No room on the ward?

For nurses, that is, not patients

The national nurse vacancy rate stands at approximately 10%, and it’s higher in New Jersey. But at Hackensack University Medical Center (HUMC), there are actually units for which there is a waiting list of nurses looking for work. The 683-bed facility has about a 6% vacancy rate, says Toni Fiore, MA, CNAA, executive vice president for patient care. It doesn’t recruit foreign nurses, use travelers or even agency nurses.

All 1,800 RNs who work for HUMC are employed by the hospital.

It’s something that has been in the making since the 1980s, Fiore says. "When I started in this position, there were recruitment issues and so we set about creating a road map to get to where we are today," she says. "One of the goals was to have all our own employees so that the loyalty accrued to us."

They started by looking at the research on the hospitals that were reputational magnets — the Magnet designation program didn’t yet exist — and doing a gap analysis. "We wanted to know what they had that we didn’t," she says. Once the Magnet program started in the early 1990s, the facility applied and was the second hospital in the nation granted a Magnet award. It has since been recertified once and is up for redesignation again this year.

"The Magnet designation is all about having the best nursing and patient care with the benefit of a good work environment," she says. "We have competitive pay and a family-friendly environment. We have a decentralized very flat organizational structure and excellent relationships between nursing and administration and nurses and physicians."

Within three years, the hospital was able to stop using agency nurses. "It isn’t that agency nurses are bad, it’s just that we wanted our own people whose loyalty was to us," she says. "We were also able to take that money we spent on agency nurses and reinvest it in our own people."

The hospital’s turnover rate for nurses also fell and has been in the single digits for some time. It was as low as 3% in June, but rose with the addition of some new beds. In some units, such as OR, there is a waiting list of nurses who want positions. Even when there is a need to recruit, Fiore says she has a pretty easy time of it. "The only difference now is that you have to hire sooner because you need more training to get the competency you want because of all the competition that’s out there."

Fiore also boasts that HUMC hasn’t cut a nursing position since 1986 when she started this process. "We have a philosophy from the top down that nurses are not costly resources; they are cost avoiders," she explains. "They help us to manage our outcomes and make sure the right thing happens for a patient at the right place and the right time."

What makes it work

It all starts at the first interview, says Fiore. In many organizations, the first interview is a feel-good affair where not a lot of information is given about the facility. At Hackensack, "we tell them our expectations of them from the start and really discuss if it is a place that they want to work. We don’t want to hire someone who just needs a job, but someone who really wants to be on the team."

Competency training doesn’t end with orientation, either. Fiore says a constant investment in the continuing education of nurses may cost more up front, but it saves in turnover. "The nurses value the investment we put into them, and it certainly works for the patient. We believe that this investment is actually a dual investment in the caregiver and the patient."

Letting nurses know they are important is another factor in keeping turnover low. Fiore says that the nurses know her and she knows them. "The leaders at the bed are the nurses, and they know that administration sees them as such," she says.

Pay is a factor — although not the biggest one. Hackensack University Medical Center makes sure that its pay is in the 75th percentile for its area. Nurses get a raise every year, and the pay scale is evaluated midyear to ensure that the facility hasn’t lost ground to competitors.

Administration also regularly seeks out the opinion of the nursing staff. There are yearly interviews on issues such as staffing and communication, and they are questioned about what it will take to keep them at Hackensack. This year, the survey focused on the differences of needs between different generations of nurses. "I’m a veteran employee," says Fiore. "What’s important to me may not be important to the younger generation."

Honesty also pays. For example, parking is a huge issue at the hospital. On-site spaces are kept for patients, visitors, and only the most senior staff. The rest of the staff are told when they are hired they won’t get on-site parking, but there is regular shuttle service in nice, clean, heated buses.

There are people who leave, but even then, Fiore tries to keep them in the system in some way. "We don’t look at the expected turnover like women leaving because they have a child. We can often keep them on in some per-diem capacity," she says. In fact, about 99% of the expected turnover cases stay with us in some way. "But what does concern us are those cases that aren’t expected. We have a very fast pace and are 98% occupied. Our emergency room is very busy. That stress level isn’t good for everyone. So if someone wants to leave, we try to get them to leave within the system." For some, the outpatient system, which has approximately 1.7 million visits per year, offers opportunity.

Not an easy road

There certainly were battles to fight to get to this point. When Fiore started in 1986, she had to go before the board and prove her case for funding. "My boss was a nursing advocate who understood that when patients are sick, they don’t ask for an administrator, but for a nurse," she says. Still, Fiore had to convince the board for money for some additional positions, training, and internships. Pensions were increased and more education was reimbursed. There was an effort to recognize that the nurses "were human beings with a whole other life outside the hospital," she adds. The hospital banned mandatory overtime even before it became illegal in New Jersey.

All of that cost money. But once the board saw outcomes improve, they were more willing to listen to Fiore’s pitches for funding. It didn’t hurt when the hospital won the Magnet designation, a Robert Wood Johnson Pursuing Perfection grant, the Governor’s Gold award, and a consumer choice award for seven years in a row. "We still have to prove we need to spend the dollars, but it’s easier now," she says. "There is a level of trust. They know that even if something is expensive up front, it’s better for us to have our own staff than foreign, agency, or traveling nurses. Why should we pay $100 per hour for an agency nurse when if we just paid appropriately and competitively, we could keep our own nurses here long term and win their loyalty?"

Hackensack isn’t the most expensive nursing service in New Jersey. It’s been in the black for 16 years, has good outcomes, and boasts a relatively seasoned nursing staff, with an average age of 38 and an average tenure of 11 years.

Fiore isn’t complacent. "I know we all face some of these issues no matter how good we are," she says. "In 10 years, if the nation doesn’t take some aggressive action on nursing school enrollments, we all will have trouble."

The job is never done, she adds. "Excellence has no finish line, and even though we do well, we have to raise the bar. There are always things we have to do better for patients and for employees."

Fiore is the first to tout how special her facility is. "We like the idea that we are huge, but we are warm." But she also contends that any facility can take steps like she has and address their turnover and vacancy rates. "It takes work, but it is doable. Take the Magnet standards and live them. Don’t just apply them and forget it. Use them as a guide, and the only outcome that is possible is you will become a place where people want to work."


• Toni Fiore, MA, CNAA, Executive Vice President for Patient Care, Hackensack University Medical Center, 30 Prospect Ave., Hackensack, NJ 07601. Telephone: (201) 996-2471.