Keep That Nurse

From The Floor

Keep That Nurse

Want a motivated, low turnover nursing team? Start by understanding your nurses' needs.

By Genevieve M. Clavreul, RN, PhD
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In April 2006, the American Hospital Association (AHA) reported that our nation’s hospitals had approximately 118,000 unfilled, full-time RN positions, which translates to a vacancy rate of 8.5 percent. Further complicating matters is a report published in the AHA State of American Hospital Report—Taking the Pulse—which reported that 49 percent of hospital CEOs felt it was harder to recruit RNs to fill vacancies in 2005 than in 2004.

Flash back to 1980—in researching an article for the September/October 1980 issue of Hospital Forum, I found reports stating that nearly 90 percent of our nation’s hospitals reported being unable to fill their full-time nursing needs. The average hospital reported having about 72 full-time RN jobs open at any given time. Nearly 28 years later, it seems that not much has changed. Such reports leave my colleagues and I frustrated—it seems that for every step forward, we take two or more steps back.

I believe that all the solutions we initiate will ultimately fail unless we first correct the flaws that riddle our profession. Two separate nursing surveys, one conducted in 2002 and another in 2004, revealed that nurses recommended that improving the work environment was key to solving the nursing shortage. These surveys echo many of the same sentiments that my 1980 article discussed. Money has always played a role in both aggravating and improving the nursing shortage. Yet compensation in the form of pay increases, bonuses and other monetary incentives only fulfills a person’s maintenance needs and does little to satisfy a person’s motivational (higher order) needs.

The nursing shortage is discussed on nursing lists, magazines, at conferences, in the halls of government and so on—and yet we seem to have made such little progress. That is in great part because some nursing leaders, supporters and even the nurses themselves fail to implement steps to deal with the motivational needs that are integral to job satisfaction, and so often remain unfulfilled.

During our nation’s last well-publicized nursing shortage (in the 1980s), I had the pleasure of serving as Director of Nursing for a local community hospital. This hospital belonged to a large corporate chain and was struggling to meet numerous JCAH (pre-JCAHO and pre-JC) citations, a huge budget deficit and, of course, a nursing staff that relied heavily on the nursing registry (nearly 70 percent of the staff positions were filled by registry nurses). Our hospital was not in the position to offer sign-on bonuses—and I’m not a believer in the sign-on bonuses theory of recruitment anyway—so my team and I had to prove to the nursing team that working for us at a pay rate slightly below average was as attractive as working for one of the larger, higher-paying hospitals.

Maslow’s hierarchy of needs

In the end, I ended up with a full nursing staff, and a waiting list to boot. There may be those among you reading this that might be thinking “in what part of Never-Neverland did this hospital exist?” Truth be told, it was in California and not so much an aberration as an example of what can happen when good, consistent management meets a strong understanding of a helpful theory known as Maslow’s Hierarchy of Needs.

For those who are unfamiliar with Maslow’s Hierarchy of Needs, here is a quick explanation. In 1943, Abraham Maslow, one of the founding fathers of humanist approaches to management, wrote an influential paper that set out five fundamental human needs and their hierarchical nature (see chart below). Over time, others have expanded upon his chart, so one can find charts depicting five, seven, and eight levels of needs. However, it’s important to note that, like so many theories, Maslow's Hierarchy of Needs should not be considered set in stone; rather, it should be seen and used as a guide, since not everyone’s needs follow the same rigid pattern. A key aspect of the model is the hierarchical nature of the needs.

This guide can be an effective tool in helping managers shed light on what motivates their staff. For example, self-esteem seems to be a stronger motivation than love for some people. For others, the need to create is often stronger than the need for food and safety. The artist living in poverty is a classic example of a reversal of the standard hierarchy of needs. Similarly, persons who have suffered hunger or some other deprivation for protracted periods may live happily for the rest of their lives if only they can get enough of what they lacked. Therefore, in Maslow's theory, human needs are arranged in a hierarchy of importance. New needs emerge only after those with higher-priority have been satisfied. By the same token, satisfied needs no longer influence behavior.

Money is not everything

This is a point worth stressing to managers and administrators, who often mistakenly assume that money and other tangible incentives are the only cures for morale and productivity problems. Instead, it may be that the need to participate, be recognized, be creative, and to experience a sense of worth are better motivators in an affluent society, where many have already achieved an acceptable measure of freedom from hunger and threats to security and personal safety, and are now driven by higher-order psychological needs.

