Reinventing the Health Care Workplace II

✯ ✯ 2003 National Health Policy ✯Conference January 22-23, 2003 J.W. Marriott Washington, D.C. 2003 National Health Policy Conference Reinventing the Health Care Workplace January 22, 2003 Massachusetts General Hospital Jeanette Ives Erickson, RN MGH - ORIGINAL CAMPUS Third oldest hospital in America - Chartered in 1811 by an act of the state legislature. MGH A premier center of patient care, teaching and research. Occupying 66 buildings, over 25 acres. MGH - EMPLOYEES MGH - EMPLOYEES - 2002 MGH WORKFORCE Management 4.2% GeneralSupport MDs 12.7% 9.5% PhDs 2% Trainees 12.1% 16,980 Employees Largest Private Employer in Boston Clerical 21.4% Nurses 17.5% Technicians 9.5% Other Professionals 11.1% PATIENT CARE ACTIVITY Despite predictions that volume would fall due to market pressures, inpatient volume grew an average of 4.2% per year Length of stay has declined 12% from 6.65 days in FY96 to 5.86 days in FY02 Average daily census has increased 13% from 616 in FY 96 to 695 in FY02 Outpatient visits grew an average of 4% per year Emergency Department activity risen to 76,000 visits per year. LENGTH OF STAY DECLINED IN THE FACE OF INCREASING PATIENT ACUITY 7.50 • 12% LOS decline came in spite of a 20% increase in acuity • Patient care staff from all disciplines rose to the challenge of this additional workload 1.90 1.85 1.80 1.75 7.00 6.50 A LOS 1 1.70 A CUITY 1 1.65 6.00 1.60 1.55 5.50 1.50 1.45 5.00 FY '0 0 FY '0 1 FY '0 2 FY 96 FY 97 FY 98 FY 99 1.40 ALOS ACUITY Linear (ALOS) Linear (ACUITY) NURSING Challenged by 30% growth in patient volume and a 20% increase in acuity Succeeded in adding over 600 nursing positions Despite this growth, the nursing vacancy rate has stayed relatively constant at just under 5% compared to a 10% statewide vacancy rate and a 13% national vacancy rate. Many programs instituted to recognize nursing professionalism as key to patient care, such as the clinical recognition program. Turnover averages 5% annually. PROFESSIONAL PRACTICE MODEL Values Philosophy Standards Of Practice Collaborative Decision-Making Professional Development Patient Care Delivery Model Privileges Credentialing Peer Review Research Descriptive Theory Models RETENTION & RECRUITMENT OF REGISTERED NURSES HIGH LEVERAGE STRATEGIES Attracting Today & Tomorrow’s Nurses Marketing • Establishing a World-Wide Identity for the MGH Nurse • Aligning with Human Resources Focus on New Hires • Creating Professional and Specialty Expertise • Securing New Hire Loyalty • Developing Tomorrow’s Nurses RETENTION & RECRUITMENT OF REGISTERED NURSES HIGH LEVERAGE STRATEGIES (CONTINUED) Retention of Talent Nurse Executive Role • • • • • • • Creating a Multidisciplinary Professional Practice Model Providing Competitive Compensation Customizing Staff Scheduling Enabling Hours Through Technology Continuing to Improve Systems Building Relationships Developing a Robust Quality and Safety Program Retention at the Front Line • Instilling Manager Accountability • Recognizing and Developing Nurses • Developing a Speakers’ Bureau CREATING A LEARNING ORGANIZATION One out of three RNs that we hire today is a new graduate! Needs of new graduates at the MGH: Responsive systems that are easy and intuitive so that new staff can provide safe and efficient care Understanding of intergenerational issues A Learning Organization ORIENTATION CHALLENGES NEW GRADUATE VS EXPERIENCED NURSES Baseline Orientation Cost Critical Care Units Experienced New Graduate Routine Units Experienced New Graduate (1) (1) Overall Productivity 1st Year of Hire 81% 50% 88% 53% $14,233 $30,556 $8,796 $24,244 Orientee and preceptor salary expense IMAGE CAMPAIGN STUDY Make nursing visible Promote the rewards of nursing generate loyalty to profession and organization stimulate interest and appreciation for nursing • potential nurses • general public FACTORS AFFECTING CURRENT NURSING SHORTAGE Image Working conditions Salary Many competing career options Low enrolment in nursing schools Unhappy nurses who don’t recommend nursing OBJECTIVES We Wanted to Understand . . . Mindset around choosing a career Interests, values, behaviors Influences Images and perceptions of nursing