Anoka-Metro Regional Treatment Center’s Nurse Retention

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Table of Contents

Abstract
Introduction
Review of the Literature
Evidence Summary
Conclusion
References

Abstract

Nurse retention is a significant challenge to the US healthcare industry. Hospitals are under-equipped with nurses, missing a good portion of their vacancies due to increasing demand and low retention of employees. Approximately 35% of new nurses drop out of the profession during their first two years of service. Some of the major reasons for high-turnover rates in AMRTC include poor safety, low salaries, and static schedules. In order to improve retention in the psychiatric hospital, the proposed plan includes improving nurse safety by implementing a 3-colored code of danger for risk assessment, a buddy system for nurses, and emotional therapy after verbal assaults. Other solutions include general payment increases and loyalty programs, as well as the introduction of flexible schedules, allowing the employees to vary between 8 and 12 hours when necessary.

Introduction

Background

The US healthcare system has been known for its chronic shortage of nurses. As it stands, the country has over 3.9 million nurses and midwives employed in the hospital system, which constitutes 13.5% of all nurses in the world (Haddad, Annamaraju, & Toney-Butler, 2020). At the same time, the country is already facing a crisis, with nearly all hospital systems experiencing a shortage of personnel between 5%-25% (Haddad et al., 2020). Reasons for nurse shortages are multiple, with the primary cause for alarm being the increasingly aging population. By 2029, the last of the Baby Boomers will reach retirement, increasing the aged population in the US from 41 million in 2011 to 71 million in 2029 – a dramatic increase of 73% (Haddad et al., 2020). At the same time, the current nurse shortage is estimated at approximately 180,000 individuals, which would only increase as older nurses retire and newer ones are not trained or kept fast enough to replace them (Haddad et al., 2020).

Nurse retention plays an important part in contributing to the ongoing shortage of employees in the US healthcare system. It is stated that the majority of hospitals suffer from a high turnover rate, ranging between 8.8% to 37%, with the highest turnover rates being found in psychiatry, emergency medicine, resuscitation, and other acute care settings (Haddad et al., 2020). Approximately 35% of all newly-graduated nurses are said to leave the profession within the first two years of employment, unable to cope with various difficulties that surround them (Haddad et al., 2020). Common contributing factors to the problem include poor schedules, overworking, low compensation, lack of proper communication and leadership, as well as a lack of retention-focused programs for stress relief. Violence against nurses has also been a significant issue that undermined retention, especially in psychiatric settings (Haddad et al., 2020).

Problem Statement

The problem addressed in this project is nurse retention in Anoka Metro Regional Treatment Center. The populations affected by low nurse retention numbers in the area include the nursing population of AMRTC, its current patient population, and the surrounding communities of Anoka, Dakota, Ramsey, Scott, Sherburne, Washington, and Carver counties (Minnesota Department of Health Services (MDHS), 2020). As it stands, AMRTC experiences critical nurse shortages, operating at about 55% capacity, servicing 110 beds out of 200 (MDHS, 2020). Not only is the available capacity not enough to handle the rising demand for psychiatric services from the surrounding community, it also reduces the quality of the provided treatment. The primary issues that affect nurse retention in AMRTC are violence against nurses, poor scheduling hours, and low compensation. The project seeks to improve nurse retention by focusing on these parameters.

Practice Change

The proposed practice change involves a three-step plan, including the increase of nurse security by assigning color codes to patients based on their likelihood of offense, with corresponding security measures taken in place, as well as changing the scheduling from 12-hour shifts to 8-hour shifts, and increases in monetary compensations for nurses. These practices are to be implemented in a tandem, connected one to another through logistical and implementation means, and are expected to improve nurse retention and decrease turnover.

Rationale

AMRTC is one of the very few hospitals in the area that provides a high-security setting for individuals with potentially violent mental disorders, as well as individuals pending trial. Regular hospitals and healthcare centers do not have the means and experience of treatment and containment of those individuals. In addition, AMRTC provides a full cycle of treatment for various psychological as well as substance-based ailments, including detox facilities, a community assistance center, and a rehabilitation wing for individuals that are to be reintegrated into the society. Therefore, the facility is of crucial importance, making nurse shortages and suboptimal performance a major issue for the community. In addition, the hospital has had major issues with hiring new talent and retaining their core specialists, resulting in a massive drop in capacity, which started in 2017 (MDHS, 2020). Unless these issues are addressed, the services provided by AMRTC will remain suboptimal, resulting in a poorer quality of treatment, increased danger for nurses that continue working in the facility, as well as significant logistical challenges for the community, which will be forced to allocate its patients to other facilities at greater distances.

