4 Things Hospitalists Can Do to Reduce Nursing Turnover

Hospitalists and hospital administrators know the greatest challenge to providing safe, high-quality healthcare day in and day out in the U.S. is adequate nurse staff. Already a problem before the pandemic, the nursing shortage continues to worsen. By 2025, less than a year from now, the U.S. will have a shortage of 200,000 to 450,000 nurses available for direct patient care, equivalent to a gap of 10% to 20%.¹ There is some dispute about the existence of an overall shortage of nurses, but what is clear is that nurses are leaving direct patient care, especially medical-surgical nurses, in droves.^2,3

As hospitalists, we might shrug our shoulders and say, “What can I do about this?” It’s hard for an individual hospitalist to impact macro trends in the healthcare workforce. However, even within an individual unit or hospital, some steps can be taken by any hospitalist to reduce nursing turnover and thereby improve staffing.

1. Respect and protect staff on your unit. This sounds basic, but if you receive safety reports regularly, you’ll realize that patients, visitors, and practitioners regularly abuse and disrespect nurses and other staff. While workplace violence is a constant risk for healthcare workers, it’s critical to avoid normalizing it and to take a zero-tolerance policy towards these behaviors.⁴ But even before the violence occurs, hospitalists can engage in training, prevention, and rapid-response plans.⁵ Hospitalists can also ensure that their group espouses practices that promote psychological safety, which are available from both the Institute for Healthcare Improvement and the Agency for Healthcare Research and Quality.^6,7

2. De-escalate monitoring and avoid ordering unnecessary interventions. As hospitalists, we often focus on the direct costs of unnecessary interventions, but the indirect cost of administering unnecessary interventions, while hard to directly measure, is often even more significant.⁸ And it doesn’t take rocket scientists to figure out that unnecessary vital signs and monitoring increase the staffing needs for a unit.^9,10

3. Improve clinician-nursing teamwork and communication. Working in a high-stress environment without the support of a team is a recipe for burnout and transferring to a different position. Not only is patient care improved when hospitalists and nurses work together as a team, but it also improves job satisfaction.^11,12 Improving teamwork can be an elusive goal, but there are concrete steps that can be taken, such as clinicians contributing to huddles, bedside rounding, and positively reinforcing “good catches” through recognitions during huddles or in a hospital-based recognition system.^13,14,15

4. Listen to your nurses. As an intern, I was told this was the first rule of surviving the year, and this continues to ring true to me as a “seasoned” hospitalist. This applies not only to specific patient concerns but also to unit-level concerns. As hospitalists, we often give a collective eye roll when being told about the importance of discharge by noon (DBN). The data, I’ll admit, is quite mixed.¹⁶ But while DBN may not actually reduce length-of-stay as has been sometimes touted, it reduces the overlapping burden for nurses trying to discharge and admit at peak admission times.¹⁷ Minimizing this chaotic overlap can reduce nursing stress and burnout.

As we continue to emerge from the pandemic, as hospitalists, we can take small but clearly helpful measures each day to improve the culture of teamwork and safety on our units that promote nursing and other staff retention. And, as we celebrate National Nurses Week this month (May 6-12), let’s continue to build on our successes with our nursing colleagues to make our units and hospitals not only great places to heal but also great places to work. 

Dr. Chang

Dr. Chang, the physician editor of The Hospitalist, is a pediatric and adult hospitalist at Baystate Medical Center and Baystate Children’s Hospital in Springfield, Mass., where he is an associate professor of pediatrics at the University of Massachusetts Medical School Baystate, chief of pediatric hospital medicine, and vice-chair for clinical affairs at Baystate Children’s Hospital.

