For Baptist Health Louisville, Nurse Retention Is Everyone’s Responsibility

Added on Jan 9, 2020

teamFor Baptist Health Louisville, Nurse Retention Is Everyone’s Responsibility
By Lauren Keeley

When Denise Carter, RN, was asked to step in as interim director of the emergency department at Baptist Health Louisville in 2016, there were 20 vacancies on the RN job posting and the unit had been without a director for two years. Retention was clearly low, and morale was even lower. On top of the existing strain of high turnover rates, the ED, which sees more than 60,000 patients per year, was just beginning a multimillion-dollar renovation and expansion.

With the goal of developing initiatives to quickly engage the staff so that patient experience outcomes would not suffer amid the frequent changes, Carter teamed up with Randall Caldwell, the hospital’s director of patient experience. It did not take the pair long to realize that seeking quick fixes was the wrong objective.

“Retention is a marathon, not a sprint,” said Carter. “After much trial and error, we found that obtaining the right talent and building relationships with new hires from the start has the greatest impact on retention.”

With some help from HR, over the next three years Carter and Caldwell developed a step-by-step toolkit for recruitment, onboarding, and retention of new nurse and tech hires that includes peer interviewing and job shadowing, personalized onboarding resources, an in-depth orientation with preceptor program, and routine retention meetings with ED leadership. As a result of these efforts, from 2016 through 2018 mean performance improved across all categories of nursing quality indicators (NDNQI) and AHRQ safety measures, and the nurse turnover rate in the ED decreased on average from 5.2 to 3.8.

Furthermore, because both leadership and staff were included in the hiring and onboarding process, the positive impact has rippled beyond new hires to the nursing team as a whole. Today, successful teamwork is one of the hallmarks of the ED, according to Carter.

Preparing for Process Change

At the start of the journey, Carter assessed the ED’s existing hiring framework and found that there was no defined process for interviewing. “Usually one person would conduct the interview and make the decision,” she recalled. Additionally, unit-based educators who were responsible for holding the hospital-mandated two-week orientations felt overwhelmed and ineffective.

“There’s just so much information for new hires, especially in the hectic ED,” Carter stated. “There are skills labs, check-offs, computer modules—two weeks simply wasn’t enough time for educators to instill confidence in their abilities.”

The preceptor program was equally challenged, with new hires shuffling between multiple preceptors during their first few months on the unit. In fact, Carter admitted that many of the staff did not know who the preceptors were.

Tackling the first order of business, Carter and Caldwell extended the length of ED orientation from two weeks to one month, per the educators’ request, and limited the number of preceptors per new hire to a maximum of two or three. Then they worked with the educators to develop a formal preceptor education program to ensure that the nurses invited into the preceptor role were fully equipped to train new hires. Developing the preceptor education with the same educators who conducted the orientation guaranteed alignment in the technical and behavioral expectations for all new nurses and techs.

At the outset, the formalized preceptor program was met with some hesitation among those invited to consider the role, because of concern over the heavier workload and a general lack of confidence in their own readiness to teach new hires. “While we respected individuals’ decisions, we always encouraged those who were invited to be preceptors to sit in on a class to see what the program was all about,” said Carter.

Preceptorship, Caldwell noted, is a great opportunity for career advancement, which is a predictor of intent to stay for all nurses. Additionally, the preceptor program nurtures a culture of collaboration and places high value on mentorship and education in the clinical setting.

Engaging All in Interviewing and Onboarding

With the extended orientation and updated preceptor education program in place, Carter and Caldwell began brainstorming ways to adjust the interview process so that it was conducive to hiring for fit rather than expediency. They landed on peer interviewing, which involves both leadership and unit staff in the interview process. To gauge interest in the idea, Carter sent an email to all ED nursing staff, clearly detailing the time commitment, requirements, and call to action for peer interviewing. Since Baptist Health Louisville uses self-scheduling, those interested in participating could set aside availability during the specified time slot—in this case the first and third Thursday of every month, from 11 a.m. to 3 p.m.

Although the peer interviewing role is voluntary and without monetary incentive, the new process created a sense of ownership for participating nurses and techs, Carter noted. “Peer interviewing gives our unit staff some control over their experience in the work environment,” she said. “It’s an opportunity to have a say as to who they work with day in and day out.”

During an interview, peer interviewers pose five questions from a list of prompts to guide their assessment of the applicant’s fit in the ED. Not only does peer interviewing usually lead to the best hiring outcome, but it promotes ongoing team building when staff changes occur, Carter explained. On the same day as their interview, applicants participate in a two-hour job shadow to get a sense of the work environment and meet other members of the unit staff.

When the interview and job shadow process leads to an accepted offer of employment, new nurses and techs receive a welcome email from HR, a welcome letter from the unit-based educators with first-week instructions, a personalized “Welcome to the Team” slideshow, and a welcome card mailed to their home. The goal of these actions is to connect the new employee to the culture from day one. This is especially important for those new nurses and techs whose hiring dates fall in between the monthly new-hire orientations. “There could be several weeks between receiving an offer and the start of the next orientation cycle,” explained Carter. “We had to figure out a way to connect with them in the interim, to start laying the foundation of those relationships.”

To further ease the new-hire transition, the unit educators tailor preceptor pathways with goals segmented by week to guide and support new employees. Each pathway is based on the new hire’s role and experience and builds on responsibilities each week. For example, a pathway for an RN with no ED experience differs from that of one with ED experience, and the guidance reflects that.

Looking Beyond the First 30 Days

With an eye toward workforce sustainability, the vice president of HR at Baptist Health Louisville suggested the ED try 30-day retention meetings with each new hire to check in on personal progress. Understanding the importance of keeping leadership visible and accessible, Carter also established 60- and 90-day retention meetings held by a member of the nurse leadership team and 45- and 75-day retention meetings held with the educators.

The 30-60-90 meetings focus on everything from ways to get involved in the wider organization to effectively managing provider interactions, Carter said, noting that the underlying hope for these conversations is that new hires form relationships with other members of the staff and feel valued as team members. These meetings also serve to bridge the gap between unit staff and leadership. “At the 90-day meeting, I ask, ‘If you were in my shoes as leader of the department, what would you do differently?’ That question usually catches them off guard, but it’s important they know their input matters,” she said. “It also opens another avenue of trust in the relationship.”

During the 45-75 meetings, educators examine the dynamic between new hires and their preceptors by observing them on the floor and then discussing challenges they’ve faced and new skills they’ve acquired so far. These meetings are also an opportunity for the new hires to ask questions and provide feedback about the orientation experience.

According to Caldwell, sustaining connections, like the ones made with the educators during the first weeks of hospital orientation, is foundational to the rest of the new hire’s experience in their first year at Baptist Health Louisville. “After those initial relationships are built, the team takes care of the rest,” he asserted. “Retention is everyone’s responsibility.”

Given the success of the engagement program in the ED, the retention toolkit is being rolled out hospital-wide, allowing leaders from each department to pick and choose what elements to implement to best meet the demands of their workforce. Moving forward, the ED’s shared governance committee is developing a retention ambassador role to uphold all staff engagement in preventing nurse turnover.

When reflecting on the three-year journey, Carter concentrates her attention on the wins, large and small. “There are always going to be blips and missteps,” she said. “But I know we are headed in the right direction—for one thing, I now have one nurse position on the job posting instead of 20.”