Recruitment and retention strategies: a Magnet hospital prevention model
As it has several times since the early 1960s, the national health care system is facing another significant nursing shortage, particularly in the acute inpatient setting (Aiken, 1984; Roberts, Minnick, Ginzberg, & Curran, 1989; Sigma Theta Tau International, 1999). Experts are finding the current nursing shortage remarkably serious–as both a demand and supply shortage, widespread throughout the country, and likely to worsen (see Table 1). On the demand side, the number of inpatient, critical, labor-intensive patients has increased because of both the aging population and medicine’s success in keeping ill patients alive longer, thus requiring increased nursing hours to care for these patients. On the supply side, some of the concerns include an aging nursing workforce and a diminishing pipeline of new students entering into the nursing profession due to a broadening of job opportunities within and outside of health care (Billingsley, 1999; Sigma Theta Tau International, 1999).
Many health care professionals are wondering why a shortage has transpired when managed care cost initiatives, implemented throughout the country, are dramatically decreasing the length of patient stays (Billingsley, 1999; Seifert, 2000). In fact, such a situation should be resulting in a nursing oversupply. However, “the key demand factor, which has not been fully appreciated in the cost-cutting equation, is that as the length of stay decreases, the acuity level of patients increases” (Seifert, 2000, p. 310). With increased acuity comes the need for more nursing patient care hours and skilled nurses (Seifert, 2000). An important element of the supply factor, too, is the unparalleled growth of nursing opportunities outside of the hospital environment (for example, day-surgery clinics, ambulatory care settings, physician offices, urgent-care centers), which has drained nurses whose patient care skills are in great demand in the acute inpatient setting (Billingsley, 1999; Seifert, 2000). Unlike previous shortages, “this one is not about sheer numbers of nurses,” but about having enough nurses with the needed specialty skills and experience to care for unique patient population demands (for example, critical care nurses and emergency department nurses) (Johnson, 2000; Sigma Theta Tau International, 1999).
Downsizing and re-engineering have also taken an immense toll on the health care industry (Seifert, 2000), and particularly on hospital nurses. In the initial adjustment to the managed care system, hospitals eliminated many nursing positions due to tight budgets and the reduced occupancies of hospital beds. Few nurses have since been hired, and those nurses who are left are required to do more with less. As a result, nurses have felt physically exhausted and emotionally drained because of the increased patient load and the conditions under which they must work (Billingsley, 1999; Seifert, 2000). The present shortage is made even more acute as a result of nurses opting out of the nursing profession due to dissatisfaction with their roles in the clinical setting. The problem, therefore, lies not only in recruitment efforts, but equally in the retention of qualified nurses (Roberts et al., 1989; Sigma Theta Tau International, 1999).
A common belief has been that increasing nurses’ salaries will attract more individuals to the profession. While large starting bonuses and other monetary marketing strategies have been instrumental in alleviating the predicament to an extent, they do not address one of the most imperative underlying causes (Aiken, 1984; Roberts et al., 1989; Sigma Theta Tau International, 1999). Higher wages alone will not be a powerful enough magnet to draw an adequate number of new students to the nursing profession, nor will they be enough to retain the excellent nurses presently practicing. Nurses want to be appreciated and respected by physicians and the administrative team; they want to be recognized for their expertise, and they want to take responsibility and participate in the decision-making processes concerning patient care (Aiken, 1984, 1989; Johnson, 2000; Trossman, 2002). Nurses want to be valued.
Hospital administrators, including nurse executives, must be proactive in seeking ways to preserve professional staff employed in the hospital settings. The executive team needs to find ways to make hospital work more appealing to registered nurses. Reorganizing the work setting to bring about increased nursing job satisfaction is a vital solution for today’s critical nursing shortage (Aiken, Havens, & Sloane, 2000; Sullivan-Havens & Aiken, 1999; Trossman, 2002). Overall, when it comes to job choice, the majority of nurses select hospitals that offer flexible scheduling, autonomy, and professional growth (Sullivan-Havens & Aiken, 1999).
