$2.6M HRSA grant will help West Virginia's 'most vulnerable populations.'
A rural grant awarded to Shepherd University’s School of Nursing will boost the number of primary care nurse practitioners (NPs) and psychiatric mental health NPs to help support West Virginia’s “most vulnerable populations.”
The four-year, $2.6 million grant, given by the U.S. Department of Health and Human Services’ Health Resources and Services Administration (HRSA) provides Shepherd $649,998 a year—about $417,000 of which will cover yearly tuition and fees for 30 graduate and certificate students, according to the university.
Beginning in fall 2023, grant money will provide scholarships for students in the Doctor of Nursing Practice (DNP) program as well as programs offering post-graduate certificates for family nurse practitioners (FNP) and psychiatric mental health nurse practitioners (PMHMP).
"This grant will support nurse practitioners who are primary care providers in the region—and there is an inadequate number of providers at this point in time," said Sharon Mailey, PhD, RN, dean, College of Nursing, Education, and Health Sciences, and director, School of Nursing.
"We have many specialists, but we don’t have sufficient numbers of individuals at the primary care level who are facilitating access into the healthcare system for patients who have the most vulnerable needs," she said.
Indeed, the need for primary care advanced practice nurses (APRNs) in rural areas is great, as hospitals close and the number of physicians declines. Nearly 80% of U.S. rural counties are medical deserts, with no access to healthcare services, according to the National Rural Health Association.
Rural residents with mental healthcare needs are also struggling with the lack of providers. Nationwide, some 158 million people live in Mental Healthcare Health Professional Shortage Areas, according to the American Association of Nurse Practitioners.
"If you can be an FNP/PMHMP, it is ideal, because there is a backlog to refer your patients anywhere for mental health," said Kelly Watson Huffer, DNP, CRNP, CNE, associate professor of nursing education and grant project director. "There’s a six-month waitlist for most psychiatry and you have kids who need stimulant medication for ADHD and patients with depression and anxiety issues. If someone can serve in both roles in a primary care office, they are really facilitating getting their patients treated in a timely manner."
The grant will help Shepherd DNP and certificate students gain practical rural health experience at four federally qualified health centers and two mental health substance abuse disorder treatment centers.
"Doctoral education is expensive and time intensive. In addition, our students are working, and have families and other responsibilities," Watson Huffer said. "Taking the financial stress away is just one more thing to help them with their education."
The grant also strengthens healthcare in northeast West Virginia’s rural areas.
"Being able to support our students and West Virginia’s most vulnerable populations allows us to keep resources in our community," said Kayla Landsberger, project coordinator.
'Nurse leaders with healthcare economics and healthcare finance acumen are important to advocate for the profession.'
A new dual advanced degree program aims to empower nurses with the expertise to advance in executive leadership and health system administration.
Graduates of the unique program, offered by the East Carolina University College of Nursing, in partnership with the ECU College of Business, will receive both a Master of Science in Nursing and a Master of Business Administration (MSN-MBA), a robust combination of qualifications that will arm graduates in tackling long-term challenges in healthcare administration. The dual MSN-MBA program isn’t the first in the nation, but the pool of schools that offer a similar pairing is small.
"As we navigate unprecedented nursing shortages, nurse leaders with healthcare economics and healthcare finance acumen are important to advocate for the profession and to partner with healthcare administrators to properly assess the nursing needs of health systems, and to make fiscally responsible decisions regarding staffing and other financial investments," said Bimbola Akintade, dean of the College of Nursing and an MBA graduate.
"Bringing their clinical backgrounds and leadership knowledge to the table, they will improve communication of financial decisions that impact nursing practice and direct patient care between administrators and bedside nurses," he said. "In addition, this knowledge will help graduates of the dual MSN-MBA program contribute meaningfully to the nursing workforce development solutions that will positively impact the health and well-being of residents of our region and beyond."
"Nurse leaders control the largest part of a hospital labor budget, in some cases the largest part of the overall budget," Douglas writes. "The effectiveness of overseeing this responsibility can mean the difference between an organization’s financial stability and financial turmoil."
ECU students will focus on business during the first semester, then on nursing coursework during the second semester. The remaining year and a half will consist of a blend of the two, according to the university.
