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English;Essay assignment
English; Urban Studies
March 22, 2019
Signature Assignment; Signature Assignment
March 24, 2019

English;Essay assignment
Please read the article that was uploaded and write an essay (5 to 6 paragraphs each paragraph needs to be 5 to 6 sentences.

article –
“Change your thoughts and you
change your world.”
––Norman Vincent Peale
For decades, efforts to
maintain adequate levels
of RNs in the healthcare
workforce have centered on recruitment. The current workforce challenges
and opportunities related to the national
shortage of RNs in health care are outlined
in chapter 9. This chapter will focus on
creating a culture of retention as one key
strategy to decrease nurse turnover and cost.
Surely the answer to RN vacancies lies in a
strong and solid recruitment effort; however,
once recruited, greater emphasis must be
placed on retention. Consider that for every
two nurses recruited, one or more could
leave. Tens of thousands of dollars are spent
each year on nurse advertising and recruitment strategies to hire RNs at all levels and
across multiple specialties. Turnover comes
at a high price to the organization and to
the staff left behind who just spent weeks,
physically and emotionally, precepting and
acculturating the new hire in orientation and
to the work environment.
Nurse managers fi nd themselves facing
an ever-challenging global nursing shortage. The current shortage of registered
nurses in the United States is expected to
intensify as baby boomers age and the need
for health care grows (American Association of Colleges of Nursing, 2003). This
shortage, to rival none in history, is sparked
by a multitude of factors: aging nursing
pool, fewer women choosing nursing as a
career, and others outlined in chapter 9. To
meet this challenge, healthcare employers
have initiated multiple strategies, from foreign nurse recruitment and sign-on bonuses
to creative benefi t packages, such as maid
service, dry cleaning pick-up and delivery,
and car washing. Although these tangible
amenities are nice, they seldom result,
alone, in retaining a satisfi ed employee
(Ropp, 2003). Recruitment bonuses serve
the purpose of alluring the nurse to the organization, but it is often a quick fi x. Once
the bonus is received, the employee, if primarily motivated by money, is out looking
for the next big payday. Often these grand
sign-on bonuses serve to devalue the current workforce and could have a negative
effect on staff retention. At best, the signon bonus is a short-term fi x. Nevidjon and
Erickson (2001) stated that past solutions to
the shortage (e.g., cash bonuses, relocation
incentives) only served to redistribute the
supply of nurses, not increase it. How to
increase the supply of RNs will be reviewed
later in this chapter.
High Cost of Turnover
In November 2003, the Institute of Medicine of the National Academies reported that
nursing staff make up the largest segment
of healthcare workers in the United States,
accounting for 2.2 million RNs, 700,000
licensed practical or vocational nurses, and
2.3 million assistive personnel, which constitutes 54% of all healthcare providers. The
national unemployment rate for RNs is at its
lowest level in more than a decade, declining
from 1.5% in 1997 to 1.0% in 2000 (U.S.
General Accounting Offi ce, 2001). This refl ects the limited pool of experienced nurses
available for employment.
A survey by the Advisory Board Company (2000b) reported that the national
Mary Magee Gullatte, RN, MN, ANP, AOCN®, FAAMA, and Evelyn Q. Jirasakhiran, MSN, RN
Retention and Recruitment: Reversing the Order
This excerpt, chapter 12 from the book Nursing Management: Principles and Practice, edited by Mary Magee
Gullatte, RN, MN, ANP, AOCN®, FAAMA, is part of a series
of clinically relevant reprints that appear periodically in
the Clinical Journal of Oncology Nursing.
From Nursing Management: Principles and
Practice (pp. 217–233), edited by Mary Magee Gullatte, RN, MN, ANP, AOCN®, FAAMA,
2005, Pittsburgh, PA: Oncology Nursing
Society. Reprinted with permission.
Digital Object Identifi er: 10.1188/05.CJON.597-604
turnover rate among hospital
staff nurses was 15%, up from
12% in 1996. A more recent report by the HSM Group (2002)
indicated a nurse turnover rate
in the United States of 21%.
The national average salary for
a medical-surgical nurse is reportedly $46,832; turnover costs are up to
two times a nurse’s salary (Atencio, Cohen,
& Gorenberg, 2003). Inherent in nurse turnover are costs associated with separation,
replacement, and development of the nurse.
Turnover costs include many variables:
direct salary of the new hire and preceptor,
education and development cost, marketing
and recruitment costs, loss of productivity
during orientation, and intangible cost of
turnover on current staff.
The American Nurses Association staffing survey (2001) reported that 75% of
nurses felt that the quality of patient care had
decreased over the past two years, and 56%
felt that they did not have adequate time to
perform patient care. Aside from the fi nancial impact of nurse staff turnover, there is
the negative effect on the staff that has been
involved in the orientation of the new member and potential adverse patient outcomes.
Staff left behind may be working longer
hours and take on increased patient assignments to fi ll the vacancy. Agency nurses may
be employed as a quick fi x. These temporary nurses are seldom as familiar with the
patient population and may not possess the
same level of skill as the organization staff.
In a workforce survey commissioned by the
jm Book Excerpt.indd 597 jm Book Excerpt.indd 597 9/19/2005 2:41:58 PM 9/19/2005 2:41:58 PM
This material is protected by U.S. copyright law. Unauthorized reproduction is prohibited. To purchase quantity reprints,
please e-mail [email protected] or to request permission to reproduce multiple copies, please e-mail [email protected]
Downloaded on 07 07 2018. Single-user license only. Copyright 2018 by the Oncology Nursing Society. For permission to post online, reprint, adapt, or reuse, please email [email protected]
Oncology Nursing Society, nearly 80% of
the RNs surveyed cited diffi culty retaining
experienced nurses (Buerhaus, Donelan,
DesRoches, Lamkin, & Mallory, 2001).
