationship Building
MD/RN relationships
The Center for Clinical &
Professional Development Programs
- Conflict Management
- Media Training
Office Of Patient Advocacy
Continuum of care assignments
Inpatient Æ Outpatient
Quality & Safety
Creating safe environment for
practice
Needle stick reduction
Back injury program
Employee Assistance Program
Quality Committee
Retention at the Front Line
Instilling Manager Accountability
Manager as “Retention Strategists”
Unit level retention report cards
Staff Perception of The Professional
Practice Environment survey
Leadership development program
360 evaluation
Recognizing and Developing Nurses
Clinical Recognition program
Collaborative Governance Committees
Fellowships
Spiritual Caregiver
Research
Diversity
Ethics
Yvonne L. Munn Nursing Research
Program
Evidence-based practice
Research grants
Post-doctoral fellowship
Doctoral Forum
Awards:
- Excellence in Clinical Practice
- Yvonne L. Munn Nursing
Research
- Durante Respite Award
- Ben Correo-Clanon Primary
Nursing Award
-Petrilli Oncology Award
-Cancer Career Development
-Raphael-Cronin Advocacy Award
-Orren Carrere-Fox FamilyCentered Care
-Family-Centered Care
-Clinical Narrative Program
-Scholarships
-Continuing education programs
-Funding for professional and specialty
certification exams
Speakers Bureau
Portfolio development
Data base