Cutting nurse stress improves retention

Physical and emotional burnout can lead to exodus

There are plenty of data to support the notion that the higher the stress level nurses face, the greater the chance they will leave their jobs. A survey by the Texas Nurses Association listed high stress in the workplace as one of the top reasons nurses cite for leaving. And a 2001 study in the Journal of Nursing Administration reported that the more job stress, the higher the anticipated turnover rates among nurses.1

But some facilities are learning the lesson and adopting innovative programs designed to give nurses — and other hospital employees — the tools they need to manage emotional and physical stress, both at home and at work. Although it is difficult to show a direct link between a given program and a decreased turnover rate, there is plenty of anecdotal information that these programs are making the work force happier.

At the Vanderbilt University Medical Center in Nashville, TN, a Be the Best, Keep the Best program led to the creation of a Nursing Wellness Task Force whose goal is specifically to address the stress and burnout nurses face.

One of the first campaigns the task force implemented was the Take Your Break Campaign, says Leah Golden, RN, MEd, educational coordinator at Vanderbilt University Hospital and a member of the task force. "Nurses are notorious for not taking their breaks," she says, especially in the critical care units. "It’s a cultural thing, I think. They don’t even eat in the break room, but eat at the nurses station so they can hear alarms on their patients if they go off."

The task force put up posters around the hospital — bathroom doors were a great place to put them since "bathroom breaks are the one break nurses will always take," Golden says. The posters included reasons why taking a break was important. For instance, one might emphasize that breaks are great for re-energizing nurses.

Another part of the campaign was a wellness day. The hospital provided information on wellness programs, nutrition, and even a chair massage. It took about 10 minutes to go through the whole thing, and door prizes were offered as a way to encourage nurses to attend. The emphasis was on the importance of taking a break during the workday.

Golden admits that the Take Your Break Campaign didn’t have as big an effect as she hoped for, but she has noticed that some units are better about scheduling breaks, and managers have gotten better at insisting that nurses take time out to eat on a busy day. Even the critical care areas are making more of an effort to schedule breaks, she says, with nurses deciding to cover each other’s patients on a rotating basis so they all have time for a breather.

Other initiatives have also been implemented. Recently, the task force started a safety campaign that examined the concerns of nurses who work at night and must walk around the campus in the dark. It started with a walkabout by police, facilities personnel, and management team members at night to see some of the places nurses walk and what might make them feel safer. The result: Bushes were trimmed, extra lighting installed, and more mirrors were put up in the parking garages.

Another initiative is looking at the needs of older nurses and determining the physical and psychological stressors. "We’ve had one focus group on that already," says Golden. One clear message: Three 12-hour shifts a week are too hard for many older nurses. The Smooth Moves Committee, an ergonomics group working with an occupational health physician, is looking at some of the other physical issue facing nurses older than 40. They are just about ready to present data and recommendations to the administration.

Part of the issue at Vanderbilt is getting the word out to a large number of employees about the programs that exist and the ones being planned. The nursing newsletter includes a wellness column. It used to be put out on the units, but nurses weren’t picking it up. Now it is included in the paycheck envelope. A weekly publication for the medical center as a whole is given out weekly, too, and that includes mentions of the programs of the Nursing Wellness Task Force.

Caregiver, heal thyself!

The program at St. Charles Medical Center in Bend, OR, is a decade old and was a direct result of the hospital deciding to become a more healing environment for patients. It is a very unhospital-like building, says Janey VanVeen, RN, health coach and facilitator at the hospital’s Center for Health and Learning. There are waterfalls, serene colors, and very little overhead paging. The hospital even has an artist on staff. "But we realized that as great as it is to make this great space for patients, we can’t heal others if we aren’t good at looking after ourselves," she says. (For 20 wellness program ideas from St. Charles, click here.)

The center of the programs is the People Centered Teams seminar, she says. It lasts 2½ days and provides employees the skills, to manage change, enhance self-awareness, improve communication skills and become more accountable in their daily lives. VanVeen says the program has helped to alter communication patterns in the hospital, cutting down on gossip, and helping staff to take their problems directly to the people who can solve them.

The seminar is offered monthly and is required for all staff. In the near future, the hospital will require staff to take it once every four years. A second level seminar called Resiliency and Renewal also is available to all staff and required for leadership and management. Designed to directly address burnout issues, VanVeen says it concentrates on giving staff the skill to sustain themselves in the face of stress and change. The course was designed with a group of University of Pennsylvania psychologists who have researched what makes some people able to grow when they face adversity, while others merely feel beaten down.