The purpose of offering the two degrees in tandem is to give students knowledge and skills to bridge the cultural gap between frontline nurses and hospital administration, who typically don’t speak the same language, said Thompson Forbes, PhD, MSN, NE-BC, ECU assistant professor of nursing and one of the program’s directors.
"We need to have leaders who can understand health system organizational theory, nursing theory, and nursing evidence-based practice, and then pair that with an understanding of finance, accounting, and marketing," Forbes said. "They will be better prepared to translate decisions that are made in the clinical environment to business environment and vice versa, so the systems can be more efficient."
Nursing will always be the largest line item on any healthcare system’s budget because they are the most patient-intensive workforce in hospitals, Forbes said.
"Instead of just striking numbers from a budget, there needs to be someone who can interpret and say, ‘We can handle this much efficiency gain on the business side, but that savings is going to result in a reduced level of quality of care at the bedside,’" Forbes said.
When conversations between the healthcare workforce and administration on how to balance patient care with keeping the lights on don’t happen, Forbes said distrust naturally festers. Nurse executives with business administration education can foster "an environment of understanding amongst everybody."
Mandating nurse staffing ratios is 'short-sighted and counterproductive,' AONL contends.
Though a handful of state legislatures are considering mandating nurse-to-patient staffing ratios, government mandates are not the answer to nurse staffing, the American Organization of Nursing Leadership (AONL) has declared.
"Staffing is a complex decision based on the experience and clinical expertise of the nurse, care team, resources, and patient needs," AONL said in a prepared statement. "Organizational leaders, nurse managers, and direct care nurses, not policymakers, should collaboratively align staffing with patient needs."
In January 2004, California became the first and only state, so far, to establish minimum RN-to-patient ratios in every hospital unit. Other states prioritize patient safety through different nurse staffing ratio rules. Just last month, New York set higher staffing ratios to hospitals’ critical care and intensive care units. It did not set minimum staffing levels for all units.
But that is for a hospital or health system to determine, according to AONL.
"Mandated nurse staffing standards remove real-time clinical judgment and flexibility from nurses. Government-mandated ratios do not account for an individual patient or the healthcare team’s needs in an ever-changing environment, nor do they account for the variability among healthcare organizations," it says. "Mandated approaches to staffing do not consider these differences and requires organizations to staff nurses to the number of patients rather than a patient’s needs."
Mandated ratios are typically based on traditional nursing care models, AONL said, which are becoming outdated and more nursing practices embrace innovation, advanced capabilities in technology, and collaborative interprofessional care teams.
Further, the nursing shortage has reached a crisis stage, some nursing organizations say. About 100,000 RNs left the workforce during the COVID-19 pandemic in the past two years due to stress, burnout, and retirement, and nearly 900,000 intend to leave the nursing workforce by 2027, according to the National Council of State Boards of Nursing and National Forum of State Nursing Workforce Centers
"Mandated staffing does not create more nurses or guarantee improvements in safety, patient outcomes, or ensure a positive practice environment. Mandatory ratios compound the strain healthcare systems are already facing, potentially forcing hospitals who do not have enough nurses to meet the nurse-to-patient ratio, to turn patients away or delay care, threatening the patient’s ability to access care in their community," according to AONL.
AONL supports the American Nurses Association Nurse Staffing Task Force’s definition of appropriate staffing, which reads, "Appropriate staffing is a dynamic process that aligns the number of nurses, their workload, expertise, and resources with patient needs in order to achieve quality patient outcomes within a healthy work environment."
It also supports most of the task force’s systematic recommendations, including reforming the work environment, innovating models of care, improving regulatory efficiency, and valuing the unique contribution of nursing.
"As an independent profession, nurses are best suited to determine staffing," according to AONL. "Asking policymakers to mandate nurse staffing ratios for our patients relinquishes nurses’ professional autonomy; it is short-sighted and counterproductive."
Bredimus, a contributor to the CNO Exchange Community*, spoke with HealthLeaders about how he and Midland Memorial approach practice redesign and how they’ve found success.
Kit Bredimus, chief nursing officer, Midland Memorial Hospital / Photo courtesy of Midland Memorial Hospital
This transcript has been lightly edited for clarity and brevity.
HealthLeaders: What is your definition of practice redesign?
