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Overview

Little mystery exists as to which practices are most effective in recruiting and retaining nurses. While nurses express dissatisfaction regarding a range of working conditions, a few key issues consistently rank as the most important for nurses deciding whether to take or remain at a job. Compensation and staffing levels are far and away the most important. Following these are reasonable scheduling practices, the ability to practice in a professional manner, opportunities for continuing education and career advancement, and a more general sense of being treated with respect and given a voice in hospital policies.

It is important to note that staffing levels are often a prerequisite for other best practices. For example, it is difficult to adopt reasonable scheduling policies or maintain high standards of professional practice if a hospital is understaffed. Similarly, where short-staffing leaves nurses overworked, exhausted and subject to mandatory overtime, it may be impossible for nurses to feel that they are respected or that they have a significant measure of autonomy or input on the job. Thus, when these issues are promoted as best practices, they often entail a prior commitment to guaranteeing adequate staffing levels.

The crisis in nurse staffing is clearly possible to reverse. The data point, above all, to the critical importance of recouping the hundreds of thousands of nurses who have left the profession, but who would like to return under improved conditions. Of nurses who are considering leaving the profession 71 percent said the most enjoyable part of their job is helping patients and families. Nurses are not leaving because they lack commitment to their patients but because the current conditions make it difficult to care for patients the way the nurses want.144 There is every reason to believe that if pay and working conditions improve, retention rates will increase dramatically, and large numbers of RNs now leaving the profession will return to work in hospitals. Indeed, those hospitals that have already moved in this direction have seen the bottom-line improvements in their own experience with recruitment and retention.

Multiple nurse surveys confirm that improving standards on the key issues is the most effective path to superior recruitment and retention. The NurseWeek/American Organization of Nurse Executives survey reports that 29 percent of current nurses believe that improved pay and benefits would alleviate the shortage.145 Furthermore, when nurses who are considering leaving the field were asked what would make them stay, increased staffing and better pay topped the list.146

Surveys of hospital administrators have produced slightly different results. While directors of nursing or hospital CEOs recognize the importance of pay and staffing, they often focus on strategies for recruiting increasing numbers of RNs from nursing schools or for making local improvements that can be accomplished within strict budget constraints. When the American Organization of Nurse Executives asked hospital administrators to identify "the most effective methods that you use to improve recruiting and retention at this time," the most common answer was salary, with 29 percent of hospitals reporting that they found some combination of increased salaries plus incentive payments for weekends, extra shifts and night shifts to be most effective. Apart from compensation, executives identified the following strategies:147

  • Outreach to nursing schools (20 percent).
  • Staff involvement and outreach to current employees (19 percent), specifically including staff input, team or committee involvement, feedback mechanisms, appreciation and respect, and "giving nurses a say in decisions about patient care and operations."
  • Sign-on, referral and retention bonuses (18 percent).
  • Scheduling options (18 percent), including varied shift lengths, flexible hours, more part-time availability, seasonal employment and "low/no mandatory overtime and/or floating."
  • Staffing (5 percent), defined as "better nurse/patient ratios, support staff."

 

 Views of Nurses Considering Leaving the
Profession: Most Effective Strategies for
Recruiting and Retaining Quality Nurses

 Strategy

 Nurses Expressing Support

 Better staffing ratios

 87%

 More patient time

 81% 

 Input in decisions

 79% 

 Higher salaries

 76%

 Performance bonus 

 71%

 Flexible scheduling options 

 69%

 More part-time options 

 63%

 Continuing education 

 61%

 Better health care coverage 

 60%

Source: American Federation of Teachers, Federation of Nurse and Health Professionals,
The Nurse Shortage, p. 24.

Since this survey asked executives to rank the strategies they actually used, it is somewhat difficult to interpret the results. The fact that only 5 percent of hospitals in this survey use improved staffing ratios, for instance, may simply reflect poor hospital practice or perceived financial constraints.

Surveys of managers reflect one additional problem. In many management-sponsored studies, hospital executives seem to be searching for any and all answers to the nursing crisis except the two that matter most: significant pay increases and real improvements in staffing ratios. Understandably, they represent the most expensive possible strategies. It is also possible that many of those answering surveys, even on the management side, do not have the authority to make these types of financial decisions but assume stricter budget constraints. Nevertheless, a disturbing pattern emerges of administrators seeking to assemble a combination of secondary strategies that cannot work without addressing the primary problems identified by nurses.

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