Staying Power

Vol. 2 •Issue 15 • Page 14
Staying Power

Palomar Pomerado Health shows its strength in nurse retention

In the heat of the nursing shortage, everyone seems to be clamoring for new nurses to fill vacant positions. Facility expansions happening all over Southern California have only increased the number of nurses needed and fanned the flames of the frenzy. A cavalcade of sign-on bonuses and other incentives are paraded in front of potential candidates each year, with the hope they’ll choose one facility over another. Palomar Pomerado Health (PPH) in San Diego knows that getting nurses in the door is only half the battle. They’ve figured out how to make them stay.

The Intangibles

“You know what they say about pay increases? The thrill lasts roughly two pay periods, then it comes down to, ‘What have you done for me lately?’”

That’s how Lorie Shoemaker, MSN, RN, CNAA,BC, chief nurse executive at PPH, sees the current contest for new nurses. She knows that all things being equal, including salary and benefits, what’s going to keep a new nurse at a facility are the intangibles, the things money can’t buy. These include trust, respect, responsibility and integrity, all stemming from the No. 1 item on the list: a great manager. While PPH boasts some of the best managers in the field and has enjoyed a record resurgence in nurse retention over the last several years, it didn’t happen overnight.

“I’ve been at PPH since 1986. In 2000, I became CNO. At that time, our turnover rate was still pretty high, around 26 or 27 percent,” recalled Shoemaker. “Having come up through the ranks of this organization, I knew what it was like to be a front line manager, so I felt I could speak to the issue of what might need to be done, but I knew I couldn’t do it alone.”

Square One

As Shoemaker began to investigate the problem, it became clear that if the hemorrhaging of new nurse recruits was to be stopped, it had to be done at the source. Every newly discovered fact seemed to support that it came down to the nurse/manager relationship.

“This was a very coordinated and comprehensive approach to retention and management,” explained Shoemaker. “We knew there wouldn’t be a silver bullet solution, but as we got further into the process, we could see it was actually management development that led to improvements in retention.”

It soon became apparent a new nursing management program needed to be created from the ground up. With such an arduous task in front of them, the investigative team led by Shoemaker didn’t have all the answers, but they did know one thing.

“It became clear that we didn’t want a system that trained managers,” shared Pamela Hoppie, MSN, RN, nurse manager of the ED at Palomar Medical Center in Escondido. “We wanted a program that created leaders. The first step of that process was realizing that leaders exist at every level of the chain of command, not just at the top. Nurses at the bedside are leaders because they’re making choices that affect changes in the care here, every day.”

The PPH team wanted to identify these leaders in the ranks of their workforce and create a succession plan for those individuals who wanted to move into management roles. At the same time, they wanted to do it in a way that would reinvent the traditional concept of what it means to be a manager into something more inclusive and progressive.

Work in Progress

Soon after its internal assessment, PPH officials contracted with an advisory board company to take part in an initiative to “reverse the flight of talent.” The first step was to survey all nurse managers and front line staff about their satisfaction with their job, their manager and a number of other important issues. The findings were surprising.

“Ironically,” stated Shoemaker, “the most unhappy group we had wasn’t the floor nurses, but the managers.”

Focus groups were assembled and included new grads, nurses with 5-10 years’ experience, nurses with 10-15 years and seasoned professionals with more than 15 years on the job. It was believed that each group would have a different view of retention as well as what was important to keep them happy.

Analytical profiles of each group were drawn up and the needs assessed. Soon after, a steering committee of both floor nurses and senior nurse leaders was assembled to address the common problems.

Data showed that changes in four main tactics were needed to improve nurse morale, as most of the new PPH nurses were leaving before their 2-year anniversary. These included compensation and benefits, the on-boarding of new nurses, general stressors and management scope and practice.

Salaries were immediately brought to competitive levels. New nurses were welcomed with education, mentoring and preceptor programs. General stress from mundane tasks such as constantly having to hunt for equipment was reduced with new protocols. Although not easy, these three tactics would prove quite simple when compared to the Herculean challenge of building a new management model. The only thing bigger than the problem, however, was PPH’s resolve to change it.

“Once these changes were in place, we knew none of it would matter if we couldn’t supply nurses with great managers,” explained Shoemaker. “The whole process had to be supported by great leaders. It really is true that people don’t leave jobs. They leave managers.”

Follow the Leaders

The idea behind the PPH management program is that there is no one singular leader. Leaders exist everywhere, in every part of nursing. They believe in nurses capitalizing on their strengths and becoming leaders in what they do best for those around them, whether they carry a management title or not. This kind of forward thinking isn’t new to PPH. They even encourage managers to take their responsibility so seriously that they think of themselves as chief retention officers.

“The first step to transforming managers to leaders was to give every nurse manager a 360-degree assessment,” explained Shoemaker. “This meant all nurse managers would be evaluated by everyone in their working circle, including superiors and subordinates. We then sought the assistance of the Nursing Leadership Academy in Washington, DC, to devise a leadership development program tailored to our nurses based on the data received from the assessments.”