Kit Bredimus: It’s really about who's delivering what aspect of care and by what means they are doing it, where it’s delivered and by whom. It’s important to understand that practice redesign is constantly occurring; it’s always happening because there are many factors that go into hospital acute-care operations.
COVID-19 changed a lot for us in practice redesign, but it was happening well before COVID; it just exacerbated with COVID. You always have to be thinking about redesign and evolution as far as the healthcare industry and who's delivering what aspects of care. Even if you think just a few years back, a lot of the things that we had nursing doing as the primary care model was what housekeeping does, what phlebotomy does, what personal care assistants do, what IT does.
There are a lot of different roles that we have delegated over the years to allow the nurse to step back and practice at the top of their licensure and scope in skills and assessment. But are they really able to do that right now? Are the models working?
HL: When is it necessary to re-engineer the way patients receive care?
Bredimus: It's necessary in the fact that resources are going to continue to dwindle as the nursing shortage is not going to get any better, so many organizations are continuing to look at new ways to take care of either the same number of patients or even more patients by maximizing nurses’ scope and skill by supplementing with different skill mixes and different modalities.
But it's going to be necessary as we continue to see the aging population hit our medical facilities. We are going to have to find ways to deliver care not only within the hospital, but also outside of the hospital, such as hospital at home or virtual nursing. There are going to be new care models that have to be put into place just to meet the demand.
HL: What does practice redesign look like in your organization in Midland?
Bredimus: We’ve done some things not considered innovative now, but they were cutting edge at the beginning. We utilize LVNs [licensed vocational nurses], but not in an assistive supportive role; we use LVNs for part of our primary care model, to have them taking patient assignments, taking fuller extent of their capacity here in Texas to evaluate patients and take care of patients. We’ve implemented and designed an LVN internship, residency, and fellowship program, recognizing that this entry to practice has not really been tapped here locally or in the region, as an opportunity to grow individuals in that space.
We put them on a path where we will pay them to get their RN through a transition program with a local community college partnership here, and that has been very successful. We had 15 individuals in our first cohort that we were able to upskill and get them onto the path to become an RN.
We are looking at our skill mix, as everyone in the country is looking at different skill mixes and how you can have unlicensed assistive personnel in the clinical environment. We redesigned some of our models where we're increasing our UAPs [unlicensed assistive personnel] and having them take on the care, feed, and activity roles where their sole focus is supplementing that aspect.
In addition, we are working further down the pipeline. We recognize that before COVID we were focusing on older adults—high school graduates, adults in the working world, or college kids trying to work toward the healthcare career. We've lowered our hiring limit to age 16. We are working with our local independent school district to create an Explorers program where not only do they get to come into the hospital and experience different areas of healthcare—different roles and disciplines—but also the ability to work as an unlicensed assistive personnel during their downtime that enables them for our employee benefits, such as tuition assistance.
We're getting these individuals plugged in earlier and getting them on a healthcare track so they're not waiting until they graduate to figure out what they want to do, and we as a hospital support them so that gives them a little bit of an edge when it comes to applying for whatever program they want to get into.
HL: What are key tips you would suggest in implementing practice redesign?
Bredimus: The primary focus for any leader planning a practice redesign is to have strong communication. You have to build in that feedback loop and make sure you've had that communication with the staff that are going to be involved with the change to get their buy-in. A leader needs to figure out what staff think is going to work and what's not going to work.
The other part is to empower them to make change. As you trial these things, it's important to hear from staff what's working well, what's not working well, and what they would like to see tweaked. Then, have planned stages where that feedback can be implemented, versus pushing it out from the top down. That has not been successful. I've been a victim of that before, where we recognize that something sounds like a great idea, but once we roll it out, it failed, so empowering the team to own the process and the change has been what’s really worked for us.
As an aside, it’s important to recognize that anytime you're talking about a practice redesign, there's not a lot of literature out there that says, “This is a tried-and-true model. Everyone should do it because it works every time,” because every situation, every organization, every community's going to be different, with different resources, constraints, and barriers. It’s important to keep that in the forefront of your mind whenever you're talking about any of these redesigns because a lot of them are unproven and you don't know if they're going to work for your organization until you try them.
That’s why it’s important to get the feedback of staff and key stakeholders—to make sure you are looking at all the variables that are specific to your unit, your area, your community.