Creating an organizational culture of
nurse retention is crucial to reducing vacancies in healthcare organizations. High nursing staff turnover and low entry of nurses
into the workplace adversely affect both
the healthcare organizations and patient
Job Satisfaction
A key factor, lack of job satisfaction, is
the most cited reason for staff turnover. Job
satisfaction is multidimensional. In a study
by Bratt, Broome, Kelber, and Lostocco
(2000), two key factors surfaced related to
job satisfaction: stress and nursing leadership. Job stress and workplace tension are
inherent in healthcare. The key is how they
are managed. The nurse manager should be
engaged in the human relations variables
of the workplace. Any nurse manager with
the responsibility of hiring, fi ring, and giving performance evaluations should have
taken at least one basic human resources
class (Cline, Reilly, & Moore, 2003). How
is the staff relating to each other? Is there
collaboration and cooperation among the
nurses and other members of the team? If the
answer to these questions is no, then what
does the manager need to do to facilitate the
communication among a diverse group of
nursing staff? It is not enough to continue to
relay the dire predictions of a catastrophic
nursing shortage facing health care in the
next decade. As nurse managers and leaders,
there must be continual proactive steps to
enact a culture of retention while leveraging
the vision of being an employer of choice
and a healing organization, which places the
value and worth of an individual as prime
mission-sensitive goals.
Sengin (2003) identified 10 attributes
that contribute to job satisfaction in acute
care hospitals based on frequency and consistency of appearance in the literature. The
attributes include (a) autonomy related to
independence within professional practice, (b) interpersonal communication and
collaboration within the workplace with
supervisors, subordinates, and members
of the healthcare team, (c) professional
practice—the opportunity for specialization
and professional care delivery modes, (d)
administrative/management practices—this
attribute relates to organizational structure
and culture, (e) status/recognition—the
value of nursing within the organization;
(f) job/task requirements—meaningfulness and variety of work, (g) opportunity
for advancement/promotion, (h) working
conditions/physical environment—includes
staffi ng and scheduling, workload/patient
assignment, equipment, and resources, (i)
pay—competitive salary and benefi t package, and (j) fairness—centered around treatment related to employment decisions in the
Fundamentally, individuals choose a career in health care to make a difference in
the lives of others. When the organization
fails to meet employee expectations because
of hectic and often failed organizational
systems, the employee is left unsatisfi ed
and unfulfi lled. Figure 12-1 compares the
percentage of employees in health care
versus the general population whose expectations are not being met. Often cited in the
literature is the notion that nurses perceive
being involved in decision making as a
very signifi cant variable in job satisfaction
(Gleason-Scott, Sochalski, & Aiken, 1999).
This involves decisions impacting clinical
practice as well as personal decisions related
to staffi ng and scheduling. Involving staff at
a high level in policy and procedure development as well as in self-scheduling will score
high on the retention scale.
Culture of Retention
The human relations efforts of managers
toward staff are key to cohesion and commitment and creating a culture of retention in the workplace (Wagner & Huber,
2003). Health systems also must pay attention to the retention of nurse managers.
The fi rst-line managers are often the glue
that holds the hospital together (Parsons &
Stonestreet, 2003). Gone are the days of
the head nurse or nurse manager responsible for a small nursing unit and a core
group of staff. Over the past decade, the
scope and breadth of the nurse manager’s
responsibilities have spanned multiple units
and, in some cases, across multiple hospital
networks, with an increased number of culturally diverse employees. There have been
human resource issues and increased demands from upper level management to recruit and retain a viable nursing workforce
amid mounting national and international
nursing shortages. First-line managers are
assuming greater work responsibility often
without formalized support or development for the expanded roles. Although
there are reports of nurse managers being
the reason for staff turnover, they are also
the reason for staff retention. Leadership
of strong nurse managers is the key to staff
satisfaction and retention (Cullen, 1999).
Thorpe and Loo (2003) reported that the
retention of fi rst-line nurse managers requires top level organizational attention to
providing adequate resources, training, and
development as well as a supportive work
When a nursing unit has a high retention
rate, one would wonder, “What is the secret?”
There is not one answer to this question. As
shown in literature and research studies, a
combination of retention strategies may work
for a unit depending on the areas needing
short- and long-term solutions, which could
be any of the following: autonomy, salaries,
schedules, credibility gap, and professional
respect (Nevidjon & Erickson, 2001). Some
general retention strategies used at healthcare
organizations were compiled under “Best
Practices in Retention” (Advisory Board
Note. From In Our Hands: How Hospital Leaders Can Build a Thriving Workforce (p. 28), by American
Hospital Association, Commission on Workforce for Hospitals and Health Systems, 2002, retrieved
February 7, 2004, from http://www.aha.org/aha/key_issues/workforce/commission/InOurHands.html.
Copyright 2002 by American Hospital Association. Reprinted with permission.
Growth Affi liation Rewards Safety/
Health Care Employers Employers in General
The Performance Pyramid™ Component
Expectations Not Met
jm Book Excerpt.indd 598 jm Book Excerpt.indd 598 9/19/2005 2:41:59 PM 9/19/2005 2:41:59 PM
Company, 2000a). The following strategies
may be familiar to you or might help strengthen a system you already have in place.