When nurses perceive that their worth is undervalued, they often feel as though they are not respected, are taken for granted, or are being taken advantage of by their superiors and/or management. In turn, superiors (who are often RNs themselves) and management often cultivate an environment that validates the nurse’s perceptions.

The following are just a few examples of how management can be out of sync with the nursing staff. I’ve heard of a large hospital that provides limousine service for potential candidates, so that they can tour the facility, meet with the nursing team and complete an application, all on the spot.

On the surface, this looks like a grand gesture; however, when you factor in that this same hospital recently lost a multimillion dollar salary dispute initiated by the staff nurses, and that the hospital stated that they probably will appeal the verdict—one can interpret this to mean that the hospital cares about wringing every last dime out of their experienced nursing staff, while handing the keys to the kingdom to the new hire.

This hospital is not alone in engaging in similar examples of largesse. Hospitals throughout the country offer new hires a variety of incentive packages, such as sign-on bonuses ranging from $5,000 dollars and up, new cars, and assistance in securing home loans, among others. Meanwhile, the experienced old-timers on staff continue to work without acknowledgment of their years of service and loyalty to the hospital. Therefore, it isn’t surprising that many nurses, both new hires and long-term employees, often share a feeling of lack of worth, but for entirely different reasons.

Hospitals that seek out Magnet recognition tend to see an improvement in nursing job satisfaction, but this is often short-lived, since all too often, the hospital and nursing team fall back into their old ways of work. In addition, many nurses don’t believe that this program has value, so they see the many thousands of dollars spent by the hospital to achieve Magnet Hospital recognition as a waste of money that could be spent directly on the nursing staff.

So why is Maslow’s Hierarchy of Needs important to nurses, and more importantly, to those who manage nurses? Simply by being cognizant of this theory and the impact of lower and higher order needs, one can better address issues that arise beyond the cry for better pay and, hopefully, develop a better understanding of the role played by work conditions, experience and morale on the nursing staff or team.

What makes a great place to work?

For example, a few days before I submitted this column to my editor, two articles came across my desk—the first was from the business section of my local newspaper, reporting on a recently released work satisfaction survey commissioned by Bloomberg Capital Partners. They surveyed 500 employees and found that how employees perceived the upkeep and attention to detail spent on the work environment played an important role in job satisfaction. Of course, these factors must be kept in perspective since, as so aptly noted by the San Francisco-based Great Place to Work Institute, employees don’t just up and quit because the restrooms are not maintained. However, it does play a role in how responsive the employees perceive management to be to the basic needs of its team.

That same day, an article reported that Griffin Hospital in Derby, CT had, for the past nine years, made Fortune’s list of the “100 Best Places to Work in America.” Factored into the ranking is how workers grade their organization for credibility, respect, fairness, pride and camaraderie. Last year, the hospital received 6,691 applications for only 180 openings, which translates into about seven applicants for each available position. Of course, one might be quick to assume that this hospital not only has a great work environment, but that they must also pay well. However, Griffin Hospital pay scales are five to seven percent lower than what the other area hospitals pay their employees.

What nurses really want

For those wondering how I solved my staffing challenges, it was simple. I made it clear that, though our pay scale was lower than other area hospitals, we had a nursing team that could rely on their DON to support them and that nurses who came to work at our hospital could look forward to a fulfilling, challenging nursing experience—and I made sure our nursing management delivered on those promises.

In short, it often boils down to the “little things,” and money is often just the salve, especially in a career such as nursing, which is a profession driven in great part by fulfilling an individual’s higher order needs. Though it is crucial that a nurse’s basic needs are met, it is even more crucial that an emphasis is placed on the nurse’s higher order needs being met.

When both levels of needs are taken care of, then you will have a greater potential to not only attract the best that nursing has to offer, but you’ll have a staff committed to nurturing its team members, and most importantly, retain staff. That way, you will not play a constant game of “let’s hire that nurse” because instead your energies, philosophy and efforts will be focused on “keeping that nurse.”

Geneviève M. Clavreul RN, PhD, is a healthcare management consultant who has experience as a director of nursing and as a teacher of nursing management.

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