* The HealthLeaders Exchange is an executive community for sharing ideas, solutions, and insights. Please join the community at https://www.linkedin.com/company/healthleaders-exchange/. To inquire about attending a HealthLeaders Exchange, email us at exchange@healthleadersmedia.com
Rhode Island RNs and licensed practical nurses will now be able to have one multistate license, with the ability to practice in person or via telehealth in both their own state and 38 others that have adopted the Nurse Licensure Compact (NLC).
Though Gov. Daniel J. McKee recently signed legislation making Rhode Island the 41st jurisdiction—along with 38 states, Guam, and the U.S. Virgin Islands—to enact the NLC, the state is awaiting implementation with no determined start date.
Implementation must be completed before its residents can apply for a multistate license, and before nurses in other NLC states who hold a multistate license will be able to practice in Rhode Island.
Rhode Island was part of the original NLC which has been operational for more than 20 years, but when the Enhanced Nurse Licensure Compact, a new and modernized version of the language was drafted and approved by boards of nursing in 2015, Rhode Island did not join.
That meant that Rhode Island nurses once again had the burden of holding and maintaining licenses for other states in which they wished to practice, and opportunities to be a travel nurse or remain competitive in a telehealth workforce became limited.
"Our state is grappling with a severe shortage of nurses. Returning to the compact is a way we can make it easier and more appealing for nurses to come here for a job, making it easier for our hospitals and health facilities to fill their staffing needs," said Sen. Joshua Miller, one of the NLC bill sponsors. "Rejoining the compact is good for our public health and safety."
Licensure requirements are aligned in NLC states, so all nurses applying for a multistate license are required to meet those same standards, including submission to a federal and state fingerprint-based criminal background check.
A multistate license eases cross-border practice for many types of nurses who routinely practice with patients in other states, including primary care nurses, case managers, transport nurses, school nurses, hospice nurses, and more. Military spouses who experience moves every few years also benefit greatly from the multistate license.
The NLC also benefits facilities that might have an acute shortage in one of their units to recruit a nurse for that unit or shift around their resources if they're an interstate facility and moves nurses between different states, according to Nicole Livanos, director of state affairs at the National Council of State Boards of Nursing (NCSBN).
Each addition to the NLC helps to strengthen the nursing workforce, she said.
"This sends a broader signal to the other states that are not yet in the NLC," Livanos said, "that the NLC can be part of broader workforce discussions in looking at how to shore up the existing nurse workforce, how to modernize the existing workforce, and how to make sure that your state remains competitive when recruiting nurses."
26% of patients wait two or more months to see a healthcare provider.
More than 40% of respondents have experienced “unreasonable wait times” wait times for healthcare, with more than 25% of those patients waiting more than two months for healthcare, according to a new survey released today by the American Association of Nurse Practitioners (AANP).
As a result, many went without needed care, including patients seeking critical mental health services, according to the survey, conducted in April 2023 of U.S. adults.
"These results are an eye-opening look at the state of access to care in our healthcare system," said AANP President Stephen Ferrara, DNP.
"A lack of timely access to care, particularly primary and preventive care, can lead to chronic conditions that put patients' lives in danger and increase costs," he said. "Delayed or deferred care can put an individual's health at greater risk for complications, which may also lead to a negative impact on mental health and lost wages for those patients. A decline in productivity for employers may also occur."
Other key findings from the survey include:
The increase in wait times extends across almost all major demographics—age, gender, education, and in rural/urban/suburban areas.
Among those with longer waits, nearly half gave up trying to get an appointment.
Those most likely to give up on seeing a provider include younger, urban, Hispanic, and mental healthcare patients.
Granting full practice authority (FPA) to NPs is one solution to eliminating long wait times, AANP has long championed.
FPA is the authorization of NPs to evaluate patients, diagnose, order, and interpret diagnostic tests, and initiate and manage treatments under the exclusive licensure authority of the state board of nursing.
This regulatory framework eliminates requirements for NPs to hold a state-mandated contract with a physician as a condition of state licensure and to provide patient care.
Momentum for FPA increased during the pandemic, when states temporarily suspended practice agreements and allowed NPs to practice at the top of their education, giving patients direct access to care.