Certain hospitals possess organizational characteristics that allow nurses to effectively use their expertise, knowledge, and skills to provide quality patient care. These organizations have been able to weather national nursing shortages because of the favorable reputations they have for attracting and retaining nurses (Sullivan-Havens & Aiken, 1999). One model that has empirically confirmed job satisfaction outcomes on numerous occasions is the “magnet hospital” model (Buchan, 1994; Sullivan-Havens & Aiken, 1999). In terms of specific measures, magnet hospitals have performed better than the average United States hospital, with lower reported turnover and vacancy rates, and higher job satisfaction levels (Buchan, 1994; Gleason-Scott, Sochalski, & Aiken, 1999).
The purpose of this study was to present a prevention model that can assist nurse executives in attracting and retaining nurses in the acute hospital setting. The model refers to the prevalence of the nursing shortage problem, the risk factors involved, and the underlying causes. In addition, the model focuses on the supply side of the nursing shortage and provides recommendations on how best to increase the nursing supply. More specifically, the recommended prevention strategies are associated with Magnet hospital designation, and include a sample cost-benefit ratio for achieving this designation. Once retention efforts have been strategized, recruitment efforts follow.
During a major nursing shortage in the early 1980s, the American Academy of Nursing (AAN) conducted an extensive research project to identify hospitals across the country that were successful in recruiting and retaining nurses. The objective of the project was to evaluate characteristics of hospital structures that supported professional nursing practice (Aiken et al., 2000; Buchan, 1999). These hospitals were not identified by low mortality rate or by patient outcomes, but rather by nursing job-satisfaction outcomes and by their attractiveness to nurses. In other words, the aim of the original study was to demonstrate that these hospitals differed from other hospitals based on their organizational characteristics and the ability of each to maintain low rates of nursing turnover, despite the nationwide nursing shortage (Aiken, Smith, & Lake, 1994).
AAN fellows were asked to nominate 6 to 10 hospitals from within their regions of the United States. The fellows had to consider three criteria: (a) did the nurses consider the hospital a good place to practice nursing; (b) did the hospital have the ability to recruit and retain nurses; and (c) was the hospital located in an area, within a city, considered to be in a competitive marketplace (Aiken et al., 1994; Buchan, 1999). The hospitals were predominantly private, nonprofit institutions, most of which had approximately 300 to 400 beds (Dwyer-Schull, 1984). Administrators of the participating hospitals completed an extensive data index form covering demographics, staffing, and leadership information. An aggregate scoring and ranking process was conducted which produced a list of 41 hospitals scattered throughout the country that exhibited exceptional organizational characteristics supporting professional nursing (Aiken et al., 1994; Buchan 1994). These 41 hospitals were the focal point of further survey and interview-based research activity and came to be known as “magnet hospitals” (Aiken et al., 1994; Buchan, 1999).
The publication of the original Magnet hospital report in the early 1980s had a significant effect on the nursing profession, coming as it did at a time of severe nursing shortage (Buchan, 1999). The organizational characteristics of these hospitals were not in themselves novel, but they were acknowledged as key indicators related to organizational attainment in attracting and retaining clinical nurses. These characteristics consisted of the professional autonomy and responsibility of staff nurses, an environment that supported professional practice and development, continuing education and research activities, and the supportive leadership attributes of the nurse executive (see Table 2). Furthermore, the turnover rate in these Magnet hospitals was 9%, whereas that of other acute care hospitals was 18% (Buchan, 1999; Gleason-Scott et al., 1999; Kramer, 1990).
