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Solving nurse shortage requires innovation
It started in the late 1990’s like a whisper: A nursing shortage was beginning to emerge. Across the board, from hospitals to home health, the need for nurses was outpacing the supply. Even more disturbing was the diminishing availability of skilled nurses.
Hospices, which rely heavily on skilled nurses to provide much of their care, have had to compete with other health care facilities in their markets, not to mention other hospices. From the onset of the shortage, hospices were at an economic disadvantage. Hospice could not compete with the higher salaries offered by hospitals and home health agencies. Even worse, hospitals and home health agencies in some markets have been offering signing bonuses to entice prospective nurses.
Then the whisper evolved into a scream. The nursing shortage was further exasperated by a red-hot economy that provided nurses with other options. The rise in health care-related companies, including Internet startups, provided new ways for nurses to apply their medical knowledge. Some even left nursing altogether for more lucrative jobs.
Hospice nursing was once considered a haven for nursing purists, a place where old-fashioned, hands-on nursing could be practiced unencumbered by bureaucracy. But even that has changed, says Janet Neigh, executive director of the Hospice Association of America in Washington, DC.
"It’s a combination of competing with hospitals and home health, and all the documentation that is involved in hospice," she says. "With all the documentation that the government requires, [hospice] nurses feel that they can’t practice nursing the way they were taught to."
How are hospices supposed to be able to recruit talented nurses and keep them? To make matters more complicated, not just any nurse will do. Hospices need nurses with experience, especially for home hospice nurses, who are asked to function independently and must make critical decisions during a home visit.
While there are inherent disadvantages that hospices will be unable to overcome, there are still recruiting tactics that can help hospices attract experienced nurses. Experts agree that the two areas hospices should highlight during their recruiting attempts are:
• high job satisfaction as a result of practicing hands-on medical care and the close relationship nurses develop with their patients and families;
• flexible working hours that will attract nurses who can’t work traditional 40-hour weeks.
Job satisfaction is perhaps hospice’s greatest selling point, says Metta G. Johnson, RN, BSN, OCN, ACRN, executive director and owner of Haven House, an Atlanta-area hospice. She and other Atlanta-area hospices should know. Because Georgia does not require a certificate of need to start a hospice program, competition is strong in Atlanta and surrounding counties. Not only are Atlanta-area hospices competing for patients; they are also competing for nurses.
Knowing that competition for hospice nurses is fierce, Johnson says she broadens her pool of prospective nurses by not limiting her search to nurses with hospice experience. Instead, her search includes all experienced nurses from a variety of disciplines. "What I’m looking for are nurses who are mission-oriented and willing to learn if they don’t have hospice nursing experience," says Johnson.
For prospective nurses outside of hospice, the message of greater job satisfaction may have greater impact. Hospices can use nurses’ current job dissatisfaction to their advantage. According to Neigh, hospices should stress how hospice nurses can have a direct and immediate impact on patients and their families and emphasize the gratitude families have for hospice workers who helped them get through a difficult situation.
"The reward comes from the patient and family," Neigh says. "It can’t only be about money. If a nurse takes a job just for the money, after a month they will still have to do the job."
Still, money is a strong motivating factor. To help neutralize the money factor, providing employment that enhances quality of life beyond professional job satisfaction can go a long way to persuading a nurse to join a hospice.
"I feel that an employer that is meeting an employee’s personal and professional goals is the one with the most satisfied workers," says Johnson.
Offer flexible working hours
The best way to do that, say Neigh and Johnson, is to offer flexible hours and working arrangements. At Haven House, Johnson allows nurses to work as many hours as they like, whether it’s 20 hours a week or 40 hours a week. This allows Haven House to employ talented nurses, who, for example, cannot work a full-time job because they want to be home with their children after school. Hospice can offer that nurse an opportunity to pursue her professional interests while still being able to fulfill family obligations.
