No Nursing Shortage Here

The alarm about the current nursing shortage has been sounding for more than a year, and continues to get louder and more urgent. In an industry that considers a 10 percent national vacancy rate to be a severe shortage, the current US national average for vacant registered nurse (RN) positions stands at 11 percent. In New Jersey, USA, it is 13 percent.
 
But not at Hackensack University Medical Center (HUMC), a 635-bed, not-for-profit, tertiary-care, teaching and research hospital serving northern New Jersey and New York, USA. Located just seven miles west of New York City, and with more than 63,000 inpatient stays and 1.7 million outpatient visits a year, HUMC is one of the busiest hospitals in the nation. Nevertheless, at HUMC, there is a waiting list of nurses who wish to work there.
 
That statement bears repeating.
At Hackensack University Medical Center, there is a waiting list of nurses who wish to work there.
 
How did this happen?
 
"We have never wavered in our support of the nurse at the bedside," says Toni Fiore, MA, RN, CNAA, executive vice president for patient care and chief nursing officer. "Through the good times and the lean times, we have never adopted a ‘philosophy du jour’ where nurses are concerned. We have never, ever cut a nursing position. During budget crunches, some organizations look at nurses as avoidable costs. We view nurses as cost avoiders."
 
That stalwart support has stood HUMC in good stead through the years, and helped to produce measurable successes such as:
  • A vacancy rate that is essentially 0. "Maybe it’s a 2 or 3 percent," says Fiore, "but we are always effectively fully staffed. We hire based on projections, we have a float pool from which we fill positions, and often the vacancies we do have reflect a new program or floor that is just opening that shouldn’t be fully staffed yet."
  • A nursing staff that is 100 percent employed by HUMC. The hospital does no foreign recruitment, does not use "traveler" nurses (who fill in for up to 13 weeks), and does not contract with nursing agencies.
  • 6.3 percent voluntary turnover among Registered Nurses.
  • Eleven-year average Registered Nurse length of service.
  • A satisfaction rate among nurses in the 97th percentile as measured by Press Ganey.
  • A ratio of 70 Registered Nurses to 30 clinical support staff in medical-surgical areas.
  • An average ratio of 80:20 in critical care units.
 
Fiore has worked closely with John Ferguson, HUMC president and chief executive officer, since he took that position in 1986, to create and support a nursing program that provides both excellent care for patients and proper rewards, recognition, satisfaction, and career opportunities for nurses.
 
So dedicated is HUMC to its nurses that in 1995 it became only the second recipient of the Magnet Nursing Services Recognition Award for Excellence in Nursing Services, a prestigious award given by the American Nurses Credentialing Center. The award, the highest a hospital can receive for outstanding achievement in patient care, reflects a hospital’s performance as measured against 14 standards related to nursing, from assessment and diagnosis to education and collaboration. Achieving Magnet Status is so challenging and difficult that only 50 health care organizations nationwide have succeeded. (Magnet Status is a four-year designation. In 1999, HUMC achieved re-designation as a Magnet hospital.)
 
Fiore says that during the nursing shortage in the 1980s, HUMC took an approach that many health care organizations still take today, and then took it a step further. "We looked at salary and benefits," she says. "However, we also knew that the key to attracting and retaining nurses is regarding them as professional partners, and that has remained our philosophy over the years." Indeed, Fiore says that while HUMC nurses are well paid, it is the atmosphere of collegiality, support, and respect that, for many nurses, is as good as gold.
 
Education and Mentoring
There are several factors that Fiore and her colleague Stephanie Goldberg, RN, MSN, vice president of nursing, point to as key to their success in building and maintaining such a strong nursing program.
 
"First," says Fiore, echoing health care professionals in a wide range of settings who have successfully implemented significant improvements, "you have to have complete support from the top. Our president, John Ferguson, has always believed strongly in our nurses, and has always been their champion." (In fact, Hackensack has an overall culture of continuous improvement; its unofficial motto is "Excellence Has No Finish Line." HUMC has just completed its participation in an IHI collaborative on patient safety, and HUMC is one of seven recipients of a Pursuing Perfection grant from the Robert Wood Johnson Foundation.
 