Approximately 5 years later, Kramer and Hafner (1989) conducted several comparison follow-up studies. The purpose of their research was to determine whether Magnet hospitals maintained lower rates of vacancy and turnover, and higher levels of job satisfaction, than nonmagnet hospitals. The researchers selected a nationwide representation subset of Magnet hospitals for an intensive analysis (N=16; one-third of the original hospitals). The nonMagnet hospitals were selected from the same Bureau of Labor Statistics regions as the original Magnet hospital study, with at least two hospitals representing a different hospital external system (Kramer & Hafner, 1989). Five indicators were used: (a) vacancy rate, which was calculated as the monthly average percentage of RN positions unfilled; (b) RN-to-patient ratio; (c) turnover rate; (d) use of supplementary agency staff; and (e) number of multiple applicants per available position (Kramer, 1990). Nurses employed at Magnet hospitals consistently rated themselves as more satisfied with their jobs than did the comparison group (Buchan, 1999). The result also revealed that staffing indices reflected a higher variation in the ratio of registered nurses employed at Magnet versus nonmagnet hospitals (1:4 RNs per occupied bed at Magnet hospitals, and 1:7 RNs per occupied bed at nonmagnet hospitals). These findings provided statistical support to the conclusion that had been made about the original study: that there were links between Magnet hospital characteristics and both lower rates of nursing turnover and greater job satisfaction among nurses (Buchan, 1999; Kramer, 1990).
There have been many significant changes in the way the U.S. health care system operates in comparison to the situation that existed when the original magnet research was published in the early 1980s. A study conducted by Buchan (1999) examined the extent to which the concept of the magnet hospital has retained validity in the changing health care environment. The most universally reported features of reorganization were the introduction of cross-trained support staff and care assistants, and the reduced layers of management. The standard form of primary nursing was no longer the template for these hospitals (Buchan, 1999). The nursing staff skill mix had undergone changes, with a substantial increase in the use of certified nursing assistants or unlicensed personnel. In addition, continuing education of clinical nurses appeared to be negatively affected by cost-containment pressures. Characteristics that continued to be present in all the Magnet hospitals were flexible nursing schedules and a decentralized administrative structure (Buchan, 1999). The outcome of the study highlighted that, despite hospital reorganization, merger, and organizational change, the majority of these hospitals were able to retain most of the characteristics of magnetism (Buchan, 1999).
At the Work, Stress, and Health 1999 Conference, job burnout research reinforced the importance of both employee autonomy and the organization’s support of employees’ professional values as essential strategies in retaining nurses in the workplace. Summarized findings presented that nurses may not experience as much stress from long hours of work if the job fulfills meaningful values, if they have sufficient control over what they do, or if they are receiving positive recognition for their accomplishments (Johnson, 2000; Sigma Theta Tau International, 1999). Magnet hospitals consistently provide autonomy, recognition, and recognize nurse value through the systems that support nursing practice (Aiken et al., 2000). Magnet hospitals repeatedly demonstrate stronger support of professional nursing practice by their greater percentages of registered nurses in the workforce, support of autonomous decision making through channels of participatory management and shared governance models, and positive recognition through the availability of advancement opportunities and continuing education.
Reversing the nursing shortage trend. Sigma Theta Tau International recognizes the nursing shortage “as a major threat to the future of the world’s health care system.” The Honor Society recommends several steps to reverse this trend today instead of tomorrow. The following initiatives have been recommended (Sigma Theta Tau International, 1999, p. 3).
1. Reposition nursing as a highly versatile profession where young people can learn science, customer service, critical thinking, and decision making.
2. Create patient care models that encourage professional nursing autonomy and clinical decision making.
3. Establish additional standards and mechanisms for recognizing professional practice environments.
4. Develop career-enhancement incentives for nurses to pursue professional practice.
5. Implement marketing efforts that address the image of nursing and recruitment of qualified students into nursing as a career.
