Avoid hiring woes: Keep your good employees

Provide educational opportunities, safe environment

The best offense is a good defense. The phrase is used often by athletic coaches, but the same concept applies to recruitment and retention of employees. While many managers look carefully at how their outpatient surgery programs recruit new employees, it is just as important to look carefully at what you are doing to retain the good employees you have now, say experts interviewed by Hospital Home Health.

While salary levels may play a part as a home health worker is looking for a job, salary is rarely the reason an employee leaves a job, says Mary P. Malone, MS, JD, president of Malone Advisory Services, a South Bend, IN-based patient and employee satisfaction consulting firm. An employee's financial compensation that includes salary, benefits, bonuses, car allowances, and educational reimbursement, all play a part in an employee's satisfaction, but mostly the employee is looking for a workplace with a sense of fairness and recognition of employees' worth, she says.

Respondents to the 2006 Hospital Home Health Salary Survey report that their salaries saw conservative increases with almost 54% of the respondents reporting an increase between 1% to 3%, and almost 31% reporting increases between 4% and 6%. Slightly more than 23% reported salaries between $70,000 and $89,000 and more than 46% reported salaries between $90,000 and $129,000.

A good example that the answer to retention is not as obvious as competitive salaries can be found at Cincinnati [OH] Children's Hospital Medical Center's home care agency. "We have not had a problem retaining employees until April 2006, when we had four employees resign in a two-month period," says Carrie Krueger, RN, BSN, clinical director of home care services. All four employees cited concern for their personal safety as the reason for their resignations.

The agency experienced two incidents in April. One involved a shooting in which bullets entered the apartment in which a nurse, nurse's aide, and escort were making a patient visit, and the other was an attempted robbery at knife point, during which the thief wanted the nurse to give him whatever drugs she had in her bag. "Fortunately, no employee or patient was hurt during these two incidents, but it did make all of us realize that we need to re-evaluate our efforts to protect our employees," Krueger says.

Her agency has paid close attention to employee safety and had developed a comprehensive safety plan that includes coordination with police and the use of escorts from the hospital security department for some visits.

"After these two incidents, we developed a new safety task force to review our safety program and find ways to improve it," says Krueger. "One of the things we discovered as task force members researched how other, similar agencies handled different situations is that the home care program at Cincinnati Children's was the only agency to schedule visits as late as midnight.

"We now only make home visits until 9 p.m. and we don't have 24-hour call," she says. Krueger and the agency's patient care coordinator handle phone triage after hours to troubleshoot problems over the phone, but if the patient needs to be seen, parents are told to go to the emergency room. "This change required a great deal of communication with other departments because it does affect our referral sources and it does mean a potential increase in emergency department visits," she adds.

An increase in the number of security escorts available from two to four full-time equivalents and a software program that uses current crime statistics to identify dangerous locations have increased the staff's sense of security, says Krueger. "In fact, one of the nurses who left in May is returning to the agency next month and two of our part-time nurses have increased their hours, so we don't have four full positions open," she adds.

Make training interesting

One way to improve retention is to make sure your orientation and continuing education program meets your staff's needs, says Malone. Once a new employee has started employment, make sure that your orientation program is interesting and specific to the job, she suggests. "Revitalize the traditional orientation to include mentors for new employees," she says. "Formalizing a mentor program not only ensures that new employees get skills training they need for their job, but also recognizes experienced employees for their knowledge and talent."

A skills fair has proved to be a successful way to help staff members stay up-to-date on their skills and meet continuing education credits, says Nancy Barnard Edgerton RN, BSN, MHA, director of home health at Visiting Nurse Association of Wyoming Valley in Edwardsville, PA. The fair is held from 10 a.m. to 3 p.m. and is repeated three times to give all employees a chance to attend, she says.

Topics at a recent skills fair included newborn assessment, pain management, nutrition information for diabetic patients, and explanation of different wound care dressings. "We serve lunch and snacks during the day and we hold door prize drawings," she explains. Not only do staff members get to take advantage of different educational seminars but they also get to see other staff members who they don't normally see during the day, she adds.

Another way to meet employees' needs is to offer ongoing seminars or educational meetings that address key issues, says Barnard Edgerton. "We have a pain initiative and a falls prevention program in place that includes ongoing education for all staff members," she explains.

Recognition of employees throughout the year includes an "Employee of the Year" who is recognized at the annual board meeting, movie tickets given to employees on their anniversary date with the agency, and an annual employee recognition dinner, says Barnard Edgerton. "Once an employee has been with us for five years or more, we pay for their dinner at the recognition dinner," she says.

