Can’t retain nurses? One hospital recruits RN grads

CCU bets heavily internships will yield retention

Struggle is a term that Kathy Arnold, RN, MS, a nurse manager at Swedish American Health System in Rockford, IL, knows all too well. Exhausted by the demands of trying to staff her CCU and coming up short each time in 1998, Arnold helped launch a plan she believes will end her hospital’s costly reliance on nurse registries and staffing agencies.

The solution: Rather than search for seasoned CCU nurses, Arnold decided to cultivate her own nurses from the bottom up. She went to the most logical place in search of raw recruits — local colleges and universities.

In June, Swedish American enrolled its first group of three recently graduated RNs into its critical care internship program. The group may be small, but the five- to six-month course has been strategically designed with a dual purpose in mind: To give interested grads a thorough immersion into a real-life critical care practice setting while giving them a compelling reason to stay at Swedish American, hopefully for years.

Although many hospitals are trying this with mixed results, Arnold, a 14-year veteran CCU manager, says her approach can and will succeed. Why? "Because we’re willing to work with these kids," she says, "to do everything we can to help them succeed. If they succeed, we succeed."

Hospital provides intensive CCU training

In this respect, Swedish American is unusual. Many hospitals simply recruit recent graduates and put them to work on medical-surgical floors before they advance to tougher assignments such as critical care. In contrast, interns at Swedish American are immediately immersed into critical care nursing and learn the specialty from day one.

However, from a management viewpoint, the program isn’t for the impulsive, Arnold quickly points out. It requires a lot of time, patience, commitment, and dedication. Due partly to the intensive nature of critical care, "It’s not for anyone looking for quick fixes," says Rita B. Klint, RN, MS, Swedish American’s vice president of patient services. (For a list of key factors, see chart on p. 35.)

But for Swedish American, the time and effort involved is worthwhile. Until recently, the unit had been spending about $90,000 per year on agencies and registries, paying RNs a whopping $45 per hour whenever they were even available. The resulting investment has proven fruitless, Arnold says.

At the end of a month, the unit was still regularly under-staffed and the money was spent. "You can recruit all you want, but if you can’t retain, you defeat the whole purpose," Arnold observes.

The combined 20-bed medical-surgical and cardiac-care ICU has been operating at least four FTE (full-time equivalent) nurses short on each shift, or 11% down, which has prevented the 20-bed unit from moving beyond an average patient census of 14, or 70% of bed capacity. The combination of the staffing costs and losses in potential patient revenue left the hospital with few options, Klint says.

Swedish American, which is located in a heavily populated suburb of Chicago, has all the urban problems of any large teaching hospital. At a cost of about $30,000 to $40,000 per intern over six months to cover salary, books, class time, and pay for an assigned preceptor, the expense is viewed as a long-term investment rather than an additional cost, Arnold says.

Beginning with the initial recruitment effort, administrators are careful not to make mistakes. Losing an intern after such a heavy investment would be a huge setback. Therefore, the following aspects of the program are carefully executed:


While the program hasn’t enjoyed an overwhelming response from applicants, management has been careful to adhere to high standards. Applicants are carefully interviewed as they would for any paid position, says Klint. Some apply from a student nurse PCT (patient care technician) program that the hospital has operated for some time.

Of key importance is whether the graduate has a sincere interest in specializing in critical care or simply wants a job, Arnold says. The internship pays between $14.00 and $23.00 per hour, depending on experience. Energy, initiative, capacity for learning, people skills, and enthusiasm are also important.


Although the internship involves practical bedside learning, the program includes a demanding regimen of classroom instruction in core competency clinical practice established by the American Association of Critical Care Nurses. About 200 hours of classroom instruction are scheduled into the 40-hour workweek over 20 to 24 weeks.

The first three weeks are spent with a clinical nurse specialist going over fundamentals such as admitting and starting intravenous feeding. The second three weeks, the intern works with patients’ nurses shadowed by a preceptor with increasing responsibility. Over the next several weeks, the intern is given more leeway in decision making and eventually works night and evenings shifts.


Each intern is assigned an experienced RN preceptor who acts as the intern’s on-the-job teacher and guide. Unlike the general medical floors, the CCU requires one-to-one nurse-to-patient staffing at times. The interns, therefore, assist the attending nurses and learn by doing under the preceptor’s supervision. The arrangement allows for thorough explanations, questions and answers, says veteran nurse Judy Bowersock, RN, a preceptor.

Clear-cut goals and objectives.

Each week, program managers outline goals and objectives for interns. The goals can range from mastering intubation, titration, taking arterial blood gasses, admitting, documenting, and daily charting. The intern’s progress is carefully monitored and discussed with the preceptor and unit manager during daily and weekly meetings. The discussions are designed to be supportive, helpful, and encouraging, says Bowersock.

Flexible pacing.

Interns are offered a positive, flexible work environment to allow them to learn at their own pace, says Glenn M. Gungel, RN, who graduated from nursing school last year and enrolled as an intern while taking his state boards. While the program offered him "great hands-on training, there was always someone there who could help with answers" and direction, says Gungel, a 50-year-old who decided two years ago to become a nurse. Gungel was among the first to complete the program and has decided to stay at Swedish American.

Pacing is important as both a means of easing the intern into a very demanding clinical job, but also as a means of giving the intern a positive, caring experience, says Arnold.

The program is new and therefore the risks are great, Klint acknowledges. "Initially, it was viewed as a huge undertaking with a doubtful payoff," says Arnold. To some degree, it still is.

Key factors in Swedish American’s graduate internship program

• High interest level and career goals in applicants.
• Thorough interview and assessment prior to recruitment.
• Assignment of qualified, compatible nurse preceptor.
• Clearly defined and detailed weekly learning objectives and goals per shift.
• 200 hours of integrated didactic classroom instruction.
• Daily supervised guidance and support of intern from preceptors.
• Phased-in clinical responsibilities for interns in assisting bedside nurses.
• Carefully monitored, increased responsibility by interns in patient-care duties.
• Daily review and feedback with preceptor of on-floor work experience.
• Weekly progress evaluation involving intern, preceptor and unit nurse manager.
• Documented progress evaluations.
• Program flexibility and focus on intern’s own pace of learning.
• Administration’s support and financial investment.

Source: Swedish American Health System, Rockford, IL.