1. Cultivate an interesting and accepting
culture. This comes from the top leadership of the organization and trickles
down to the manager. A manager who
understands diversity and promotes an
atmosphere where everyone can be engaged in working together in harmony
will get a lot of mileage from staff. Nurse
managers who are seen by their staff as
always displaying a positive attitude,
no matter how stressful and challenging
a day can be, will fi nd that it rubs off
on staff when positive comments are
heard from patients and staff from other
departments. Retention is maintained in
a culture where nurses feel they make a
difference, their talents are tapped, and
their contributions are acknowledged. To
make the work environment interesting,
staff can be competitive and join hospitalsponsored contests, such as holiday decorating contests, which promote teamwork
and bolster morale. They also can submit
entries to contests by nursing magazines
such as “The Best Nursing Team Contest” sponsored by Advance for Nurses.
Activities that bring pride to a unit foster
teamwork and, most of all, retention.
2. Implement professional clinical/career
ladders. This opportunity gives the nurse
autonomy and a sense of accomplishment
and value, as well as a way to impact personal earnings based on the level achieved
in the clinical/career ladder.
3. Develop fl exible work arrangements.
Empower staff to participate in selfscheduling; make the full-time benefi ted
positions less than 40 hours a week (32
or 36 hours). Staff is able to schedule
around work and personal activities to afford them fl exibility to balance work and
home. With guidance and directions from
the nurse manager, this is a major gain for
the staff to feel empowered to have some
control over their work schedule. For this
to work, it requires some give and take on
the part of the staff.
4. Offer encouragement, praise, and recognition. Making employees feel that
they are valued by the organization often
is revealed as one of the highest reasons
for retention. A manager who gives immediate recognition for a job well done
often will fi nd the employee striving to do
better and better. A pat on the back always
works, as it makes the employee know
that you care and that you are paying attention. Depending on the situation, some
praise is better given on a one-to-one basis
and other times in front of an audience.
Sharing letters of compliments written to
senior administrators from patients and
family and posting thank you cards from
patients and their families are examples of
recognizing staff for quality care.
Another form of recognition comes
from staff themselves sharing praises given by employees from other departments
or from patients. Hospitals have their own
programs for recognizing employees who
go the extra mile. At Emory Healthcare,
a program called “I just noticed you doing something special” allows patients,
visitors, and employees to write on a card
any exceptional action that an employee
did. The card is faxed to the patient relations offi ce, and a quarterly drawing
for a customer service award gives the
employee a chance to win a cash prize.
Individual organizations will have ways
of recognizing and rewarding employees
to express value and appreciation. These
activities should be encouraged. Every
unit has its own way of recognizing staff:
an employee of the month/quarter award,
a casual dress day, and celebrating various
holidays and staff special occasions. A
good idea is to engage the physicians of
a unit to donate prizes for employees of
the month/quarter and for the staff to do
special things for other members of the
healthcare team, including physicians, social workers, and pharmacists. Branham
(2001) reported that many managers believe that employee retention is primarily
tied to money, but in survey after survey,
financial compensation is only one of
many factors employees cite as a reason
to seek or leave an employer.
5. Encourage direct manager-to-employee
communication. According to Ribelin
(2003), nurses do not leave hospitals, they
leave managers. In an interview conducted
by a manager of her own unit, staff nurses
were asked what they like in a manager.
Being approachable came to their minds
right away. A manager with an open door
policy who allows them the opportunity
to voice concerns or express appreciation is another characteristic they liked.
Getting back with employees and following up on their concerns shows that the
manager listens. Often a manager can be
overwhelmed with paperwork, deadlines,
or meetings and is unable to meet with
staff on a regular basis. Meeting with staff
face-to-face at least every month allows
them to ask questions about new policies
or changes in practice that may come to
them in memos or announcements. You
can tell the difference with a staff who is
well informed and those who are not by
looking at compliance on different audits
done either by their own unit or by other
A staff that is well informed will most
likely work to show fi duciary responsibility when it comes to the unit budget related to supplies or staffi ng. Making time
to meet with staff is something that must
be emphasized with managers. One staff
meeting a month that covers only a certain
shift will not do. Expecting the staff to
come in on their days off to attend staff
meetings has not worked. The manager
must be fl exible to meet the needs of the
staff and schedule several meetings that
will cover all shifts, including weekends.
A manager who has frequent face-to-face
communication with staff will reap the
rewards of a high-performing unit.
6. Competitive compensation and benefi ts. Even though salary is not the number
one reason for retention, it does come up
somewhere along the line. Most young
nurses are lured by higher paying institutions or those who offer sign-on bonuses.
Unlike their more experienced counterparts, benefi ts do not seem to retain
younger nurses. Nurses with less than one
year in the profession are more likely to
quit their jobs (Reilly, 2003). The future
is too far for them to imagine, and they
do not want to think of retirement money
or benefi ts such as tuition reimbursement.
They want to see the money that comes in
their paychecks now, either because they
have a student loan to repay, a new apartment to furnish, or a new car payment.
Hospitals, therefore, have to compete with
salaries within the metro area. It then becomes imperative that hospitals conduct
an ongoing market survey of compensation. It is also important for compensation specialists to make sure that nurses
with longevity are not paid less than new
hires. On exit interviews of operating
room nurses (Nissen, 2003), a nurse was
humiliated when she found out she was
training someone who was making $2
more an hour. This could be vital in retention. Nurses should be paid for the professional service that they provide (Holcomb
& Kornman, 2002). Most nurses who try
to balance their professional and personal
lives will stay with hospitals that offer
services such as child care, dry cleaning,
car washing, housekeeping, and banking
(Neuhauser, 2002).