"You need to come up with creative scheduling," says Neigh. "Try to come up with a more flexible schedule that allows nurses to have a better quality of life and reduce burnout."
Noncompetitive salaries and the potential to make more elsewhere are still factors hospices must contend with even after a nurse is hired. And while the job provides precious moments with patients and their families, it can also prove to be an emotional burden, with few outlets to allow nurses to unload their grief and frustration.
Hospices’ ability to keep nurses happy will depend on how well hospices recognize nurses’ contributions to the success of the organization. Yet, while ceremonies and rituals that pat nurses on the back have some impact, it is more important to recognize how nurses are affected by caring for the dying day in and day out, says Johnson.
"Being a hospice nurse is not dinner party conversation," says Johnson. "After you tell someone you are a hospice nurse, they say how wonderful that is and how they admire you for doing what you do. But they don’t want to hear any further, they don’t want to hear about the 19-year-old man you are taking care of." They especially don’t want to hear about how emotionally trying it can be, adds Johnson. So, hospice nurses are left with few outlets to express their emotions at the end of the day. "Allow them time to express their feelings," says Johnson.
Hospice requires support group attendance
For example, the Hospice of Northern Virginia requires its workers to attend a support group twice a month. The support group is facilitated by an outside psychologist, and management personnel are not allowed to attend in order to promote frank conversation without fear of reprisal.
Yet, some hospices find it impossible to require their busy nurses to attend support groups. Rather than making attendance a requirement, they place a priority on providing a formal outlet to allow nurses to express their emotions.
Other venues in which nurses can share their feelings include:
• Interdisciplinary team meetings. A great deal is discussed during team meetings, from the patient’s progress to spiritual matters. The team meeting also can serve as a platform for nurses and others to share their feelings, especially following a difficult case. This allows a nurse to share his or her feelings with peers who can empathize with the emotions a troubled nurse is going through.
• Patient memorial services. Most hospices hold these services on a monthly basis to allow staff to recall patients who have died that month. The event gives staff a chance to share their feelings about their patients with colleagues and sometimes with the family of the deceased as well.
The effort to retain workers by supporting them starts from the time they are hired. At the Hospice of Central Virginia, new nurses have an orientation program that not only introduces them to the organization but also provides coping skills to help them deal with the emotional rigors of caring for the dying.
"They aren’t sent into the field until they are comfortable," says Cheryl Rodgers, RN, BSN, staff development-quality assurance coordinator. "The nurse stays in the orientation program for as long as the nurse needs it. It also gives me a chance to determine whether being a hospice nurse is the right job for the person."
The orientation program includes the following topics.
• Organizational philosophy. Recently hired workers are schooled on the hospice philosophy and mission.
• Hospice basics. For nurses who have never worked in hospice, there is a need to become familiar with ideas such as the interdisciplinary team, palliative care, spiritual care, advanced directives, and other tenets of hospice that are critical to getting nurses oriented.
• Communication. New nurses are taught how to listen to patients and take clues from patient interaction.
• Death and dying. New hires are asked to explore their own feelings about death and dying, perhaps by revisiting their own loss of a loved one.
• Stress management. The hospice emphasizes the importance of communication, not only for the sake of patient care but also for the mental well-being of its nurses. New nurses are taught the importance of using resources available through the interdisciplinary team, such as other team members who can provide additional support to the patient and alleviate the stress of having to support the patient on their own.
Neigh also suggests that hospices regularly survey their staff to gauge which aspects of the job they like the most and which ones they dislike or find frustrating. The results of the survey will provide important information on the areas in which a hospice needs to provide more support to its staff.
For example, if staff indicate that keeping up with documentation is a problem, then the hospice could find ways to improve the documentation process or provide more staff education on it.
In the end, says Neigh, hospices battling to hire experienced nurses will realize that money isn’t the only answer to attracting nurses to hospice work. "It’s a beginning," she says. "But you have to believe in what you are doing."