Review of the Literature

Credible Sources

Utilizing credible, relevant, and peer-reviewed sources is essential when developing an intervention. Evidence-based practices include a conscientious, explicit, judicious, and reasonable use of modern, best evidence in making decisions about the care of individual patients. In order to generate an intervention that is likely to work, it is necessary to utilize sources that have been proven valid for the research. Such practices not only safeguard the patients, but also help reduce the chances of error and the wasting of time and resources by the researchers. All sources can be evaluated based on their applicability, evidence grade, and the information they provide that could be included in the research. A table with a short evidence summary of all sources can be found in Appendix A.

Evidence Summary

Retention, Threats of Violence, and Possible Solutions

Violence is considered to be one of the most prevailing factors in facilitating high nurse turnover rates. Sharma and Sharma (2016) report that the incidence rate of violence in the workplace for nurses varies from station to station, with the average of 9.3 per 10,000 for healthcare personnel, 15 per 10,000 for social workers, and 25 per 10,000 for nursing and personal care facility workers. The researchers also reflect on the fact that part of the reason for nurse turnover in relation to violence is their powerlessness to do anything against the assaulting patient, as fighting back or engaging in self-defense often results in reprimands and even threats of being fired (Sharma & Sharma, 2016). The article provides several means of reducing violence in the workplace, such as learning to recognize small signs of aggression, erection of physical barriers to protect against possible violence, the use of a buddy system, and psychological means of resolving conflicts before they even happen (Sharma & Sharma, 2016).

Threats of violence are considered to be some of the biggest issues among young nurses. A study on developing programs of retention by Wolford, Hampton, Tharp-Barrie, and Goss (2019) state that 45% of young nurses that experience violence for the first time are rendered inoperable and unable to return to duty within a month, and 73% of all nurses leave the profession after the first major incident. Wolford et al. (2019) state that nurse retention programs must, first and foremost, ensure nurse safety against patient as well as nurse violence.

Nyman, Hofvander, Nilsson, and Wijk (2020) provide insights on how nurses perform risk assessment of individual patients before starting the interaction. They utilize history and diagnosis analysis as primary means of determining if the patient would pose serious danger or not. Nyman et al. (2020) state that these assessments prove to be generally accurate, so long they are extensive and performed by experienced nurses. It is speculated that new and inexperienced nurses would be more likely to misjudge a patient and not notice any potential signs of hostility towards their persons (Nyman et al. 2020).

These findings are argued against by Florisse and Delespaul, (2020), who state that risk assessment procedures did not provide any positive effects on aggression rates towards nurses, neither did they result in reductions of the use of coercive pacification techniques. Florisse and Delespaul (2020) explain this through the absence of coherent frameworks for assessing and working against patient aggression. Hospital protocols towards violent patients vary from place to place and are often based on personal experiences rather than evidence, which could be the cause of negligible positive results in the short-term perspective (Florisse & Delespaul, 2020).

The relationship between retention, burnout, and patient-nurse violence is stated to be mutually-involving, so state Laeeque, Bilal, Hafeez, and Khan (2018). Their findings indicate that the threat of violence increases burnout in nurses, especially those new to the profession, which in turn makes them apathetic and less responsive to indicators of possible violence (Laeeque et al., 2018). The researchers also found that patients being attended by a burned-out nurse may be triggered to violence by the perceived lack of compassion and care (Laeeque et al., 2018). In other words, burnout breeds violence, and violence creates burnout, reducing hospital retention.

