The Challenge: Nurses are often described as the heart and soul of hospitals, but they are more like the backbone, providing essential support for the entire system. Like hundreds of other US hospitals, McLeod Regional Medical Center in Florence, South Carolina, has struggled against a nationwide nursing shortage that first took hold during the mid- and late-1990s. This shortage has been particularly bad in southern states, and even worse in the rural region where McLeod is situated. Against this backdrop, during the past several years McLeod has worked to strengthen its nursing program and its ability to recruit and retain nurses.
The Background: McLeod Regional Medical Center, part of McLeod Health, is a large acute care hospital serving 12 rural counties with a population of close to one million. Located in Florence, a city of about 30,000 in northeast South Carolina, McLeod is in the heart of South Carolina’s Pee Dee region, named for the Indian tribe that originally inhabited the area. The scarcity of nursing schools in the region has always made it challenging to recruit new nurses. However, as the region’s population started growing in the late 1990s, leading to increasing demand for medical care, McLeod’s staffing challenges turned into a crisis.
The Situation: In 2000, McLeod typically had a nurse vacancy rate between 15 percent and 18 percent, with some units as high as 25 percent, according to Marie Segars, RN, MSN, CNAA, McLeod’s Vice President of Patient Services and its Chief Nursing Officer. “We tried to fill the gaps with agency nurses, we worked our nurses overtime, sometimes we even closed certain clinical areas or beds if we just weren’t staffed for them,” she recalls. Leaders knew this was an untenable situation, and one that needed to be addressed with more than just bandaid solutions.
“Because we had been working with IHI and doing successful improvement work before we got involved with Pursuing Perfection, we knew we needed to take an evidence-based, data-driven approach to solving this problem,” says Segars.
Segars says she and others analyzed data about their own nursing workforce and reviewed the literature on nursing shortages. This gave them a clearer idea of what their own staffing patterns and problems were, and helped them begin to create an idealized design for hospital nursing. Pursuing Perfection enhanced this effort by strengthening the foundation of improvement principles that supported all aspects of the hospital’s work, says Segars. “We used the same methodology in our approach to nursing issues as we used to improve care for AMI patients or to reduce medication errors: Rely on evidence to find out what works, test ideas in small ways, and spread the successful strategies.”
The Solution: Nursing leaders at McLeod knew they had to focus on improvements in two key areas: recruitment of new nurses, and retention of those on staff.
Recruitment. Segars says they learned from reviewing the literature on nurse staffing about the importance of rapid “throughput” of new hires; McLeod’s throughput was anything but. “We had a very sluggish system in terms of getting new nurses hired and working,” she says. “Our recruiting cycle was as long as 90 days from the initial interview to the nurse’s first day of work.” Now, that cycle is down to a stunning nine or ten days, says Segars, thanks to use of online applications, two new recruiters focused solely on filling nursing positions, dedicated administrative support, and a heightened focus on moving the process along more quickly.
A new Recruitment and Compensation Committee was also formed, headed by a nurse leader, to monitor and address issues related to recruiting nurses, and to serve as an important liaison between nursing and the human resources department.
McLeod’s nursing leaders have worked to strengthen important working relationships with two nursing programs in the area that supply McLeod with most of its nurses: Florence-Darlington Technical College (FDTC), which has a two-year nursing program; and nearby Francis Marion University (a satellite of the Medical University of South Carolina), which offers a four-year nursing program.
“We believe it is important to support our local nursing schools,” says Segars, “both financially and by providing training opportunities and faculty.” In addition to making financial contributions to both schools, McLeod provides faculty for the FDTC program and serves as a training program for nurses in both programs. By the time they graduate, nursing students have spent 600 hours training at McLeod, getting hands-on experience and mentoring in their chosen field. “This is a great recruiting opportunity,” says Segars. “They already know our system, and we already know them.”