Tailor program to age, experience, skill

When you evaluate programs for recognition and reward to enhance your retention rates, it is important to look at employees' experience and age, suggests Malone. "You might have a nurse in her mid 30s with over 15 years of experience and a nurse in her mid 40s who is just entering the profession," she points out. "Each of these employees is looking for something different to stay interested in your organization."

Remember, too, that you need to take into account how long the employee has worked in home health, not just health care, suggests Malone. "A nurse with 15 years of experience in a hospital setting and just a few in home health is a very different employee than another new employee with 15 years of home health experience," she points out.

It is common to have employees move from hospital employment to home health as they gain the experience they need, as shown by salary survey respondents, of whom more than 76% have worked in health care for 15 or more years, but almost 54% have been in home health for less than 15 years.

Make sure that employees do have an opportunity for professional advancement, even if you don't have opening for additional supervisors and managers, suggests Krueger. A clinical ladder at her agency gives nurses a chance to move from clinical nurse 1 to clinical nurse 2, along with pay increases. "There is a clinical nurse 3 designation, but because it requires ongoing research, there is not as much opportunity for this advancement within our agency."

If a nurse is not ready to seek advancement on the clinical ladder, he or she can still apply to the preceptor program, Krueger says. Staff members in these positions work with new employees and help them learn skills needed for their jobs, she says.

As you offer staff members a chance to learn and advance, keep in mind that not all employees make good supervisors, warns Malone. "The strongest relationship an employee develops is with his or her immediate supervisor," she says. More than 69% of the salary survey respondents carry the titles of director, CEO, or vice president, but there are many supervisors within an outpatient surgery program that can affect the organization's retention rate, she explains. "One mistake that is often made is to promote people for the wrong reasons," she says. Instead of basing promotions on seniority, years of experience, or clinical skills, look for people who can develop strong relationships, she suggests.

Give employees support they need for job

Another way to show employees that you recognize their importance is to give them the support they need to do their jobs, says Barnard Edgerton. "We do not have point-of-care computers in our agency, so we had to find other ways to make the field staff members' jobs easier," she says. By hiring a "verbal order nurse" who takes the calls from physicians' offices when a field nurse has called about a patient, the field nurse is free to continue visits and patient care rather than waiting by the phone, she explains.

"The field nurse makes the contact with the physician's office, then leaves instructions for the office to call the verbal order nurse with information," she says. "Once the physician's office calls, the verbal order nurse contacts the field nurse with the information." This process saves a lot of time and prevents missed calls, she says.

"We also knew that most staff members did not like having to rotate time for night call after working a regular schedule," says Barnard Edgerton. "We have now hired two full-time equivalents for home health and one full-time equivalent for hospice to handle night call," she says. The two home health nurses are each on call for seven nights, then off for seven nights. "This has been a big morale booster for our regular staff, especially since we have a busy infusion therapy service and there are a lot of night calls," she adds.

Long hours are not limited to field staff, as shown by the responses to the salary survey. More than 61% of survey respondents report working between 41 and 55 hours per week, and more than 23% report workweeks of 65 or more hours.

Even with long hours, paperwork and forms, and venturing into areas they might not have traveled before, home health is a special place to work, says Krueger. "My staff is here because they love children, they love their independence, and they get to see kids in their own homes, even children they cared for while they were in the hospital," she says. "Retention of employees who want to be at your agency is a matter of listening to their concerns, meeting their needs, and making sure they know that your priority is their well-being."


For more information, contact:

  • Carrie Krueger, RN, BSN, clinical director, Home Care Services, Cincinnati Children's Hospital Medical Center, MLC 5017, 3333 Burnet Ave., Cincinnati, OH 45229-3039. Phone: (513) 636-4663. Fax: (513) 636-7152. E-mail: carrie.krueger@cchmc.org.
  • Nancy P. Barnard, RN, BSN, MHA, director of home health, Visiting Nurse Association of Wyoming Valley, 468 Northampton St., Edwardsville, PA 18704. Phone: (570) 552-4054. E-mail: nbarnard@wvhcs.org.
  • Mary P. Malone, MS, JD, president, Malone Advisory Services, 412 S. Twyckenham, South Bend, IN 46615. Phone: (574) 876-3039. E-mail: mary@maloneadvisoryservices.com.
  • For other information about research and strategies used by other health care organizations to retain employees, go to the Robert Wood Johnson Foundation website at www.rwjf.org. Choose the " interest areas" tab on the top navigation bar and select "nursing." Under "publications" (on the left navigation bar), you can find "Wisdom at Work: The Importance of the Older and Experienced Nurse in the Workplace" and under "research" you will find articles such as "How Can Employment-Based Benefits Help the Nurse Shortage? Making nursing more attractive involves more than just wage levels".