"As a nation, we can solve the growing crisis in access to care by modernizing the outdated policies that sideline NPs from delivering care they are educated and clinically prepared to provide," said Jon Fanning, MS, CAE, CNED, the association’s CEO. "We can help shorten wait times and give patients timely access to the care they need by removing barriers to America's 355,000 NPs."
A holistic admissions process looks beyond grades to deliver a diversified student body.
Colleges and universities may be scrambling for new ways to uphold diversity after the U.S. Supreme Court’s recent decision to ban affirmative action, but the University of California, Davis, adopted a holistic admission process more than 25 years ago when California banned race-based admissions in 1996.
The court found it unconstitutional for colleges and universities to use race as a factor in student admissions, creating a particular challenge for the nursing profession, which seeks to better reflect its patient demographic. Indeed, a nursing workforce that mirrors its patient demographic makes healthcare more comfortable for every patient, several studies, including a Joint Commission report on cultural diversity, have shown.
But UC Davis has managed to accomplish that without affirmative action. Instead, its holistic admissions process looks beyond grades, says Jessica Draughon Moret, PhD, RN, an associate professor who chairs the Betty Irene Moore School of Nursing’s Recruitment, Admissions and Fellowship Committee.
"We are looking for unique experiences that will increase the diversity of our cohorts. We are looking for diversity of thought, in addition to diverse experiences. We weigh applications based on different life experiences," she says. "Then we also look at GPA, aptitude, essays, and letters of recommendation. We do look at all of that, but we also know those are not necessarily the best measure of program success."
The holistic review considers markers common for people from underserved backgrounds, such as rural versus urban environments and current or former military service experience.
Applicants answer questions regarding their socioeconomic background regarding:
Attending an under-resourced high school
A primary language other than English
Living in a medically underserved area
Being the first in their family to attend college, known as a first-generation student
When the School of Nursing launched in 2009, the founding faculty decided against requiring a Graduate Record Examination (GRE) score for admission, arguing that data from standardized tests is based on cultural bias and a barrier for underrepresented students, according to the university.
"We also look at the clinical and life experiences applicants have that align with our mission, such as commitment to service, cultural sensitivity, empathy, capacity for growth, emotional resilience, and interpersonal skills," says Teresa Thetford, director for the Physician Assistant (PA) program.
That approach resulted in the most diverse class of P.A.s in the history of the school last year, with more students older than 35, more men, and the largest group of Hispanic students yet.
To help attract a diverse pool of applicants, the school developed a series of videos advising prospective students on how to, in part, submit the strongest personal statement and letters of recommendation.
The admissions process and student success resources are working. For the past two years, according to the university, the class of students entering the entry-level nursing program mirrors the program’s applicant pool.
Those who are most interested in a rural healthcare practice are those who grew up in and prefer a rural setting.
With the need for rural practitioners critical, the most effective way for rural hospitals and health systems to adequately staff for nurses and nurse practitioners is to grow their own, says nurse educator and practicing clinician.
Michele Reisinger, DNP, APRN, FNP-C, should know. She is a Kansas native with a decades-long clinical practice as a family nurse practitioner in her hometown of Onaga, population about 700.
She also is an assistant professor of doctoral nursing at Washburn University School of Nursing in Topeka, Kansas, where she is the primary investigator on a Health Resources & Services Administration-funded $2.4 million, four-year grant focused on the education and preparation of rural nurse practitioners for practice in medically underserved communities.
The need for advanced practice nurses (APRNs) in rural areas is great, as hospitals close and the number of physicians declines. Nearly 80% of U.S. rural counties are medical deserts, with no access to healthcare services, according to the National Rural Health Association.
"I have students that live out in western Kansas and southwestern Kansas, and these students are being recruited heavily a year before they even graduate because those rural health clinics are having to staff with long-term locums who have been present for several months to a year because they don't have enough bodies to physically fill the positions that are there," Reisinger says.
The question is whether those APRNs will stay for the long term, she says.
"You can provide incentives, such as participation with tuition reimbursement," Reisinger says, "but often what we will find happens is those entities then put in the number of years they're required to pay back their tuition reimbursement and they don't often stay sustainably in the community."
For example, the National Health Service Corps Scholarship Program essentially removes a clinician’s educational debt once they’ve fulfilled an obligation of a particular number of years to a community.