Benefits and barriers to nursing RESEARCH METHODOLOGY Qualitative (January/February 2002) 5 focus groups • Nursing Students (1st & 2nd year) • Urban teens grade 7 - 11 • Suburban teens grade 7 - 11 • Parents of youth grades 7 - 11 • Potential career switchers Quantitative (April/May 2002) 400 Telephone surveys • Junior high/high school students (Grade 7-11) • Career switchers (adults 18-49) CONCLUSIONS: FOCUS GROUP RESULTS Big challenges and promising opportunities WE HEARD LOUD AND CLEAR... “We don’t know what nurses do”. Source: Partners Healthcare nursing as a career focus groups IMAGE “Supply of nurses is negatively influenced by the inaccurate media images of nursing, decreasing the selection of nursing career options by young people.” William Mercer, Inc. 1999 NEARLY ALL PARTICIPANTS HAD AN IDENTICAL STEREOTYPE White hat Short white skirt Blond Sexy Young, attractive, cheerful… When asked to picture a nurse, without exception, everyone saw nurses in a white hat, short skirt, young, and sexy often with zippers half way down their chests or very old and serious like school nurses. NEGATIVE IMPRESSIONS OF NURSING 20% of teens believe nurses perform menial clean-up tasks Only 39% of teens believe nurses are critical thinkers, capable intelligent problem solvers Do not believe that nursing pays well (less than 20% believe that nurses earn $45,000) Few believe that nursing offers: Career advancement Flexible schedule Happiness at work Source: Partners HealthCare nursing as a career telephone survey DOCTORS ARE IT They saw nurses as less than doctors, second best. Doctors are smarter, more respected, paid more, and, in short, it is a better career. Nurses are second class citizens, it’s all about the doctors. This sentiment was even expressed by the student nurses. Many wanted to do better than nurse relatives and become doctors. SALARY Although many felt nurses are finally being paid adequately… they underestimated today’s salary by half Potential career switchers estimated today’s nurse salary by half WHAT YOUNG PEOPLE LOOK FOR IN A CAREER Make a difference Be passionate about their job Be somebody Have a flexible schedule Make money Have stability in their job Be intellectually stimulated Be needed CHALLENGES OF NURSING Long hours (mandatory overtime) Early mornings, late nights, they want a life Stress Workload Unpleasant working conditions Education is challenging Lack of respect Low pay Not all viewed nursing as a career or profession WHO INFLUENCES CAREER DECISIONS Teachers, especially science teachers Visitors to schools talking about their careers or the opportunity to shadow nurses Science club, community service, relatives Pushed by a boss who was a nurse Relative or parent of friend speaking about nursing as a career Many began thinking about a career as early as age seven. WHO DOES NOT INFLUENCE THE CAREER DECISION Guidance counselors were not helpful; they only helped schedule and select classes, not make career decisions. Parents do not push children into any field or discourage any field. So… where do we go from here? NURSING PROVIDES BENEFITS THEY WANT, THEY JUST DON’T ALWAYS KNOW IT Career Motivators Students Adults Perceptions of the Benefits of Nursing Students Adults Enjoyment Making a difference Importance Money Flexible schedule Learning opportunities/ growth Teamwork Working with people you like 88% 57% 50% 43% 38% 25% 31% 44% 81% 56% 52% 50% 61% 54% 40% 47% 35% 78% 63% 26% 16% 31% 46% 57% 33% 78% 72% 29% 28% 40% 55% 62% Source: Partners HealthCare nursing as a career telephone survey HOW TO REACH YOUNG PEOPLE They listen to the radio constantly They are on the internet daily 35% of teens 30% career switchers Source: Partners HealthCare nursing as a career telephone survey INFLUENCES Students who spoke to someone about nursing, and have heard or seen something in the news or entertainment, are three times more likely to choose nursing as a career. Source: Partners HealthCare nursing as a career telephone survey HOW CAN WE ENCOURAGE YOUNG PEOPLE TO CHOOSE NURSING? There is no substitute for first-hand experience and knowledge. Relatives Job shadow, career days Volunteer opportunities Science teachers, mentors