Find out why people stay and not why they leave

New consulting style cuts turnover rates

Most of health care these days seems to be about problem-solving — figuring out what is wrong with a patient, a process, or a system and fixing it. This is a negative way of viewing things, says Kathleen Davis, RN, MBA, vice president of hospital and nursing services for the Lovelace Health System in Albuquerque, NM. Take nurse retention, she says. "Everyone is focused on why people are leaving, not why they stay."

So when Davis got a grant from the Robert Wood Johnson Foundation, she wanted to look at the positive side of the equation and figure out why the best nurses stay at Lovelace. Using a consulting process called Appreciative Inquiry (AI), she did just that. And along with finding out the good things about the system that encourage nurse retention, Davis saw turnover rates decline by about 10%.

Appreciative Inquiry was developed by David Cooperrider at Case Western Reserve University in the 1980s. It is a strength-based approach to consulting in which the positive aspects of an organization are delved into and studied. "It actively seeks that which is good and admired," says Davis. "You have to develop questions based on what you think you value."

Traditionally, an organization that wants to have an impact on something like retention would have taken the medical model technique of finding an area of deficit, analyzing it, and fixing it. "That puts the focus on what is bad, not what is good. This allowed us to determine our core values in nursing and concentrate on those positive things."

After learning about AI, Davis formed a steering committee that investigated the areas that nurses value in the workplace. They came up with four things to focus on: the privilege of nursing, humor, appreciation, and the exceptional team.

The committee then interviewed nearly 100 people using a cascading process in which those interviewed were then trained to interview others. "We sat down and asked questions one on one. The questions were designed to trigger stories from the nurses." For example, concerning teamwork, nurses were asked to:

  • describe a time when they believe their team performed exceptionally well;
  • discuss the circumstances during that time;
  • share a story about a time when they were proud to be a member of a team;
  • describe the elements that made them proud.

What Davis and her team accumulated were hundreds of stories that illuminated just what those four core values meant to the nurses in everyday practice. The committee took these stories and developed a brochure that explains the health system’s vision and values and how these are demonstrated at work, and calendars for nurses that include pictures of them at work and quotes from their own stories. "It’s real feel-good stuff," Davis says.

Along with creating iconography and literature that emphasized the positive aspects of being a nurse at Lovelace, Davis says the AI project has led to changes in many processes in the system. For instance, interviewing prospective employees has a different tone. "We used to ask about how people would solve a problem. Now we ask questions in a more positive way. We ask them to tell us about when something went really well, or some success they had."

Assessment tools for nurse internship programs also have been reframed to be more positive. In staff meetings, too, Davis says nurses make use of the lessons they learned from the AI project. "In our own monthly meetings when I start, rather than go right into the agenda, I ask the people there to reflect on what has been going well. I’ll ask them what lately has made them want to stay at Lovelace."

Some might see the process as a Pollyanna approach to the realities of health care, but Davis disagrees strongly. "We still get issues to come out. We still discuss problem areas, but they surface differently, and our approach to them is more positive." Besides, she adds, with a declining turnover rate, what more proof does she need that it works?

"I think we have to find new ways to approach some of the old problems we have in health care," Davis concludes. "Using the same old techniques to deliver nursing care may be comfortable and may work fine for patients. But I don’t think it works as well with environmental issues. To a large extent, high turnover rates relate to work environment issues. If you talk about an issue and people walk away feeling bad, that can’t be good for morale. We are trying to work on issues in a purposely positive way. That way, when people walk out of a discussion, even if it was about a problem, they walk away feeling good about themselves, about their work, and about Lovelace."