Education, says Goldberg, is another critical element in supporting any group of professionals. Goldberg is responsible for organizational education at HUMC. "We believe that education is the key to creating more well-developed practitioners," she says. "We have always had a strong education program, both for our current nurses and for young future nurses."
 
The HUMC nursing program works in partnership with local universities such as Fairleigh Dickinson, William Patterson University, Seton Hall, and Rutgers to provide internship programs for nursing students between their junior and senior years, as well as work-study programs during the summer. "We give them classes and let them work with our nurses, and they gain clinical skills and academic learning," says Goldberg. "And it’s also a great recruiting tool, because many of them come back to us as nurses after they graduate."
 
Goldberg says that through these training programs they have specifically targeted specialties in which it is often hard to recruit enough nurses. "We have excellent preceptor programs in oncology, bone marrow transplant, and in women and children’s health and medical-surgical," she says. "Nursing students who train in these areas often decide they like it and come back to us when they are ready to begin their nursing careers."
Mentoring is an important component of the nursing program, and Fiore says it is enormously beneficial for both young nurses and more experienced ones. "You put these young, energetic nurses in an environment with nurse leaders who work with them, listen to them, and really walk the talk about nursing excellence, and it raises everyone’s standards and expectations of themselves," she says.
 
Nurses at HUMC are encouraged and supported in their pursuit of continuing education, and an in-house training program enables them to move to more challenging and rewarding positions. "You can’t always recruit an experienced Intensive Care Unit (ICU) nurse," says Goldberg, "so we have a three- to four-month training program for nurses who want to move into the ICU. They attend classes and work alongside a senior nurse preceptor who helps them integrate their academic learning into clinical practice."
 
As full partners in the patients’ care team, nurses at HUMC work closely with physicians. "The relationship between the doctors and nurses is phenomenal," says Fiore. "One of our strong points is multidisciplinary rounding, which really strengthens the partnership between physicians and nurses and other members of the patient care team, and highlights the ways in which they contribute to each other’s ability to care for patients."
 
The Pursuing Perfection grant, says Fiore, is evidence of the sophistication of their care model and their effective use of advanced practice nurses. HUMC is using the grant to extend the intensive care now required for congestive heart failure patients to the home in order to prevent repeated hospitalizations; and to establish an anti-coagulation service to improve the system of care for patients with blood clots by reducing the over- and under-use of warfarin. Ultimately, says Fiore, they hope to extend the successes from these pilots to all hospital departments.
 
A Commitment to Listening
Another important reason for HUMC’s success at attracting and retaining nurses, says Fiore, is the hospital’s commitment to listening to the nursing staff. "We have done three descriptive research surveys with staff over the past several years, asking them why they came here and what keeps them here," says Fiore. "We take that data and respond to those things we believe are the highest priority. We have a very active Recruitment/Retention Strategic Planning Committee, and they are always looking at ways to better meet our nurses’ needs." As a predominately female profession, nursing has a higher rate of family-related leaves of absence and turnover than other professions, so recruitment is a year-round job, says Fiore, not simply an issue during times of shortage.
 
Nurses are also integral parts of important hospital-wide committees, or counsels as HUMC calls them, including counsels on performance improvement, professional practice, education, leadership, mentoring, and research. "Here, nurses are part of the solution, not part of the problem," says Fiore.
 
Hackensack’s reputation for leadership in nursing has attracted the attention of other health care organizations from around the country that hope to achieve Magnet status themselves. They visit HUMC to learn about the nursing program and see it first-hand. Fiore says the nurses at Hackensack are proud to be Magnet nurses, and proud to show others how they achieved that status.
 
Fiore adds that the patients are the ultimate beneficiaries of HUMC’s dedication to nursing. "Our unwavering commitment is to provide excellence in patient care. We are continually learning and striving to do better. Excellence," Fiore reminds, "has no finish line."
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