PPH nurse managers were soon able to attend courses, conducted by Nursing Leadership Academy instructors, geared toward improvement in the very areas they needed in key competencies. In turn, PPH nurse managers traveled to Washington, DC, to develop training skills of their own they could bring back to San Diego and teach their peers.

With enough trainers of their own, the PPH Leadership Academy was formed for internal management development. Nurse managers can now take intensive courses internally dealing with coaching, counseling, conflict resolution, teamwork, breakthrough leadership, evaluating the health of your unit, motivating staff and customizing the job for staff.

“We really see managers as leaders,” added Linda Urden, DNSc, RN, CNA, FAAN, executive director of nursing quality, education and research at PPH. “It’s the culture we are building that has changed the way we think, which ultimately changes what we do and how we do it. What it really comes down to for us is having that solid support mechanism for the nurse at the bedside.”

“We don’t hire nurses here,” Shoemaker agreed. “We hire leaders. Some of them happen to specialize in management while others happen to specialize in patient care.”

Constant Change

As the PPH nurse managers’ skills evolved through training, so did their position descriptions. More responsibility was delegated to staff nurses through shared governance, giving them a new sense of importance and trust while freeing up managers for more interpersonal time with their staff. Equally, staff size was reduced for each manager, some of whom previously supervised up to 150 people at a time.

Managers now make regular rounds not just with patients, but also with their staff. Taking the time to personally connect with each nurse and discuss her daily concerns, once a luxury, has proven to be an absolute necessity in building positive work relationships.

“I think it’s crucial that managers do rounds,” emphasized Hoppie. “This is where they’re able to connect on a personal level, find out how a nurse’s day is going, really get into the inner workings of her concerns and show that she is valued. When a nurse knows you’re interested in her personally, you’ll get her very best in return.”

Two Little Words

It might seem simple, but one “thank you” can go a long way. PPH nurse managers go out of their way to make sure a nurse’s valiant efforts at work do not go unnoticed in a protocol they refer to as “managing up.”

If a nurse is singled out for doing great work in a particular area, her manager notifies the CNO. In turn, the CNO sends a personal, handwritten note to the nurse mentioning her manager singled her out for recognition. The gesture might seem simple, but the impact is great.

“I remember an instance where a patient wrote some excellent things about a nurse who cared for her and forwarded the letter to her manager,” recalled Shoemaker. “I wrote the nurse a note telling her how much her work meant to me and the patient. Little did I know how much that ‘thank you’ meant to her. Six months later, when I finally met her, she was still carrying my note in her pocket. It was that important to her to be recognized.”

Building Relationships

From making rounds with staff to personal recognition, the PPH management style is anchored in building positive relationships between nurses and managers. They believe when people can share thoughts and feelings, free from undermining emotions and stress, an upward spiral of positive change is inevitable.

“I feel relationships are more than 50 percent of anything,” said Dr. Urden. “The workplace is no exception. The interactions we have with those at work affect everything we do. There always will be a handful of challenging relationships in the workplace, so it’s a matter of having the tools to bridge those gaps to a better understanding of each other and a shared realization that we’re all there for the same reasons.”

To ensure these relationships are growing in the right direction, PPH employs a bi-annual Q12 questionnaire from the Gallup organization with several questions that deal specifically with manager/nurse relations. These include items such as, “My manager cares about me as a person” and “I’ve had the opportunity to learn and grow by working with them.”

“Nurses’ opinions are very important to us,” stated Shoemaker. “Managers are held accountable for these semiannual scores and are responsible for improving them through interactions and strategies. Every year we have seen an increase in staff satisfaction.”

Best Investments

It’s clear that re-imagining what management means has satisfied quite a lot of people at PPH. Shoemaker sees it more as an investment in their best asset — the nurses.

“Creating this management development system has been both a huge investment personally and financially for PPH,” Shoemaker explained. “For every 1 percent reduction in turnover, you can realize a $250,000 savings. That’s how much it costs to lose a nurse, and they’re invaluable to us.

“Our turnover rates now run consistently below the California Healthcare Association’s numbers of 15-18 percent, while we remain steadily between 10-12 percent,” she added proudly. “That’s a significant difference when you look at the nurses retained and the dollars saved.”

Word of Mouth

Perhaps the best barometer of the effectiveness of the new management model at PPH is the reaction of new nurses inside and outside the facilities. It’s turned into the kind of advertising money can’t buy.

“A great example of our staying power is the number of travel nurses who have come here and decided to stay,” said Hoppie. “They’ve been all over and worked in countless environments and they say PPH feels like home to them. That means we’ve done our job.”

“I have heard so many positive things, particularly from the nurses I hired in the last several months,” chimed Dr. Urden. “People are saying, ‘What’s going on there? Things are really happening.’ PPH has become a place where people really want to be.”

Luke Cowles is regional editor at ADVANCE.