7. Develop mentoring and preceptorship
programs. Nurses with less than one
year in the profession are most likely
to quit their job, making it critical that
veteran nurses lend support to their
rookie colleagues (Reilly, 2003). Emory
Hospitals in Atlanta take pride in their
jm Book Excerpt.indd 599 jm Book Excerpt.indd 599 9/19/2005 2:41:59 PM 9/19/2005 2:41:59 PM
residency programs for new graduates
in the oncology, operating room, critical
care, emergency room, and medical-surgical fi elds. The residency programs vary
in length from six months to a year. The
specialty residency combines classroom
learning with precepted skills and leadership development. New graduate nurses
as well as novice specialty nurses are
transitioned to their role as professional
or specialty nurse with confi dence and
less anxiety.
8. Streamline paperwork. Nurses are reportedly spending more and more time
documenting/charting and cite this as a
dissatisfi er. Nurse executives should fi nd
ways and resources to support computerized/electronic documentation.
Retention Refl ects Leadership
The management skills and attributes of
the nurse manager enhance job satisfaction,
sustain organizational commitment, and
encourage retention (Boyle, Bott, Hansen,
Woods, & Taunton, 1999). Managers are
critical components in building a strong
workforce (Ribelin, 2003). It is essential
that the nurse manager be fully engaged
with staff. The manager is the key player
in advocating and implementing a culture
of workplace retention. Managers often
struggle with accomplishing all the goals
set by the organization while wearing multiple hats and trying to maintain balance
and energy. Grove (1995) wrote that the
single most important aspect of managerial
output is the organizational unit under the
supervision or infl uence of the manager.
Output is more than the sum of daily activities around achieving objectives; it is actual
outcomes achieved based on project goals.
These outcomes are not achieved by “I” but
through a “Together Everyone Achieves
More” attitude, headed by a dynamic and
visionary leader who can get things done
through and with others.
One strategy to assist the manager in
achieving the desired organizational goals
is to leverage the activities needed to achieve
the outcome. Leverage is the measure of increased power of purposeful action to achieve
movement (Barnhart & Barnhart, 1991, p.
1204). Leverage can be positive or negative. An example of positive leverage is the
manager who delegates (an essential aspect
of a successful manager) with clear direction
and effectively communicates expectations,
timelines, and outcomes. On the other hand,
an example of negative leverage is a manager
who pretends to delegate but continues to micromanage the delegated tasks. This negative
leverage stifl es employee growth potential,
which leads to underdevelopment and dissatisfaction of the employee and does not bode
well for the organization under the leadership
of such a manager. The leadership style of
the nurse manager should refl ect fl exibility,
responsibility, effi ciency, customer-focused
innovation, and profi tability (Ribelin, 2003).
The nurse manager should strive for consistency and regularity in management style
and approach, manage and disseminate
information, and facilitate communication
and collaboration through consultation
and consensus with subordinates and senior management. Keep your pulse on the
activities within the organization through
personal contact with employees. Manage by walking around. Do not get caught
up day-after-day laboring over countless
e-mails and telephone conversations and
neglect contact with grassroots staff. Do not
underestimate the value of physical presence to the frontline staff. Leverage your
actions to achieve desired organizational
outcomes. Remember to take care of the
people who take care of the patients.
Nurse Manager Retention
As a nurse leader and manager, ask for
what you need in terms of formal development and education to maximize effectiveness in your role. It is recognized, although
not often acknowledged, that the fi rst-line
manager provides the glue that holds the
hospital together. The question that is often
not asked is where is or who provides the
glue that holds the nurse manager together?
In a study by Parsons and Stonestreet (2003),
six themes were recorded in interviews
with nurse managers related to factors that
contribute to their retention: (a) communication—ability of their boss to listen and
provide guidance, effective communication,
clear expectations, and feedback, (b) administrative management philosophy—included
an opportunity to participate in decision
making and empowerment to manage, (c)
effective administrative systems—availability of and access to resource management systems, meaningful orientation and
professional development systems, and
manager compensation systems, (d) successful personal practices—balance in life
and work, (e) quality of care—the ability
to support systems and processes to deliver
quality patient care and safety, and (f) retention—79% of the nurse managers participating in the study verbalized plans to remain
in their roles. However, they reported that
they would leave their job when they could
no longer ensure quality of care because of
staffi ng shortages.
With these factors in mind, it is important
for the fi rst-line manager as well as the senior administrative manager to mentor and
develop staff at all levels. The job satisfi ers
and motivators are often the same regardless
of job title.
Employer of Choice
If the revolving door of recruitment and
turnover could be stopped or slowed down,
the vacancy rate for a given institution
would be signifi cantly curtailed. So what
is this retention culture anyway? Retaining highly skilled staff in the workplace is
coveted as silver and gold. The goal in the
workplace for the managers and leaders
is to become known in the healthcare and
business sector as the healthcare employer
of choice. That is to say, the institution is
the one magnet workplace that people in the
local area and people looking to work in the
area want to seek employment. The responsibility for creating that environment of job
satisfaction and sense of value, worth, and
family lies, in large part, with the manager,
backed by the senior level management.
The healthcare leadership is responsible
for creating an organizational culture and
must adopt a “culture of caring.” Within
this culture of caring are employee expectations coupled with commitment to integrity,
value, compassion, respect, recognition,
and truth. Kouzes and Posner (1999) wrote
on the principles and practices that support
the basic human need to be appreciated and
valued for contributions.
