OR nurse leaders are struggling not only to recruit staff, but to retain them—especially as younger generations begin to dominate the work pool. A 2019 study by Dowling Dols and colleagues found that Millennials were generally satisfied with their jobs, yet they anticipated staying with their current employer for 3.03 years, compared with 5.83 years for Generation X and 8.25 for Baby Boomers. In this two-part series, we explore staff retention: leadership and culture (Part 1) and career development and engagement (Part 2).
Staff satisfaction is the keystone of retention, but creating satisfaction isn’t easy. For instance, an American Association of Critical-Care Nurses (AACN) study of more than 8,000 critical-care nurses found that only 25% of direct-care nurses were satisfied with their jobs, and 23% planned to leave their current positions within the next 12 months (another 35% planned to leave within 3 years). According to a study by Buffington and colleagues, nurses in Magnet-designated hospitals might leave for reasons such as management, workload/staffing, salary/benefits, scheduling/shift hours, and retirement/family.
Although that list is daunting, OR leaders can take practical steps to improve retention among staff, beginning with a new employee’s first day. “Start talking with your valued employees about retention on day one, and keep talking about it,” says Bruce Tulgan, founder and chief executive officer of RainmakerThinking, Inc, a research, training, and consulting firm in New Haven, Connecticut (http://rainmakerthinking.com), and best-selling author of It’s Okay to Be the Boss. “If you are talking with them about how to meet their needs and wants on an ongoing basis, they are much more likely to be open with you at those key points when they are trying to decide whether to leave or stay.”
OR leaders also need to assess their own skills and build a culture that encourages nurses to stay.
“All the research being done is leading to the same conclusion, that the frontline manager is the most important relationship for staff retention and engagement,” says Rose Sherman, EdD, RN, NEA-BC, FAAN, professor emeritus at Florida Atlantic University in Boca Raton and author of The Nurse Leader Coach: Become the Boss No One Wants to Leave. “Managers need to understand that they are the linchpins: Nurses don’t leave organizations, they leave their managers.”
Unfortunately, most nurses aren’t satisfied with their frontline managers. In the AACN study, 39% of direct-care nurses rated the overall effectiveness of their frontline nurse manager as fair (26%) or poor (13%). “Those working for an excellent manager are less likely to leave because they have higher job satisfaction,” says Beth Ulrich, EdD, RN, FACHE, FAAN, professor in the Cizik School of Nursing, University of Texas Health Science Center in Houston, and a consultant on Healthy Work Environments for AACN.
Excellent managers are those who respect their employees and—in the case of younger generations—serve as coaches. “Managers who adopt a coaching mindset do a much more effective job of retaining their staff,” Sherman says. Coaching includes both career and professional development. “You want them to know what they do well and what areas they need to work on,” Sherman says, adding that coaching requires active listening. “Ask open-ended questions and mutually set goals to achieve objectives.”
Sherman notes that leaders must understand that younger generations have brought a different mindset to the workplace. “We’re past the days when an OR manager could reliably select a perioperative nurse and expect that they would remain with them for the entirety of their career,” she says. “These young nurses strongly desire career development opportunity and continuous professional growth.”
Little data for Generation Z exists, but a Rainmaker Thinking survey that asked respondents to rank the top three considerations for a job found that supportive leadership, positive relationships at work, and scheduling flexibility topped the list for this generation.
The goal should be to meld generations, reaping the best of what each brings to the table, says Jane McLeod, MS, RN, co-founder/principal for Capstone Leadership Solutions, Inc, in Sault Ste Marie, Michigan. “Younger nurses know the cutting-edge research; older nurses know the history of the organization and how things have been done,” she says. “We need to have the two work together to find common ground.”
It’s worth noting, however, that there are many similarities among the generations. Dowling Dols’ 2019 study found that when asked what the hospital needed to do to retain them for the next 5 years, members of all generations identified pay, staffing, and nurse leadership support. And a Rainmaker Thinking report concluded that workers of all ages today are more likely to disagree with their employers’ missions, policies, and decisions and to question employers’ rules, managers’ instructions, employment conditions, and established rewards structures. Current workers don’t believe promises of long-term rewards, and they want more flexibility in working conditions.
Tulgan says leaders also should remember that the goal is to take control of turnover, not eliminate it. “If you are serious about retaining the best, one of the most important questions you should be asking yourself is how you can get turnover to skyrocket among the low performers,” he says. For staff who fall in the middle, leaders should help them better understand their work targets. “By paying attention to them and their work, you tell them they are important and their work is important,” Tulgan says. “Best of all, you will help them work a little faster and a little better.”
AACN defines the components of a healthy work environment (HWE) as skilled communication, true collaboration, effective decision making, appropriate staffing, meaningful recognition, and authentic leadership. A HWE isn’t just a nicety. “Patient mortality and employee intent to leave are linked to an unhealthy work environment,” Ulrich says. A 2019 meta-analysis by Lake and colleagues found that better work environments are associated with better nurse job outcomes, safety and quality ratings, patient outcomes, and patient satisfaction.
“The manager has a big part in setting up a culture that’s healthy, that has a lot of shared decision making, that’s psychologically safe, and that focuses on growth and learning,” Sherman says. Four “c’s”—community, celebration, civility, and communication—help create a positive culture.