The course has been offered four times per year for the last two years. So far, about 200 of the hospital’s 2,200 employees have taken it. "The feedback we get it is that it helps those who take it to challenge their assumptions and improve their critical thinking skills," says VanVeen. "It helps them to become more resourceful."

The courses certainly help nurses and other staff to develop the skills to manage emotional stress, but for physical issues, there is a host of other programs. One, called New Directions, is a 10-week risk-reduction and health-enhancement program for those who may have chronic illnesses, ongoing stress, or situations that must make them want to feel more empowered. Led by a doctor and nurse, the program is 80% covered by the hospital’s insurance program, and employees taking it get a 50% discount on the 20% they have to pay.

The program emphasizes the mind/body/spirit connection, VanVeen says. A different topic is presented each week. For example, there is a week on relaxation responses, another on nutrition. Exercise, communication, listening, self-esteem, stress management, and spirituality also are covered. The course is a mix of large group educational sessions, small group discussions, and individual work. "They can learn to manage symptoms with a positive attitude."

One local insurance company found that those who take the course — and it is open to the community at large, as well — have fewer claims than those who do not.

Another program is called Life Choice, a one-day seminar free to staff and the wider community that helps participants identify what personal health means to them, what life patterns get in the way of attaining personal health, and how to challenge those patterns.

For immediate stress relief, the hospital offers free 15-minute chair massages in each unit six times per year. For a dollar a minute, you can have additional massages with a massage therapist who comes to the hospital twice a week. "Massages can be very renewing," says VanVeen. "The staff really appreciate it, particularly the free ones that are in their own department every other month."

Calculating the benefits

Like so many of these programs, there aren’t a lot of data that what they do works, says VanVeen. One nurse from the hospital is actually working on her PhD trying to figure out what outcomes can be related to the use of the People Centered Teams program.

Staff satisfaction is high, turnover low, and nurses tell the administration they love the programs. "But it’s hard to pin it on any one of these programs," VanVeen says, noting she’s heard comments from nurses about how they can communicate better with their teenagers or spouses or parents at home, which makes them feel more comfortable being away from family while at work.

"This has been life-transforming for many who’ve gone through it," VanVeen says, adding there is another way to calculate that it works: the opinion of other health organizations around the country that have asked the folks at St. Charles Hospital to teach them about their programs as they try to deal with the issue of nursing burnout.

Vanderbilt University Hospital has seen some improvement in retention rates since the Nursing Wellness Task Force was created 18 months ago. But there were other groups also working on recruitment and retention, so Golden isn’t sure how much of that improvement is due to the task force’s work.

However, one indicator that the work is paying off is the number of nurses using the employee assistance program has doubled. "That’s a reactive thing, but a good sign that when a problem occurs, they will go out and seek help." The future, she says, will hopefully include nurses taking a more proactive role in their well-being.

Regardless of how successful any of the campaigns are by themselves, Golden says putting a wellness program for employees in place sends a vital message. "It tells them we care about their well-being," she says. "And if you don’t take care of your nurses and other staff, you’ll find you don’t have any to take care of. This is a hard job. Nurses spend all their time giving to others, but they can be very bad at taking care of themselves. I think it’s up to hospitals and other health care organizations to teach them how to do this. If we don’t, no one will chose to go into this field, or stay in it if they do."

The average stay in the nursing profession hovers around seven years, VanVeen concludes. "We lose a lot of great talent to burnout. Anything you can do to support caregivers in being more successful and healthy will result in benefits in workplace — through retention and more capable staff. Home issues won’t spill into work because we offer skill sets to deal with any stress. Our caregivers are our biggest investment. We can’t heal our patients if we are not healing ourselves first."


1. Shader K, Broome ME, Broome CD, West ME, Nash M. Factors influencing satisfaction and anticipated turnover for nurses in an academic medical center. J Nurs Adm 2001; 31(4): 210-216.


• Leah Golden, RN, MEd, Educational Coordinator, Vanderbilt University Hospital, Nashville, TN. Telephone: (615) 835-1843.

• Janey VanVeen, RN, Health Coach/Facilitator, Center for Health and Learning, St. Charles Medical Center, 2500 N.E. Neff Road, Bend, OR 97701. Telephone: (541) 617-2694.