Word of the seriousness of this current
and future nursing shortage has reached
a large audience outside of the nursing
profession. This interest has brought new
stakeholders into the mix to partner with
professional nursing organizations to preserve the health care of Americans. Because of the magnitude and complexity
of the nursing shortage, there has been an
outpouring of interest and support from
the private sector and corporate and governmental agencies offering to partner
with professional nursing organizations by
employing short- and long-term strategies
to eliminate the nursing shortage. Recruitment into the nursing profession brings a
quagmire of issues, challenges, and opportunities unlike any other.
There is also heightened awareness that
strategies and solutions of the past will
not meet with past successes. A key reason for this revelation is that the changing
demographics such as age distribution and
jm Book Excerpt.indd 600 jm Book Excerpt.indd 600 9/19/2005 2:42:00 PM 9/19/2005 2:42:00 PM
multigenerational issues are impacting retention of nurses as well as recruitment into
the nursing profession. In a report by Kimball and O’Neil (2002), a key recruitment
strategy should be to focus on recruiting a
more diverse nursing workforce, with both
ethnic and racial minorities as well as men.
In 2000, men constituted 5.4% of the RN
pool in the United States, up from 2.7% in
1980 (Sagon, 2003). Figure 12-2 depicts the
percent of women in healthcare careers and
shows an actual decline between 1989 and
1999—an opportunity to recruit more men
into nursing. Figures from the U.S. Census
Bureau (2000) and Health Resources and
Services Administration (HRSA) (2001),
outlined in Figure 12-3, show the racial
composition (African American, Hispanic,
and American Indian/Alaskan Native) of
the U.S. population versus the percentage
that are RNs. This fi gure illustrates a need to
recruit a more diverse RN workforce and to
meet the changing demographics of a more
diverse patient population. The new nurse
workforce will need to be recruited from the
population who is younger than 30, which is
more diverse and will create an even greater
dislocation, in the future, if nurses from
this current generation are not successfully
recruited into the profession (Kimball &
O’Neil, 2002). Other recruitment challenges
lie in the plethora of labor force options for
women and the multigenerational issues of
the generation X employee. A more detailed
discussion of the multigenerational issues
can be found in Chapter 2.
Some of the multiple negative indicators
affecting retention also impact recruitment
(see Figures 12-4 and 12-5). It is important
to offer long-term retention incentives for
the applicant seeking employment within
your organization as well as current employees you desire to retain.
Specialty Nurse Recruitment
The past two decades have witnessed an
erosion of specialty, disease, or symptombased nursing units and, in some cases,
services. These units or services often were
small and were sacrifi ced to the administrative budgets as administrators struggled
with balancing healthcare revenues and
expenses. The philosophy of “no margin,
no mission” was likely in the forefront of
decision making to downsize and, in some
cases, eliminate specialty units such as oncology in areas across the country.
As patient care services for some diagnoses shifted to ambulatory services, the
demand for the oncology beds in community hospitals felt the decline in census
and inpatient revenue, forcing tough decisions. The units were reconfi gured usually
for medical-surgical beds, and staff that
remained gave up their specialty identity.
Another cost-cutting measure across many
hospitals, academic and community, was
to downsize master’s prepared advanced
practice nurses (nurse practitioners as well
as clinical nurse specialists). The loss of
these experts along with the dissolving of
the specialty unit had the potential to impact quality cancer care (Lamkin, Rosiak,
Buerhaus, Mallory, & Williams, 2001;
Satryan, 2001).
Recruitment and education of specialty
nurses is often more challenging and expensive than recruiting for generalist nurses.
The specialty nursing expertise is generally
obtained on the job, all the more reason to
make every effort to retain the experienced
specialty nurses, whether oncology, critical
care, emergency department, or operating
room. Offering internship and residency programs in areas of specialty nursing will serve
to attract generalist nurses and new graduate
nurses to the specialty. Partner with local
specialty nursing organizations as a means
to offer networking opportunities to the new
specialty nurse.
Professional, Public, and
Private Partnerships
The U.S. Department of Labor (2004) projected a 27% increase in the need for nurses
nationwide from 2002–2012. There have
been a number of initiatives launched over the
past fi ve years that have focused on reversing
the nursing shortage. Groups that participate
with partnering professional nursing organizations include the Robert Wood Johnson
Foundation, Johnson & Johnson (Campaign
for Nursing’s Future), American Hospital
Association, federal government (Nurse Reinvestment Act Legislation), and HRSA, just
to name a few. These multifaceted initiatives
have begun to make an impact. In June 2003,
the U.S. Department of Health and Human
Services announced awards of $3.5 million
in grants to promote diversity in the nursing
workforce. These funds are earmarked to
support disadvantaged students, including
those from racial and ethnic minorities who
are underrepresented among RNs.
Remember the projection is that there
will be in excess of a million nurses needed
within the next seven years. The work is not
fi nished. Look within your community for
opportunities to bolster the image of nurses
and promote nursing to all as an honorable
and sustaining profession.
Reach out to youth in schools and youth
organizations to promote nursing as a career
choice. Offer to mentor a young student
who expresses interest in the profession.
Bring them into your work setting for a day.
Share with them the rewards of a career in
Recruiting Internationally
When American healthcare organizations
recruit internationally, it impacts the nursing
Note. From In Our Hands: How Hospital Leaders Can Build a Thriving Workforce (p. 48), by American
Hospital Association, Commission on Workforce for Hospitals and Health Systems, 2002, retrieved
February 7, 2004, from http://www.aha.org/aha/key_issues/workforce/commission/InOurHands.html.
Copyright 2002 by American Hospital Association. Reprinted with permission.