Violence against nurses has an immediate negative effect on personnel as well as long-lasting implications for the organization. Hassankhani, Parizad, Gacki-Smith, Rahmani, and Mohammadi (2018) reports that violence negatively impacts nurses’ social and professional lives. Choi and Lee (2017) confirm these findings, stating that 95.8% of all nurses participating in the study reported having faced workplace violence from patients in the scope of a single year. Niu et al. (2019) identify verbal assaults and harassments as primary means of violence against nurses, having occurred in 78.4% of registered cases in psychiatric settings. Jeong and Lee (2016) connect with the conclusions drawn by previous researchers and add to it by stating that emotional damage can lead to burnout and the desire to leave the profession prematurely. They also discovered that emotional coping strategies are the most effective against verbal abuse (Jeong & Lee, 2016). Finally, Cho, Pavek, and Steege (2020) highlight that a failure to address verbal harassment as part of interventions or practices leads not only to lower quality of care, but also makes nurses close up and under-report abuse, internalizing the offenses instead of rejecting them.

Retention and Monetary Rewards

Monetary compensation plays an important part in attracting and retaining nurses. Although many nurses choose their field of expertise out of a desire to help people, proper compensation for their efforts is important for retention and self-realization of employees. Munawarah, Maidin and Sidin (2019) report that many nurses come from underprivileged backgrounds and see work in the hospital as an opportunity to get out of poverty, making compensation a tool for retaining them. Goodare (2017) is congruent with these findings and states that the slow growth of nurse salaries compared to inflation is one of the primary reasons why retention efforts in hospitals are largely ineffective in the long-term perspective. Ashwood, Macrae, and Marsden (2018) indicate that new nurses (ones employed in the field for 1-2 years) view payment as a primary reason for being attracted to a hospital and staying in it for the first few years, before being integrated into the collective.

Heidari, Seifi, and Gharebagh (2017) discuss several monetary rewarding strategies that could be implemented to increase retention. Some of them are connected to overtime compensation, stating that many hospitals do not compensate for overtime (Heidari et al., 2017). Overtime compensation increases retention by 5-10% on average (Heidari et al., 2017). Kossivi, Xu, and Kalgora (2016) discuss increasing the base payment as an effective means of retention. Their findings state that doing so increases the number of new nurses joining hospitals, but the effects on retention are lessened by the fact that employees think they were overdue for a raise (Kossivi et al., 2016).

Another possible method of compensation for nurses involves pay-for-performance, where either the baseline pay or the bonuses are determined by nurse performance in the field. Shurson and Gregg (2019) correlate these practices with retention, finding that baseline pay connected to performance is less popular among nurses than bonus-for-performance. They find that when baseline payment is on the line, nurses are hesitant to work with patients that might be detrimental to their statistics (Shurson & Gregg, 2019). Yoon, Lim, and Kang (2017) support these findings, stating that while there is some hesitation in treating problematic patients in nurses with bonuses attached to excellency, the potential for receiving a bonus has a greater effect on nurse retention.

Finally, there is a practice of implementing loyalty bonuses for nurses that have worked in a hospital for an extended period of time, as a means of improving retention.

Yusuf, Christyana, Has, and Yunitasari (2020) state that a practice of providing financial bonuses and pay increases in nurses that have worked for over 2 years has positively improved retention. Christopher, Waters, and Chiarella (2017) find that such options affect young nurses the most, motivating them to stay. The report states that loyalty programs are most effective on Gen X, Millennial, and Gen Z population subgroups (Christopher et al., 2017). Finally, Fackler (2019) adds to the consensus by focusing on retaining older and experienced staff, stating that loyalty programs should have a clear progression and not focus on young specialists alone, in order to motivate loyalty growth throughout the journey.

Retention and Scheduling

Comfortable scheduling plays an important role in moderating burnout and nurse retention. Yu, Somerville, and King (2019) report that 12-hour shifts and rotating shifts result in low-to-moderate levels of fatigue in experienced nurses, and higher stress levels in younger nurses. These findings are partially supported by Shin et al. (2018), who found no statistical differences in fatigue levels, but had higher scores for work-life balance in nurses on 8-hour shifts. Shin et al. (2018) reflected on how fatigue levels and work-life balance are both effective predictors of nurse retention. Blasche, Baubock, and Haluza (2017) discovered that the fatigue recovery rates during 12-hour shifts are lower due to fewer opportunities for rest and relaxation. Aveyard (2016) continues the discussion by stating that preferences for 12-hour shifts vs. 8-hour shifts can be split by generational difference, with younger nurses preferring 8-hour shifts, whereas older ones are used to 12-hour shifts. Ryan, Bergin, and Wells (2017) summarize that 8-hour shifts would do less for the retention of older nurses, as it would put them under stress to reschedule a life they have been leading for most of their lives.