6. Develop and implement strategies to promote the retention of RNs and nurse educators in the workforce.
Also, as a follow up to the Nurse Recruitment and Retention Study conducted in 1998 by the American Organization of Nurse Executives (AONE) Institute for Patient Care Research and Education, several recommendations were made to potentially alleviate the nursing shortage. These recommendations included offering competitive compensation, providing enhanced respect and recognition of nurses, improving communication between management and staff, improving professional development opportunities, and increasing opportunities for decision making (Johnson, 2000). Overall, the AONE suggested that the first step in meeting the needs of the nursing profession is to create a working model of a hospital culture that values the profession of nursing and supports autonomous decision making (Aiken et al., 2000; Johnson, 2000). The central organizational characteristics of Magnet hospitals are very similar to the recommendations made by Sigma Theta Tau International and AONE. The major characteristics of Magnet hospitals that exemplify the recommendations made by the two national organizations suggest that Magnet hospital structures are designed with the aim of supporting and recognizing nurses, as well as involving them in decision making about patient care and hospital governance (Gleason-Scott et al., 1999). Magnet hospitals have a system of autonomous, self-managed operation at the unit level, as well as systematic and participatory involvement by unit staff-nurses in nursing department-wide governance issues. In addition, flexible staffing, adequate nurse-patient staffing ratios, and an emphasis on providing clinical career opportunities are significant attributes found in Magnet hospitals (Gleason-Scott et al., 1999; Sullivan-Havens & Aiken, 1999). In all, these organizations enable professional nurses to use their knowledge and to do for patients what they know should be done in a manner consistent with professional standards (Lewis & Matthews, 1998).
Recommendations: Magnet hospital prevention model. A prevention model is presented to assist nurse executives affiliated with acute care hospitals in finding ways to attract and retain qualified professional nurses. The model refers to the prevalence of the problem, the risk factors involved, and the underlying causes of the shortage. Specifically, the model focuses on the supply side of the nursing shortage and, based on the literature, provides recommendations on how best to increase the nursing supply. Prevention strategies are associated with Magnet hospital features that increase nursing job satisfaction, thus, in turn, increase retention and longevity. Once retention efforts have been strategized, recruitment efforts follow.
Prevalence. The nationwide vacancy rate of registered nurses in acute inpatient settings has reached an all-time high, equaling nearly 20% vacancy (Sigma Theta Tau International, 1999). The shortage is also an international problem. The United Kingdom, Canada, and several other countries report problems similar to the United States. The reasons are two-fold: poor pay and poor working conditions (Billingsley, 1999).
Underlying causes. On the demand side, hospitals are becoming large intensive care units, with patient acuity rising and length of stay decreasing. Skilled and specialized nurses are in great demand. In addition, managed care initiatives have forced hospitals to function with tight budgets (Johnson, 2000; Seifert, 2000). Many nursing positions have been eliminated and those nurses who are left are physically and emotionally exhausted, having to care for more patients with fewer resources (Billingsley, 1999). On the supply side, enrollment in nursing programs is on the decline. As presented in Table 1, entry-level BSN enrollment has fallen 6.6% from where it was a year ago (Sigma Theta Tau International, 1999). Also, baby boomers are now entering middle age and require more health care services, while generation X contains the smallest pool of entry-level workers. As one generation is growing, the other is shrinking (Sigma Theta Tau International, 1999).
Risk factors. Risk factors are two-fold. Newly graduated nurses are unprepared and disillusioned, and are opting out of the profession, or at least out of working in an acute inpatient setting. Seasoned nurses are exhausted and dissatisfied due to nonsupportive environments. They are opting for early retirement. In fact, 40% of the nursing workforce will retire over the next 15 years (Billingsley, 1999).
Possible outcome. With a 20% nursing vacancy rate, there are currently not enough nurses to care for patients in the acute care setting, causing a potential deterioration in patient care. The overall nursing shortage will only grow worse over time.
Recruitment efforts. The impact of the nursing shortage crisis, in combination with the high patient acuity, is a vital concern for any nursing administrative team specifically related to balancing staffing needs with patient needs. Hospital nurse executives attribute the shortage to women having numerous and increasing opportunities outside of the health care field and to insufficient reimbursement for the work that is being done. Yet, most leaders perceive that the crisis is bigger than the dollar; it also involves the hard work and the sometimes unequal relationships with physicians (Johnson, 2000; Sigma Theta Tau International, 1999). Multiple recruitment initiatives can be instituted to assist in reversing the trend. Local initiatives might consist of offering referral bonuses, working collaboratively with nursing schools as primary clinical site rotations, hiring new graduate nurses, establishing residency programs, targeting more males for the field, and having clinical nurses visit high schools to increase students’ interest in the health care field. Internal initiatives might consist of paying nurses premium dollars for working above their full-time equivalent status, providing nurses with annual bonuses related to longevity of employment, assuring a large per diem pool of nurses to replace agency use, offering tuition reimbursement and scholarship programs for nurses returning to school for their BSNs, and establishing flexible schedules and hours (Johnson 2000; Trossman, 2002).