Clinical laboratory technologists and technicians
Occupational therapists
Radiologic technicians
Registered nurses
Social workers
Speech therapists
Nursing aides, orderlies,
and attendants
Physical therapists
Licensed practical nurses
0% 20% 40% 60% 80% 100%
1989 1999
jm Book Excerpt.indd 601 jm Book Excerpt.indd 601 9/19/2005 2:42:00 PM 9/19/2005 2:42:00 PM
shortage in a global way. Foreign nurses
often are attracted to the higher standard of
living, earnings potential, and many other
benefits of working in America, leaving
their home healthcare system with fewer
nurses. However, Christmas (2002) pointed
out those organizations investigating foreign
nurse recruitment should fi rst focus internally on retention initiatives prior to making
a commitment to recruit from abroad. There
are numerous strategies involved in planning
to recruit an international nursing pool.
The manager must be attuned to the
needs of the foreign nurse prior to and after
recruitment. These needs include fi t within the
culture of the organization, language, socialization, support structures, licensure, working or permanent resident visa, and fi nancial
resources. When a hospital decides to recruit
foreign nurses, a designated person from
nursing administration may be assigned as
the point person to work hand in hand with
human resources. The hospital may choose
to send a nurse manager and a nurse recruiter
from human resources to go to the foreign
country or countries of choice to personally
interview applicants. Applicants can come
from an agency in that country or an agency
based in the United States that has its pool of
applicants in that foreign country. A contract
between the hospital and the agency of choice
must be signed before the process begins.
A hospital also may choose to interview by
phone the applicants chosen by the agency,
provided a resume is on hand. Once the
interview is done, a contract is offered to the
foreign nurse by the hospital representative
or the designated agency. Necessary paperwork must be submitted by the applicant
to process the visa application. Paperwork
must include copies of passing TOEFL (Test
of English as a Foreign Language) results, a
passing CGFNS (Commission on Graduates
of Foreign Nursing Schools) certifi cate or
result, or a passing NCLEX–RN (National
Council Licensure Examination for Registered Nurses) result, transcript of records, letters of recommendation, and a contract with
the sponsoring hospital. An application to the
Bureau of Citizenship and Immigration Services together with the application for Alien
Employment Certifi cation must be fi lled out
by the hospital designee. An approval or
denial letter will be sent to the hospital offi cial who signed the petition. If the petition
is approved, paperwork will be forwarded
to the U.S. embassy where the applicant
resides. The embassy will notify the nurse of
the approval and a list of requirements prior
to the interview date, when the appropriate
visa is given. Once the nurse receives the
visa, fl ight schedules can be arranged by the
recruitment agency or a travel agency chosen
by the hospital. Depending on the type of visa
applied for, the process can take from several
months (for working visas) to two years (for
permanent resident visas). Prior to the nurse
arriving in the United States, someone from
the hospital (usually human resources) will be
responsible for arranging housing. It is a good
idea to identify nurses in the organization to
serve as their adoptive sisters to orient them
to the country and show them around their
new environment. Transportation to and from
the hospital must be arranged if their housing is not within walking distance. A good
thorough orientation will be key to successful
integration into the system. A warm welcome
from the nurses and other employees within
the hospital will help early adaptation to the
new workplace. Foreign nurses have been
known to stay with the hospital that recruited
them as a sign of gratitude and loyalty. The
• Sell the organization and unit (do not make false promises or paint a false picture).
• Create a shared vision.
• Market the image of nursing.
• Improve the work environment.
• Offer nurse internship and residency programs for novice nurses into a specialty.
• Develop institutional nurse reentry education and training programs.
• Recruit retired nurses to form the basis for a professional mentoring corps.
• Make the interview work for you.
• Develop an in-depth orientation program to attract new graduate nurses.
• Form some community alliances with local schools; visit on career days; give interactive health presentations; sell nursing to the next generation; talk about the rewards of nursing, service, and healing.
• Foster relationships with nursing students and faculty.
• Create a learning and mentoring environment for nursing students.
• Go to local nursing schools and provide a pizza luncheon to students during fi nal examination week.
• Offer an educational program and skills fair for faculty at local schools of nursing.
• Offer recruitment fairs on-site and offer tours of specialty areas.
• Offer an on-site National Council Licensure Examination review course for new graduates waiting to
take the State Board Examination.
• Offer recruitment incentives to new hires and current staff.
• Offer service cancelable student loan repayment packages.
• Conduct prompt follow-up with applicants to schedule interviews and facility tours.
• Add a personal touch when calls come in from prospective applicants; put the “human” back in human
• Find a way to personally respond to inquiries of available positions, especially if there is an online
application process.
• Provide a hassle-free interview encounter; facilitate parking; and avoid applicant waits and delays when
it is a scheduled interview.
• Value workplace diversity.
• Partner with local specialty and diverse nursing organizations.
• Offer competitive salary and benefi t packages.
Note. From In Our Hands: How Hospital Leaders Can Build a Thriving Workforce (p. 47), by American
Hospital Association, Commission on Workforce for Hospitals and Health Systems, 2002, retrieved
February 7, 2004, from http://www.aha.org/aha/key_issues/workforce/commission/InOurHands.html.
Copyright 2002 by American Hospital Association. Reprinted with permission.
