Hospice program improves RN recruitment, retention

Re-entry RNs are untapped source

Hospices have had to deal with the periodic nursing shortages for decades, but California arguably has one of the most challenging problems, so a Sunnydale, CA, hospice has developed a nursing retention and recruitment program that tackles the problem with innovative solution.

"The pool in California of nurses is shrinking a little faster than nationally," says Jane McLeod, BSN, MA, a professional staff recruiter with Pathways Home Health and Hospice of Sunnydale, CA.

Starting Jan. 1, 2005, California requires all hospitals to have a ratio of one RN to five patients, and this has caused hospitals to rapidly staff up with RNs, she explains.

"This leaves community health providers with a huge challenge," McLeod says. "So we looked at some of our options, and we saw that the pool of nurses that hospitals weren't actively recruiting were re-entry nurses."

Hospitals weren't recruiting these nurses because it took re-entry nurses longer to regain full competency and productivity, and they weren't a good match for hospitals' new graduate programs, she says.

"Many of them had been away from the bedside too long and were not competent in their skills anymore," McLeod notes. "The acuity of a patient in the hospital is so much higher than it was five years ago."

However, these same re-entry nurses had qualities that were ideal for the hospice environment because they brought to the role a necessary maturity, independence, adaptability, and problem-solving ability, as well as the ability to handle stress and crises, she says.

"We identified that this type of nurse might be well suited for end-of-life care, and so we had to go out and figure out where you could find those nurses," McLeod says.

Hospice nurses need to think on their feet and understand the symptoms they observe in patients, which is why new nursing graduates do not do as well in the environment as do re-entry nurses when they're trained, she says.

The next step was to find out the state's requirements, which in the case of California meant that RNs had to have one year of nursing experience within the last three years in order to qualify for hospice licensure, McLeod says.

"So we had to apply for a waiver from the state in order to hire re-entry nurses, and we had to construct a program," McLeod says. "I worked with the state licensing board to see what they would accept as a training program and supervision program."

Hospice managers applied for waivers for each nurse who didn't make hospice nursing requirements, says Jane Hoffman, BA, BSN, MS, staff education coordinator for Pathways Home Health and Hospice.

McLeod also contacted the state's board of registered nursing to make certain there weren't additional requirements for re-entry nurses.

As a result, the hospice's re-entry nurses complete a re-entry program and then go through preceptor training, she says.

Technically, the state of California doesn't require re-entry nurses with BSN degrees to apply for the waiver, but Pathways Home Health and Hospice decided to require re-entry nurses with BSN degrees to go through the re-entry program if they had been away from nursing work for more than three years, McLeod adds.

"We made a decision to invest in these nurses because they're a valuable resource," she says.

The training program has also helped with nursing retention. The hospice has hired eight re-entry nurses within the past 1½ years, and seven of the nurses still are with the hospice, McLeod says.

Here's how the re-entry program works:

1. Find re-entry nursing prospects.

The hospice has recruited re-entry nurses who have been out of the field for up to 15 years, and most are women older than 40, McLeod says.

"Most women with young families are looking for per-diem work," she notes. "They cannot commit to the hospice schedule because of their family responsibilities."

The re-entry nursing recruits typically are parents and sometimes grandparents who have raised their families and now want to return to nursing, but think that hospice nursing is what they'd really like to do, McLeod says.

2. Screen and interview re-entry nurses.

Hospice managers have designed a set of interview questions to assess the job candidate's personal qualities and to filter out the nurses who may not be a good fit with hospice, McLeod says.

"We require all candidates to spend one day with a hospice nurse before we even interview them," she says. "It gives them an opportunity to see if this might be a good fit for them."

Hiring preceptors also helps evaluate the potential employees during the tag-along day, observing how the nurses behave in the hospice home and to see if they've asked appropriate questions, McLeod adds.

Job candidates who pass the first screening test are then interviewed by hospice managers.

3. Train re-entry nurses.

Re-entry nurses take a nursing training program of 90-plus hours, meeting three days a week for four weeks at a continuing education facility, McLeod reports.

"They go through physical assessment, medical management, IVs, wound care, nutrition, and a very broad curriculum," she says.

The re-entry nurse's orientation at the hospice then is longer than the standard orientation program, and it includes quarterly meetings with preceptors over the course of a year, Hoffmann says.

"Re-entry nurses make no independent visits for the first month and are asked to observe and put their observations in writing," Hoffmann adds.

"One thing we found out is these nurses, even though they've been through refresher courses, need extra clinical experience," Hoffmann says. "So we have them all spend some time with one of our nurses from the home health section to review clinical areas, such as wound care, phlebotomy, IV education, and pain and symptom management."

The additional training is individualized, she says.

"If I have a nurse who doesn't do urinary catheters, we can send the nurse out with a home health nurse to review and practice," Hoffmann notes.

"Sometimes the re-entry nurse will make joint visits with physicians so the doctors can review their physical assessment and give them a more thorough one-on-one mini-refresher program," McLeod says.

"What we're finding from the nurses we've hired is if they have a strong medical or surgical background, then they have some of the core clinical skills that it's hard to teach people," McLeod explains. "They understand critical thinking and are good problem-solvers, so we give them a lot of practical experience."

While hospice managers expect the re-entry nurses to become fully productive and competent members of the hospice team, they don't expect them to learn everything as quickly as other newly hired nurses, Hoffmann says.

"Part of their big adjustment is just coming back to work and being back in the work force," Hoffmann explains. "That's a challenge to them."

So re-entry nurses are assigned preceptors who case manage the re-entry nurse as the nurse makes patient visits for three to six months, Hoffmann says.

"The preceptor who is an RN, is teacher, trainer, and manager, and we put a lot of resources into training preceptors to train new nurses how to be hospice nurses," McLeod says.

Need More Information?

  • Jane Hoffmann, BA, BSN, MS, Staff Education Coordinator, and Jane McLeod, BSN, MA, Professional Staff Recruiter, Pathways Home Health and Hospice, 585 N. Mary Ave., Sunnydale, CA 94085. Telephone: (408) 730-5900.