In addition, a new position was created at McLeod: a nurse who serves as a liaison with the nursing schools. Renee Kennedy, RN, works with the schools and the hospital to make sure that needs are being met for both organizations, and regularly elicits feedback about the working relationship through formal surveys and personal contact.
Retention. Strategies to support nurses and enhance retention vary from hospital to hospital across the US. At another Pursuing Perfection hospital, Hackensack University Medical Center, in Hackensack, New Jersey, there’s a strong nursing program, and the existence of a “collegial triad” to support nurses on the units is one major reason why. The triad consists of a nurse manager, a nursing educator, and an advance practice nurse who work together as a management team. This triad provides not only essential leadership for unit nurses, but also coaching, mentoring, and role-modeling. The nurse vacancy rate at Hackensack is essentially zero.
Meanwhile, at McLeod, review of data on nurse turnover revealed a pattern, says Chief Nursing Officer Marie Segars. “We know that, statistically, nurses are most likely to leave in their first two years of employment, and the risk is highest at about 18 months.” So nurse leaders at McLeod put some things in place to support nurses through this vulnerable time, including a retention champion on each unit — a nurse who can watch and listen for problems and initiate interventions — and a nurse liaison who functions like a case manager or social worker for the nursing staff.
Renee Kennedy also serves in this important liaison role, checking in regularly with new nurses, making herself available to them as a resource for information, guidance, or just a friendly listener. “I don’t wait for them to come to me,” says Kennedy. “I seek out new nurses to see how they are doing. If I see a nurse beginning to show signs of trouble, like absenteeism, I get involved in a quiet way to see how I can help.”
Kennedy also knows that nurses who are new to the profession need additional support. “Going from graduation to the real world of nursing can be difficult,” she says. “Most new graduates are young, lacking in both life experience and professional experience. Not only are they just beginning to use their technical skills, but they are also learning to deal with the emotional aspects of being a nurse. Most wonder how they can continue to grow as a nurse while maintaining an emotional steadiness in the midst of very human dramas,” observes Kennedy.
To help sort out these issues, and appreciate the challenges they have in common, new nurses can turn to one another in small discussion groups. Says Kennedy, “We might talk about how to get out on time at the end of your shift, or how to supervise an assistant who is older and more experienced. Some of these are questions they don’t feel comfortable asking their managers, and this is a comfortable way we can guide and support them in their work,” says Kennedy.
In addition, McLeod has created a new nursing leadership council to focus on issues specific to the nursing workforce. According to Marie Segars, “They meet regularly with the hospital administration to provide input from the nurses, and they take information, such as data about nurse turnover and vacancy rates, from administration back to the units. We think that, with good information, nurse managers on each unit will make good decisions about how to support nurses.”
The Results: Today, McLeod’s nurse vacancy rate is about 2.7 percent, with a turnover rate of 8 percent. As impressive as these numbers are, Segars is clear that one of the lessons of Pursuing Perfection applies to nurse staffing. “It would be easy to stop being vigilant when you see that kind of improvement, but you have to keep a constant watch on the data and the evidence about what affects it,” she says.
What Team Members Say: “I come from a generation of leaders who were taught to think about projects with a beginning and an end. But when you really go about the business of transforming an entire system and its culture, as we are doing with Pursuing Perfection, at some point all your projects become woven into a tapestry and you can’t separate them. We have learned that you can’t perfect anything in isolation, and the same skills we use to improve AMI care help us support the nursing workforce.” — Marie Segars,RN, MSN, CNAA, Vice President of Patient Services and Chief Nursing Officer
“Nursing is rewarding work, but also demanding. Supporting nurses is good for nurses and good for the hospital, but most importantly it’s good for our patients. And that’s what Pursuing Perfection is for us: We don’t see it as a specific program, but more as a way of focusing all our efforts on behalf of our patients.” — Renee Kennedy, RN, Nurse Liaison
Learn more about Pursuing Perfection at McLeod Regional Medical Center