U.S. Population RN Supply
African American Hispanic American Indian
Alaskan Native
jm Book Excerpt.indd 602 jm Book Excerpt.indd 602 9/19/2005 2:42:00 PM 9/19/2005 2:42:00 PM
majority of foreign nurses have become very
successful in their careers and have proven
to be great assets to their adoptive healthcare
The advent of the nursing shortage extends beyond the borders of the United
States. In a recent publication on ethical
issues in the recruitment and retention of
graduate nurses, Johnstone and Stewart
(2003) reported on mounting concerns in
Australia that by the year 2010, Australia
will face a shortage of 40,000 nurses. As
a consequence of this concern, one Australian state has given rise to a computer
match service. This service, a recruitment
strategy aimed at matching new graduate nurses across participating healthcare
organizations, is challenged to distribute
the nurses equitably within this Australian
state. Reports of unethical recruiting strategies by healthcare facilities in the region
has drawn criticism of the tactics used by
some to entice nurses away from one employer to another. Unfortunately, the new
nurses are not fi nding the promises being
kept by the employer once they change
from one job to another; hence, the nurses
are left feeling unsupported, cheated, and
disillusioned (Johnstone & Stewart).
The concerns of nurse leaders in Australia
seem to mirror many of the same issues and
challenges facing healthcare organizations
and nurse leaders in America. Recruiting
and retaining new and experienced nurses
is critical to the survival of the healthcare
system, patient care, and safety.
Adopting a culture of retention is key to
organizations maintaining adequate staffing levels to meet the complex care needs
of patients. It is imperative that employees
feel empowered, in control of their own
performance, and willing to help move the
organization to achieve its strategic goals
(Trofi no, 2003). Nurse managers must be
actively engaged in implementing strategies to promote job satisfaction and retain
a viable workforce of RNs. Engage staff in
assessing the work environment and culture
of retention. Work within your individual
circle of infl uence to make a difference in
reducing turnover and promote a culture of
retention. The recruitment strategy should
be one of bringing new people into the
profession, not merely relocating nurses
who are already employed. Ensure that
your organization is committed to being an
employer of choice for current and future
Advisory Board Company. (2000a). Best practices in retention. Executive summary. Washington, DC: Author.
Advisory Board Company. (2000b). The nurse
executive center. The nurse perspective: Nurse
job satisfaction and turnover. Washington,
DC: Author.
American Association of Colleges of Nursing.
(2003). Nursing shortage fact sheet. Retrieved
February 7, 2004, from http://www.aacn
American Nurses Association. (2001). Nurses
concerned over working conditions, decline
in quality of care, ANA survey reveals [Press
release]. Retrieved August 26, 2004, from
Atencio, B.L., Cohen, J., & Gorenberg, B.
(2003). Nurse retention: Is it worth it? Nursing Economics, 21, 262–268.
Barnhart, R.K., & Barnhart, C.L. (1991). The
world book dictionary. Chicago: World
Boyle, D.K., Bott, M.J., Hansen, H.E., Woods,
C.Q., & Taunton, R.L. (1999). Managers’
leadership and critical care nurses’ intent to
stay. American Journal of Critical Care, 8,
Branham, L. (2001). Keeping the people who
keep you in business. New York: American
Management Association.
Bratt, M.M., Broome, M., Kelber, S., & Lostocco, L. (2000). Infl uence of stress and nursing leadership on job satisfaction of pediatric
intensive care unit nurses. American Journal
of Critical Care, 9, 307– 317.
Buerhaus, P., Donelan, K., DesRoches, C., Lamkin,
Value and respect staff.
• Break down any caste system.
• Empower staff to be involved in decision making that directly affects their work and practice.
• Support shared governance within the workplace.
• Provide timely coaching and counseling.
• Recognize and reward high performers.
• Use progressive discipline to remove poor performers who consume too much time and have a negative effect on overall staff morale.
• Work with staff to create unity and harmony and promote a sense of teamwork.
• Treat staff like adults; they do not need a mother or father.
• Establish open and honest communication.
• Treat staff fairly.
• Embrace and teach corporate values.
• Offer educational development.
• Conduct a skills fair annually for all clinical staff.
• Provide paid time off for continuing education.
• Offer residency or internship programs in specialty areas.
• Offer scholarships or percent reimbursement for formal career education.
• Develop leadership opportunities for staff.
• Be a mentor.
• Assign a consistent preceptor to the new orientee.
• Adjust patient assignments of the preceptor to allow ample time for teaching.
• Create a learning organization.
• Implement RN clinical/career ladders.
• Maintain functional and state-of-the-art equipment for staff.
• Provide appropriate staffi ng.
• Seek volunteers when overtime is needed.
• Listen and take immediate action regarding workplace concerns from staff.
• Offer self-scheduling.
• Offer fl exible work hours and/or job sharing.
• Offer competitive compensation and benefi ts.
• Offer a package that includes health, education, and retirement benefi ts.
• Take ownership for retention in your area of responsibility.
• Engage staff in taking ownership for workplace retention.
• Encourage collaborative relationships between physicians and nurses.
• Provide challenging work opportunities for professional growth.
• Work with multigenerational issues.
• Inject some spontaneity in the staff work day with FUN.
• Celebrate successes (e.g., high patient satisfaction scores) with simple things such as pizza or an ice
cream treat, theater tickets, a spa day, or a fi tness center membership.
• Decorate your unit during holidays and enter contests if sponsored by the institution.
• Enter your unit in contests such as “Best Nursing Team Contest” sponsored by a nursing magazine.
• Write articles about your unit for celebrations and recognitions received and publish it in your institution’s newsletter.
• Conduct exit interviews and make personnel and/or environmental adjustments as needed.

jm Book Excerpt.indd 603 jm Book Excerpt.indd 603 9/19/2005 2:42:01 PM 9/19/2005 2:42:01 PM
L., & Mallory, G. (2001). State of the oncology
nursing workforce: Problems and implications
for strengthening the future. Nursing Economics, 19(5), 1–11.
Christmas, K. (2002). Invest internationally. Nursing Management, 33(11), 20–21.