"Sometimes it works, sometimes it doesn't," Reisinger says. "Sometimes those people stay for 10 or 15 years, sometimes they stay there for three years and move on, because they've got their educational debt paid off."
But that’s not for lack of trying on Reisinger and Washburn’s part to get them to stay.
The nursing school requires students’ rotations to include a certain number of hours in rural health settings to expose them to a practice of which they might not otherwise be familiar.
"The reason for that is twofold," Reisinger says. "One is to effectively prepare them educationally, but it’s also to generate interest because it's very difficult to recruit nurse practitioners to the rural areas, so this is also a workforce type of issue."
Coming back home
Those who are most interested in a rural healthcare practice are those who grew up in and prefer a rural setting, Reisinger notes.
"In my little corner of the world, we've recruited a lot of different ways, but what really works is you have to raise them in a rural community, send them away to get educated, and hope they migrate back to the rural community because they recognize the benefit of a rural community in raising their own children or have that piece of community attachment," she says.
"It's really hard to relocate a provider who has never experienced rural living or who doesn’t have a sense of community in a rural entity," she says.
That’s why hospitals or extended-care facilities are tending to recruit locals within their own communities.
"Rather than spending those additional funds outside and trying to recruit it, if you can recruit within and then bring them back, retention is much greater, at least in my experience," Reisinger says.
Better staffing, cost savings
Eastern Maine Community College’s nursing program in Bangor, Maine, collaborates with the region’s rural hospitals to provide nursing education for students who prefer to stick close to their communities.
Northern Light Mayo Hospital in Dover-Foxcroft, Maine, graduated six students in the class in 2020 and nearly all continued working there, according to The Hechinger Report, a national nonprofit newsroom that reports on education.
Not only did that help with staffing levels, but in the first nine months after the nursing students’ graduation, the hospital saved $360,000 in travel nursing costs, according to Hechinger.
Building a pipeline
Rural and underserved citizens of Colorado have gained access to healthcare providers through the Grow-Your-Own APRN Fellowship, an innovative model that builds an advanced practice (APRN) primary care workforce and pipeline for rural and underserved areas by recruiting and developing nurses already committed to their own rural community.
The program was developed by Ingrid Johnson, DNP, MPP, RN, FAAN, president and CEO at the Colorado Center For Nursing Excellence, who recruited rural BSN nurses to return to school, earn advanced practice degrees, and transition to practice as a rural primary care APRN. The fellowship provided financial support, individualized coaching, and leadership support.
“The model significantly reduces financial and continuity-of-care costs related to recruiting and turnover of providers that have no interest in living long-term in rural areas and often leave after loan-forgiveness obligations are met,” according to the center of excellence.
The $70 million, 90,000-square-foot building also will expand the college’s capacity to educate future nursing faculty members, according to the university.
UCF graduates about 260 nurses annually, though last year it added 100 students beyond its usual enrollment in response to the state’s demand for new nurses. The expansion will enable the college to increase enrollment by at least 50%, significantly boosting Florida’s nursing workforce. Indeed, 85% of the school’s 16,000 nursing alumni live and work in Florida.
Alliances between hospitals or health systems and colleges are becoming more common as healthcare leaders search for creative ways to bolster the number of nursing students, and thus, their nursing pipeline.
"Ensuring we have well-educated, highly trained, and skilled nurses to meet Florida’s growing healthcare needs is a pressing challenge for the entire healthcare sector," says Randy Haffner, CEO of AdventHealth Florida. "Partnering with leading educational institutions such as UCF is absolutely vital to ensuring these efforts are successful."
"We are excited about our long-term partnership with UCF as we continue to strategically plan nursing workforce opportunities for the future," says Karen Frenier, senior vice president, human resources and chief nurse executive, Orlando Health.
Each hospital’s gift, in addition to contributing to the new building, will support students with the creation of a scholars’ program named in their honor. Each of those programs will provide tuition assistance to 10 senior BSN students annually and establish a paid summer internship program for an additional 10-15 students annually.
UCF continues to seek philanthropic investments in the new building, as it nears the goal of raising $70 million needed to break ground. To date, more than $26 million has been raised through philanthropy, which will be combined with $43.7 million committed by the State of Florida.