References

1. Berlin G, Lapointe M, Murphy M. Assessing the lingering impact of COVID-19 on the nursing workforce. McKinsey & Company website. https://www.mckinsey.com/industries/healthcare/our-insights/assessing-the-lingering-impact-of-covid-19-on-the-nursing-workforce. Published May 11, 2022. Accessed March 27, 2024.
2. NCSBN Research Projects Significant Nursing Workforce Shortages and Crisis. National Council of State Boards of Nursing website. https://www.ncsbn.org/news/ncsbn-research-projects-significant-nursing-workforce-shortages-and-crisis. Published April 13, 2023. Accessed March 27, 2024.
3. Carbajal E. Where are all the med-surg nurses? Becker’s Hospital Review website. https://www.beckershospitalreview.com/nursing/what-will-it-take-to-get-more-nurses-in-med-surg-2-leaders-weigh-in.html. Published August 10, 2023. Accessed March 27, 2024.
4. AACN Position Statement: Zero Tolerance for Bullying, Incivility, and Verbal Abuse. American Association of Critical-Care Nurses website. https://www.aacn.org/policy-and-advocacy/aacn-position-statement-zero-tolerance. Published November 1, 2019. Accessed March 27, 2024.
5. Appold K. How Hospitals are Tackling Violence. The Hospitalist website. https://www.the-hospitalist.org/hospitalist/article/34288/practice-management/how-hospitals-are-tackling-violence/. Published March 1, 2023. Accessed March 27, 2024.
6. Baker N. 5 Ways to Improve Psychological Safety. Institute for Healthcare Improvement website. https://www.ihi.org/insights/5-ways-improve-psychological-safety. Published November 7, 2018. Accessed March 27, 2024.
7. Kingston MB, Dowell P, et al. Annual Perspective: Psychological Safety of Healthcare Staff. Agency for Healthcare Research and Quality website. https://psnet.ahrq.gov/perspective/annual-perspective-psychological-safety-healthcare-staff.  Published March 31, 2022. Accessed March 27, 2024.
8. Sørensen CA, et al. Cost–consequence analysis of self-administration of medication during hospitalization: a pragmatic randomized controlled trial in a Danish hospital setting. Therapeutic Advances in Drug Safety. 2020;11. doi:10.1177/2042098620929921
9. Orlov NM, Arora VM. Things We Do For No Reason™: Routine Overnight Vital Sign Checks. J Hosp Med. 2020;15(5):272-4.
10. Davis K, Tolstrup K, et al. When Should Hospitalists Order Continuous Cardiac Monitoring? The Hospitalist website. https://www.the-hospitalist.org/hospitalist/article/122074/when-should-hospitalists-order-continuous-cardiac-monitoring/3/. Published November 4, 2015. Accessed March 27, 2024.
11. Huang B. Increased Familiarity Between Residents and Nurses Improves Team Performance and Communication. The Hospitalist website. https://www.the-hospitalist.org/hospitalist/article/34699/patient-care/increased-familiarity-between-residents-and-nurses-improves-team-performance-and-communication/. Published May 1, 2023. Accessed March 27, 2024.
12. Kalisch BJ, Lee H, Rochman M. Nursing staff teamwork and job satisfaction. J Nurs Manag. 2010;18(8):938-47.
13. Aase I, Tjoflåt I, Urstad KH. Using the ‘huddle’ to enhance interprofessional teamwork among nursing students through a podcast: a qualitative and exploratory pilot study. BMC Nurs. 2021;20(1):235.
14. Caceres V. Bedside Rounding—Pros, Cons, and Tips for Success. The Hospitalist website. https://www.the-hospitalist.org/hospitalist/article/35641/practice-management/bedside-rounding-pros-cons-and-tips-for-success/. Published October 2, 2023. Accessed March 27, 2024.
15. Teamwork Toolkit. Duke Center for Healthcare Safety and Quality website. https://www.hsq.dukehealth.org/files/2019/06/TeamworkToolkit.pdf. Accessed March 27, 2024.
16. Beresford L. Does morning discharge really improve hospital throughput? The Hospitalist website. https://www.the-hospitalist.org/hospitalist/article/249851/transitions-care/does-morning-discharge-really-improve-hospital. Published December 13, 2021. Accessed March 27, 2024.
17. Farah M. Don’t Let Me Be Misunderstood: Discharge Before Noon Measure. LinkedIn website. https://www.linkedin.com/pulse/dont-let-me-misunderstood-discharge-before-noon-marina-farah-md-mha-1c/. Published June 12, 2019. Accessed March 27, 2024.