The academic community is in general agreement that fatigue brought upon by 12-hour shifts can reduce retention rates in a hospital. Steege, Pinekenstein, Arsenault Knusden, and Rainbow (2017) claim that prolonged exposure to stressful environments, such as that of acute care, psychiatric, or long-term care settings result in care fatigue, which makes nurses less fit for duty and result in some leaving the profession. Sun et al. (2017) find that physical exhaustion hits new and old nurses in equal measure, as new nurses find themselves incapable of handling 12-hour shifts on a regular basis, and older nurses suffer from reduced physical capacity due to their age, resulting in turnover.

Scammell (2019) connects retention, exhaustion, and burnout, finding the psychological condition to develop from the predictors of care fatigue, physical exhaustion, and general unhappiness, resulting in nurses leaving the field for prolonged periods of time. Finally, the last two sources discuss two potential scheduling models to be utilized to fix the problem. Kester, Lindsay, and Granger (2020) finds that a flexible model, where nurses are capable of choosing their own schedule is an improvement over the inflexible 12-hour and 8-hour models. Keys (2020) largely sustains that claim, though noting potential difficulties with balancing shifts where individual nurses can switch their schedules at a whim.

Best Practices

Best practices, as indicated from the dissemination of information provided in the literature review section, depend on the type of intervention sought to improve retention, in relation to the factor they seek to address. For nurse safety, practices can be split into ensuring physical and psychological protection of nurses from violence. Physical violence can be mitigated by the use of protective barriers (Sharma & Sharma, 2016), the use of the buddy system (Sharma & Sharma, 2016), and the development of evidence-based frameworks for risk assessment (Florisse & Delespaul, 2020). Verbal violence is much harder to counteract, but can be mitigated by the use of emotional comfort strategies (Jeong & Lee, 2016). Reduced violence leads to improved retention.

Monetary rewards as a means to improve retention rates can be used in different ways. Three practices highlighted in the review include general pay increases, pay-for-quality practices, and loyalty bonuses (Heidari et al., 2017; Shurson & Gregg, 2019; Yusuf et al., 2020). These strategies have a varied effect on nurses based on their predisposition towards money as well as age-range, but have been positive for improving retention, in general. A combination of all three could be utilized as a part of a compensation-based retention strategy.

Finally, the review of scheduling strategies to improve retention rates shows that the existing 12-hour schedules are the least effective tools of improving nursing rates (Yu et al., 2019). Two potential practices to replace them include static 8-hour shifts and floating shifts, where nurses are free to choose between 12-hour shifts and 8-hour shifts. It is reported that the latter is more effective in improving nurse retention compared to the former (Kester et al., 2020). At the same time, flexible shifts are more difficult to manage (Keys, 2020).

Conclusion

Since the problems that affect retention are interconnected with one another, a complex and multi-layered approach to solving them must be taken. The proposed solutions to retention problems at AMRTC will seek to target the primary trouble areas the hospital has, namely low salaries (compared to the rest of the country), poor safety measures for nurses, and 12-hour schedules. The solutions to these problems, based on the best practices and EBP, are as follows:

Develop an EBP framework for risk management procedures on patients in AMRTC, using the three-colored danger code (Florisse & Delespaul, 2020). Nurses are to be distributed appropriately to the danger posed by the patient, with young and inexperienced nurses handling green patients, while red and yellow patients must be treated by experienced nurses working in pairs. Verbal abuse should be managed by after-treatment emotional therapy sessions (Jeong & Lee, 2016).
Nurse base salary must be increased to improve retention and recruitment rates (Heidari et al., 2017). Loyalty bonuses for staying in AMRTC for long periods of time should be widely introduced as means of improving retention as well, for both new and old employees (Yusuf et al., 2020).
Scheduling rates should be shifted from 12-hour shifts to flexible shifts, as a means of managing patients better, reducing burnout and fatigue, and improving retention (Kester et al., 2020).

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