Retention efforts. Implementing Magnet hospital features will assist in retaining nurses presently practicing in the acute care setting. For instance, work environments can be fashioned according to Magnet characteristics that provide access to supportive infrastructures in order to empower nurses in their roles. Creating work environments that foster professional accountability, by eliminating stringent rules and allowing nurses the flexibility to act on their expert judgment to solve patient care issues, encourages an autonomous practice climate. Participatory management and shared governance models are two examples of constructive ways to spread formal power that support autonomous workgroups and allow nurses greater control over their work environments (Aiken et al., 2000; Gleason-Scott et al., 1999).
Additionally, organizational efforts that focus on improving access to opportunity, information, and resources have the potential to empower staff and increase the level of job satisfaction among nurses (Laschinger & Wong, 1999). Granting access to opportunity structures can be accomplished by offering advancement positions to nurses, implementing clinical ladders, or offering nurses additional responsibilities that challenge their creative energies (Gleason-Scott et al., 1999). Involving nurses on unit committees and hospital-wide task forces that cut across department and managerial levels is a significant strategy that will provide them with additional responsibilities and opportunities for learning new skills (Gleason-Scott et al., 1999). Another way that nurse leaders can reward clinical nurses is by encouraging relationships outside of the organization via financial support, so that they can attend professional conferences and participate in community organizations.
Access to more and better information for nurses can be obtained through formal and informal communication channels among nurses and the management team (Laschinger, Sabiston, & Kutszcher, 1997). Periodic staff meetings scheduled with the nursing administrative group will ensure a regular exchange of information; managers who share information build on a foundation of trust and cooperation. In addition, participatory management approaches have the potential to increase communication between nurses and managers (Laschinger & Wong, 1999; Laschinger et al., 1997). Ensuring access to resources is a pivotal point in increasing job satisfaction and empowerment among nurses (Spence-Laschinger & Sullivan-Havens, 1996). This, again, can take the form of participatory management, in which nurses can influence the decision-making processes of acquiring both supplies and equipment, and additional support services.
Upholding the primacy of the nurse-patient relationship is an extremely vital strategy in the effort to retain nurses in the hospital setting. Though difficult to implement due to today’s cost-conscious health care environment, adequate staffing ratios represent to nurses that they are valued within the organization, and that the quality care they provide to patients makes a difference in organizational outcomes (Gleason-Scott et al., 1999; Robinson-Walker, 1999). However, to be implemented effectively, this strategy requires the business astuteness of the nurse leader (Robinson-Walker, 1999). Furthermore, obtaining adequate supplies for nurses so that they are able to do their jobs competently is another essential element of the retainment strategy. With fiscal restraints restricting the sums of funding available for supplies and resources, innovative and practical strategies are required on the part of the nurse leaders.
Cost benefit. The sample cost-benefit equation is based on annual costs associated with the recommendation of Magnet hospital designation, and with diversified nursing recruitment and retention efforts (see Figure 1). The costs are linked with the initial costs of Magnet designation and are based on trends and estimates of a specific geographic location (Washington State Nursing Practice Act, cost estimates of several Seattle-area 300-bed acute care hospitals). Other costs will be incurred in the maintenance of the Magnet program (for example, recognition program for nurses, hiring of clinical nurse specialists, etc.). These costs have not been calculated nor incorporated into this initial financial analysis. However, it can be highly anticipated that, with the maintenance of Magnet designation, the additional costs associated with the program will outweigh traditional recruitment efforts, particularly related to reducing the 20% nursing vacancy rate (see Figure 1).
[FIGURE 1 OMITTED]
Even with the implementation of various Magnet recruitment and retention strategies (residency programs, bonuses for longevity, tuition reimbursement, premium pay, increased staffing ratios, and increased nurse involvement in hospital governance issues), cost effectiveness is achieved via the substantial decline in agency utilization and nursing turnover.