OR leaders can create a community by fostering bonds among employees. “Making the people at work feel like a family is one of the most successful strategies for retaining staff,” says Sarah Bosserman, MSN, RN, CNOR, perioperative clinical nurse educator and CNOR coach and instructor at WellSpan Health—York Hospital in York, Pennsylvania. This is especially true for Millennials, according to Jim Clifton, coauthor of the book It’s the Manager. Clifton says that for this group, “the workplace has become their family and community.”
One strategy to achieve community is to spend time together outside work to get to know one another. Bosserman takes new staff out for group activities such as bowling, dinner, and axe throwing, which encourage a deeper connection. “Some tell me that when they were struggling halfway through orientation, it was the activities outside of work that kept them going,” she says.
Providing support to staff when difficult situations arise also fosters community. WellSpan Health has an employee assistance program, and also uses therapy dogs. “If staff are going through a tough time, we’ll bring in a pet therapy dog to spend time with them,” Bosserman says. The dogs’ primary purpose is to visit with patients, but a visit with staff, either as a planned or surprise event, boosts spirits.
Although employees value community at work, they also want work-life balance. “Call schedules have to be flexible,” McLeod says. Creating employee-driven teams to address scheduling gives the opportunity for input, which further enhances retention.
Celebration promotes community and boosts employee recognition. “We celebrate both big and small accomplishments,” Bosserman says. Accomplishments might be mentioned in staff huddles or via email notifications. Those who advance in the clinical ladder get to choose a cake for the celebration, and a plaque in the main lobby lists all employees who have achieved certification.
Natasha Luster, MSN, RN, CNOR, says nurses at Premier Health—Miami Valley Hospital in Dayton, Ohio, receive a small gift such as flowers or a mug with their name. Other techniques that Luster, nurse manager of surgical services, uses to celebrate staff accomplishments include sending staff cards to mark milestones such as birthdays, having a baby, or buying a house, and thank you cards that point out specific positive actions of staff.
Work environment civility, whether from colleagues, patients, or families, plays a large role in retention. “Organizations need to protect nurses not only from lateral violence, but from assaults by patients and families,” says Kathy Casey, RN-BC, professional development specialist and nurse residency program coordinator at Denver Health.
McLeod says leaders should note any generational patterns. “We are seeing a definite issue with silos among the generations, especially in the operating room setting,” she notes. For example, a long-term Baby Boomer employee may say to a Millennial with less experience: “As soon as you’ve been through what I’ve been through, you can talk to me about your new ideas.”
It’s best to take a comprehensive approach to address civility. Indiana University Health (IU Health) is rolling out a program that has leaders and employees working together to be sure employees understand behavioral expectations and the importance of accountability. Change is already occurring. “Holding people accountable when behaviors aren’t appropriate has been very impactful in improving the work environment,” says Nikki Walke, MBA, BSN, administrative director for perioperative services and sterile processing.
Talk to employees on a regular basis. “Understanding an individual employee’s unique needs or wants is the key to being able to reward that person in a meaningful way,” says Tulgan, who adds that providing more generous rewards and work conditions to retain high performers is a good idea. He says that high performers want more attention.
“The superstars want managers who know exactly who they are, help them succeed, and keep close track of their success.” It’s still important, however, to focus on every employee.
Tulgan says employees want to know:
• What do you want from me today, tomorrow, this week, this month, this year?
• What do you have to offer me in return today, tomorrow, this week, this month, this year?
Luster and her director hold open forums with each specialty team every other month. “I let staff know that this is their time,” Luster says. “I’m here to talk about what they want to talk about.” The agenda is short because general information is delivered via monthly staff meetings. She invites staff to submit questions ahead of time so she can be better prepared for the meeting. Luster cautions that it can take as long as a year to develop an effective forum. “At first it was very quiet, and then we went through a phase where complaints were the focus, but now we’re at the collaboration phase,” she says.
Rounds are most often associated with patients, but staff rounding is an effective communication tool. Luster and her associate managers meet with every staff member at least once per quarter. Sample questions include:
• What’s going well?
• Do you have the supplies you need to do your job?
• Is there anything different you need from the leadership team?
• Do you have any outstanding concerns?
Responses are recorded in the computer to detect trends and to facilitate follow-up. That follow-up may occur as part of a monthly “stoplight report” that lets staff know the progress of projects. Red indicates that something can’t be completed and cites a reason; yellow signifies the project is in process; and green means the project has been completed.
Communication also can help managers and staff understand one another’s role. “Frontline staff don’t always understand the manager’s job, and managers forget what frontline staff members are dealing with,” Ulrich says, adding, “Don’t assume what staff know, and let them hear what you think and know.” For example, staff might not understand how staffing decisions are made. The AACN survey found that managers reported having appropriate staffing 54% of the time, compared to just 36% of staff nurses. Managers need to talk to staff about these different perceptions and be open to feedback.
Leaders need to understand that staff are looking for recognition and the ability to grow and contribute. “They want to be able to say, ‘I have the opportunity to grow myself professionally so I can better take care of my patients,’” Bosserman says. “We owe them [staff] for all the hard work they provide.” Leaders can meet these needs through a supportive culture and through career development, which is discussed in Part 2 of this series. ✥
–Cynthia Saver, MS, RN, is president of CLS Development, Inc, Columbia, Maryland, which provides editorial services to healthcare publications.
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