"AdventHealth and Orlando Health have been valued, transformative partners to UCF as we collaborate to support the health and well-being of our community," says Alexander N. Cartwright, UCF president. "Their continued partnership and generous investment in UCF’s College of Nursing will make a difference in our region for generations to come."
Your current method of rounding isn't one of them.
One of the most common practices among nurse leaders to improve retention is employee rounding—so much so that the time-consuming practice has been “hard-wired” into leadership routines.
That was one of the findings in the study, Connection is Retention: Lessons from Leaders with Unusually High Nurse Retention, conducted in March 2023 by AONL and Crucial Learning. The research studied 1,559 nurse managers and 562 clinical staff at hundreds of U.S. hospitals to discern the drivers behind high levels of nurse turnover.
“The first surprise was that employee rounding—a practice intended to connect clinical staff to their managers with regularity and purpose—had no effect on whether nurses were likely to quit their jobs within the next three years,” the report states. “In fact, employee rounding seemed so irrelevant that employees often didn’t seem to know it had happened.”
Indeed, while 81% of managers in the study reported that they round regularly, only 36% of clinicians say their managers round regularly.
"As we dug into this curious and concerning inconsistency, we concluded that the most likely explanation for the gap is that rounding is being done in a way that is meaningless to the real concerns of frontline nurses," says Joseph Grenny, lead researcher and Crucial Learning co-founder.
Instead, the study found that nurse managers with surprisingly high retention of their staff were “preternaturally effective” at creating connection with their nurses by offering three things:
Care: I feel a sense of belonging and believe my manager cares about me as a person.
Growth: My manager takes an active interest in my personal and professional growth.
Help: My manager steps in to help when I need it.
Nurses who reported that their nurse managers offered care, growth, and help were more than 80% likely to intend to continue with their work indefinitely, the research indicates.
“One common argument for employee rounding is that frequent structured contact should help nurses know leadership cares about them, is there to help, and invests in their growth. But once again the study found no relationship between consistent reported rounding and perceptions of care, growth, and help,” the report notes.
How to connect
As researchers reviewed nurse experiences that led to both connection and disconnection, four manager best practices emerged, according to the report.
1. Connection is about feeling not frequency. Connection is not made from a certain frequency of interaction. Rather, what created connection was some meaningful moment—an interaction that showed presence, planning, personalization, or follow-up—in a way that made it stand out.
2. Always Be Collecting Dots (ABCD). The report referenced hospitality guru Danny Meyer, who creates connection with his hundreds of thousands of daily guests by advising his employees to always be collecting dots.
“Every time you interact with anyone, they generate dots of information about what’s going on in their life,” he says. “Your job is to collect these and connect them in how you respond to customers to create a special experience for them.”
Great nurse managers do the same, the study says, by taking note of conversations with their nurses about family, interests, or work challenges.
“These dots are leadership gold, if the manager records them, reflects on them, and uses them to inform ways they can show care, facilitate growth opportunities, and offer help,” the researchers write.
3. Connection = Sacrifice. People perceive you value them when you show you’re willing to sacrifice things valuable to you, such as time, money, or other priorities. It doesn’t require a vast amount of sacrifice; just enough to show you value care, growth, and help.
4. Don’t make promises you can’t keep. Keep the promises you make. “Even the smallest broken promises damage perceptions of care, growth, and help far faster than equivalent promises kept,” the authors write. “Better managers are crystal clear about commitments made and impeccable about keeping them. When, on rare occasions they break them, they quickly acknowledge the transgression and find ways to make amends—without waiting to be confronted.”
These recommendations should help overloaded nurse managers create teams of engaged and satisfied nurses, says Robyn Begley, DNP, RN, NEA-BC, FAAN, one of the report’s authors and CEO of AONL.
"We recognize these recommendations might sound daunting to already overwhelmed nurse managers. They should not," Begley says. "The first two don't require time; they simply require thought.”
“In fact, the first—connection is about feeling not frequency—suggests that time spent today in ritualistic employee rounding might be recovered and repurposed. Our study suggests that replacing any recovered time with the second two activities will yield dramatically different results in engagement and retention,” she says. “These are things managers are doing consistently and successfully in units just like yours and if replicated, will make a difference in your team."