Tutoring, environmental, organizations serving youths Source: Partners HealthCare nursing as a career telephone survey EXISTING OPPORTUNITIES Classroom visits to schools by nurse ambassadors Elementary, middle and high school Entrée through science and / or health curriculum Multiple visits to build relationships and deepen content Arrange job shadow opportunities Baby sitting classes at hospital Student volunteers for community service projects Student internships Student part-time employment Clubs and organizations (scouts, science club) Health fairs with a career component FEDERAL LEGISLATION NURSE REINVESTMENT ACT August 2, 2002: signed into law Authorizes loan repayments and scholarship programs for nurses; public service announcements re: nursing profession: career ladder programs; best practice grants; and Long Term Care training grants $250 million requested for funding; however, no funding was allocated this fiscal year American Organization of Nurse Executives (AONE) requesting all members to contact their Senators and Representatives to allocate funds Symptomatic Solutions • • • • • • Mandatory overtime Hiring bonuses Mandated ratios Advertising (in absence of image campaign & supportive practice environment) Escalating wages (in absence of image campaign & supportive practice environment) Heavy reliance on agency staff Demand & Supply: Driving Factors Society’s Increased Need for Nurses • Population growth • Baby Boomers aging • Growing immigrant population • Increased life expectancy • Increased survival from severe illnesses • Improved diagnostics and more treatment options • Less-invasive therapies • Less restrictive insurance policies • Heightened consumer expectations • More liberal employer health benefits Increased Demand for Patient Care • Patient acuity & workload • Fast pace & complexity of care delivery • Shorter length of stay • Increasingly specialized care beyond what is taught in basic education Composition of Nursing Workforce • Aging workforce • Current workers staying longer • Increased number of new graduate nurses • Number retiring greater than number entering • Growth and demand has increased number of job opportunities • Approximately 50% of staff nurses work parttime • Workforce does not match diversity in US Nursing School Enrollment • Although 30% decline in nursing enrollment over last 5 years; enrollment in nursing programs is now increasing • Aging of nursing faculty • Racial/Ethnic group under-representation • High Cost of education; lack of scholarships and loans Contributing Factors Difficulty attracting people into profession • Image in media not attractive • Public does not know what nurses really do • More career options open, especially to women • Decreased enrollment in nursing programs • Today’s workers want to balance life with work • Gen X & Y are smaller cohort of workers – more competition for talent pool Workplace conditions • Inability to offer competitive wages • Need for flexible hours • Childcare • Transportation and parking • Stress of providing care for today’s patient population (acuity, workload, physical demands) • Need for safe environment for practice • Need for autonomy over practice • Need for administrative support and control over resources • Need for collaborative and respectful relationships with colleagues (esp MDs) • Increased specialization, can’t move staff between areas • Increased use of technology • Orientation & preceptors to transition from student to clinician Inadequate Reimbursement • Does not cover actual cost of care • Does not support training for specialty areas and new graduate orientation provided by institution Copyright © Massachusetts General Hospital Department of Nursing May 2002 Demand-Driven Nursing Shortage Fundamental Solutions Professional Practice environment that influences recruitment & retention • Nurses sense of control over their practice • Collaborative nurse-physician relationships • Administrative support • Staffing adequacy, quality • Quality of nursing leadership • Quality of care • Professional advancement and recognition programs • Internships & new graduate programs • Work schedules, flexibility • Competitive wages and benefits • Enabling technology & support services Strategies to grow tomorrow’s Nurses • Image Campaign to change image portrayed in media • Partnerships w/ youth-serving groups • Classroom visits, Career fairs & Student shadowing • Develop Web Site to stimulate interest in nursing & facilitate enrollment • Financial aid, (loans & scholarships) Clara Barton Bill (MA) Nurse Reinvestment Act (Federal) • Increase number of faculty • Shift attention from active to passive nursing market • Reach out to students & new graduates • Accelerated degree, new learning options using technology Develop long-term pipeline • Create a state taskforce to assess, monitor & address healthcare workforce requirements • Minority recruitment • Maintain image campaign and financial support MGH: Retention & Recruitment Registered Nurses A High Leverage Strategy to Maximize Nursing Retention & Recruitment in an Era of an Impending World-Wide Shortage Attracting Today & Tomorrow’s Nurses Marketing Establishing a World-Wide Identity for the MGH Nurse Magnet Hospital application Nursing Image Campaign Increase advertising Journal Publications National conference attendance and presentations Narrative book Annual report Retention of Talent The Nurse Executive Role Multidisciplinary Professional Practice Model Career mobility Advancement Retention Collaborative Governance Providing Competitive Compensation Salaries & benefits Tuition reimbursement Back-up child care FMLA Customized Scheduling Flexible staff scheduling Job sharing Staffing to demand Enabling Hours Through Technology Narcotic dispensing Electronic assessment tool Electronic discharge planning Electronic patient education material Continuing to Improve Systems Medication administration Supply management Food service Transcription Support Relationship Building MD/RN relationships The Center for Clinical & Professional Development Programs - Conflict Management - Media Training Office Of Patient Advocacy Continuum of care assignments Inpatient Outpatient Quality & Safety Creating safe environment for practice Needle stick reduction Back injury program Employee Assistance Program Quality Committee Focus on New Hires Creating Professional & Specialty Expertise Multidisciplinary Professional Practice Model Continuum of care assignments Inpatient Outpatient Retention Culturally Competent Care Curriculum Recruitment & Retention Population specific patient care Continuing education support State of the art learning & simulation lab Tuition Reimbursement Securing New Hire Loyalty New hire coordinator Competency based orientation Preceptor and Mentor Programs Pipeline programs with local schools of nursing Unit-based CNS support New graduate development programs (generic, oncology and critical care) Collaboration with nursing schools to create certification programs for new grads in critical care, and OR nursing. Developing Tomorrow’s Nurses Grammar school and high school “Nurses of Tomorrow Programs” to promote nursing as a career. Web site orientation Collaboration with youth-serving organizations - Girl Scouts - Big Sisters Retention at the Front Line Instilling Manager Accountability Manager as “Retention Strategists” Unit level retention report cards Staff Perception of The Professional Practice Environment survey Leadership development program 360 evaluation Recognizing and Developing Nurses Clinical Recognition program Collaborative Governance Committees Fellowships Spiritual Caregiver Research Diversity Ethics Yvonne L. Munn Nursing Research Program Evidence-based practice Research grants Post-doctoral fellowship Doctoral Forum Awards: - Excellence in Clinical Practice - Yvonne L. Munn Nursing Research - Durante Respite Award - Ben Correo-Clanon Primary Nursing Award -Petrilli Oncology Award -Cancer Career Development -Raphael-Cronin Advocacy Award -Orren Carrere-Fox FamilyCentered Care -Family-Centered Care -Clinical Narrative Program -Scholarships -Continuing education programs -Funding for professional and specialty certification exams Speakers Bureau Portfolio development Data base P R O G R A M S Human Resource Alignment Align recruits with programs Open Houses Web site Image Relocation assistance Referral program