Cline, D., Reilly, C., & Moore, J.F. (2003). What’s
behind RN turnover? Nursing Management,
34(10), 50–53.
Cullen, K. (1999). Recruitment, retention and
restructuring report: Strong leaders strengthen
retention. Nursing Management, 30(5), 27–28.
Gleason-Scott, J., Sochalski, J., & Aiken, L. (1999).
Review of magnet hospital research. Journal of
Nursing Administration, 29, 9–19.
Grove, A.S. (1995). High output management. New
York: Vintage Books.
Health Resources and Services Administration,
Division of Nursing. (2001). National sample
survey of registered nurses. Washington, DC:
Holcomb, S., & Kornman, C. (2002) A decent proposal. Nursing Management, 33(1), 39–40.
HSM Group. (2002). The 2002 acute care hospital
survey of RN vacancy and turnover rates for
2000. Journal of Nursing Administration, 32,
Institute of Medicine. (2003). Substantial
changes required in nurses’ work environment to protect patients from health care
errors. Retrieved February 7, 2004, from
Johnstone, M.J., & Stewart, M. (2003). Ethical
issues in the recruitment and retention of graduate nurses: A national concern. Contemporary
Nurse, 14, 240–247.
Kimball, B., & O’Neil, E. (2002). The evolution of
a crisis: Nursing in America. Policy, Politics and
Nursing Practice, 2(3), 180–186.
Kouzes, J.M., & Posner, B.Z. (1999). Encouraging
the heart. San Francisco: Jossey-Bass.
Lamkin, K., Rosiak, J., Buerhaus, P., Mallory, G.,
& Williams, M. (2001). Oncology Nursing Society workforce survey part I: Perceptions of the
nursing workforce environment and adequacy
of nurse staffing in outpatient and inpatient
oncology settings. Oncology Nursing Forum,
28, 1545–1552.
Neuhauser, P. (2002). Building a high-retention
culture in healthcare. Journal of Nursing Administration, 32, 470–478.
Nevidjon, B., & Erickson, J. (2001). The nursing
shortage: Solutions for the short and long term.
Online Journal of Issues in Nursing, 6, 1–17.
Nissen, S. (2003). Practical steps for boosting staff
retention. OR Manager, 19, 18–19.
Parsons, M.L., & Stonestreet, J. (2003). Factors
that contribute to nurse manager retention. Nursing Economics, 21, 119–126.
Reilly, P. (2003). Trying to keep their own. Modern
Healthcare, 33, 17.
Ribelin, P. (2003). Retention refl ects leadership
style. Nursing Management, 34(8), 18–19.
Ropp, A.L. (2003). Are sign-on bonuses an effective recruitment and retention strategy? Writing
for the CON position. American Journal of
Maternal/Child Nursing, 28, 291.
Sagon, E. (2003). Nursing recruiters tailor pitch
to men. Arizona Republic. Retrieved July 15,
2003, from http://www.azcentral.com/arizona
Satryan, M. (2001). The oncology nursing shortage
and its impact on cancer care services. Oncology
Issues, 16(1), 21–23.
Sengin, K. (2003). Work-related attributes of RN
job satisfaction in acute care hospitals. Journal
of Nursing Administration, 33, 317–320.
Thorpe, K., & Loo, R. (2003). Balancing professional and personal satisfaction of nurse
managers: Current and future perspectives in a
changing health care system. Journal of Nursing
Management, 11, 321–330.
Trofi no, J. (2003). Power sharing: A strategy for
nurse retention. In H. Feldman (Ed.), The nursing shortage: Strategies for recruitment and
retention in clinical practice and education.
New York: Springer Publishing.
U.S. Census Bureau. (2000). Profi les of general
demographic characteristics, 2000. Washington,
DC: Author.
U.S. Department of Labor. (2004). 2004–05 editions of the Occupational Outlook Handbook
and the Career Guide to Industries available on
the Internet. Retrieved August 18, 2004, from
U.S. General Accounting Offi ce. (2001). Nursing
workforce: Emerging nurse shortages due to
multiple factors. Report to the chairman, Subcommittee on Health, Committee on Ways and
Means, House of Representatives. Retrieved
February 25, 2004, from http://www.gao.gov/
Wagner, C.M., & Huber, D.L. (2003). Catastrophe
and nursing turnover. Journal of Nursing Administration, 33, 486–492.
Recommended Web Sites
to Visit
American Hospital Association Commission on
Workforce for Hospitals: www.aha.org/aha/
American Nurses Association: www.nursing
Bureau of Labor Statistics: www.bls.gov
Forum on Healthcare Leadership: www.health
Historically Black Colleges and Universities:
Johnson & Johnson’s Campaign for Nursing’s
Future: www.discovernursing.com
Leapfrog Group: www.leapfroggroup.org
Male Nurse Magazine: www.malenursemagazine
Minority Nursing Associations: http://ninr.nih
National Alaska Native American Indian Nurses
Association: www.nanaina.com
National Association for Equal Opportunity in
Higher Education: www.nafeo.org
National Association of Hispanic Nurses: www
National Black Nurses Association: www.nbna
National Coalition of Ethnic Minority Nurse Associations: www.ncemna.org
National League for Nursing: www.nln.org
Nurses for a Healthier Tomorrow: www.nurse
Oncology Nursing Society: www.ons.org
Philippine Nurses Association of America, Inc.:
Transcultural Nursing Society: www.tcns.org
jm Book Excerpt.indd 604 jm Book Excerpt.indd 604 9/19/2005 2:42:01 PM 9/19/2005 2:42:01 PM

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