The nursing shortage is real, and likely to grow worse. Nurse executives must act on a variety of fronts because no single strategy will cure the crisis. Both recruitment and retention efforts must be put into action, specifically as related to respecting and recognizing nurses for their expertise and providing them with responsibility to participate in the decision-making processes concerning patient care. If we do not act, we run the risk of experiencing a major shortage in the acute care setting, which will ultimately lead to a deterioration in patient care.
Magnet hospital features have been associated with lower turnover and higher levels of job satisfaction. These key organizational characteristics include such elements as decentralized organizational structures, emphasis on participatory management, value of professional nursing practice, and systematic communication between clinical nurses and leadership. Nurse involvement in decision making has been reported as the most significant variable explaining job satisfaction (Gleason-Scott et al., 1999). Magnet organizations have enabled professional nurses to be autonomous and empowered, and to do for patients what they know should be done in a manner consistent with professional standards (Sullivan-Havens & Aiken, 1999). This philosophy of nursing excellence is crucial for attracting and retaining clinical nurses, as well as vital for enhancing job satisfaction and longevity–a key strategy in surviving the nursing shortage.
Facts on the Nursing Shortage
2000 2010 2020
Registered Nurses with a BSN
Nurses Available 596,000 656,000 635,000
Nurses Needed 854,000 1,385,000 1,754,000
Shortage 258,000 729,000 1,119,000
Registered Nurses with a
Master’s or Doctorate Degree
Nurses Available 175,000 250,000 315,000
Nurses Needed 377,000 532,000 822,000
Shortage 202,000 282,000 507,000
Sources: Bureau of Health Professions, U.S. Department of Health
and Human Services; Sigma Theta Tau International Honor Society
of Nursing, 1999
Key Characteristics of Magnet Hospitals
Administration[check] Participatory and supportive management style[check] Well-prepared and qualified nurse executives[check] Decentralized organizational structure[check] Adequate nurse staffing[check] Development of clinical specialists[check] Flexible working schedules[check] Clinical career opportunities
Professional Practice[check] Professional practice models of delivery of care[check] Professional autonomy and responsibility[check] Availability of specialist advice[check] Emphasis on teaching responsibilities of staff
Professional Development[check] Planned orientation of staff[check] Emphasis on service/continuing education[check] Competency-based clinical ladders[check] Management development
Source: Buchan, 1999
Recruitment Costs 1. Advertising to local newspapers $50,000
2. Residency Programs $344,400
(20 RNs for 12 weeks biannually;
Retention Costs 3. Bonuses for longevity of $85,000
(1 year = $100; 2 years = $150;
5 years = $250, etc.)
4. Continuing Education $200,000
(10-16 hours per RN for
approximately 450 FTEs;
5. Attendance at National $45,000
(3-4 RNs per unit based on reward
system; 12 inpatient nursing units)
6. Tuition Reimbursement $87,750
(0.6 FTE = 50% of tuition paid; 0.8
FTE = 65%; 1.0 FTE = 80%)
7. Premium Pay/Overtime $1,468,400
($200 per shift above FTE level;
approximately 20 shifts per day)
8. Increasing Staffing Ratios $2,084,000
(increasing RN-patient ratio)
9. Shared Governance Councils $20,000
(bi-monthly meetings for 12 nursing
units; 10 to 15 nurses per unit
council @ $25-$30/hour)
10. Hospital-Wide Governance $10,000
(bi-monthly meetings for hospital
nursing council; 20 to 25 nurses @
Magnet Designation 11. Magnet Designation Fee $30,000
(initial cost for designation) — + —
Cost Savings 1. Lower Turnover Rate of RNs
(9% vs 20%)
a. Salary savings $2,745,600
(approximately 44 nurses
b. Orientation savings $316,800
c. Employee health $50,000
2. Decrease in Agency Utilization $2,592,000
(5% vs 20%; for example, 5
agency shifts per day vs 20 shifts;
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Valda Upenieks, PhD, RN, is a Faculty Member, Green River College, Auburn, WA.
Note: This article originally appeared in Nursing Economic$, 21(1), 7-13, 23, and is reprinted here with permission of the publisher.
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