An incredible amount of published material exists on the topic of registered nurse turnover. Renowned institutions including the Robert Wood Johnson Foundation, PwC, Oakland, Calif.-based Kaiser Permanente and just about every industry journal have published a study on it, and rightfully so. Turnover is an incredible disruption to a healthcare provider. It affects morale and quality — and the cost can put a lot of strain on institutions already under pressure.
While there are tomes on the topic of turnover, there is very little information specific to the effect staffing metrics have on it. "Staffing" is consistently ranked as one of the top reasons for turnover, but what in particular about staffing leads to turnover?
We are all aware of the elements that dissatisfy staff, e.g., floating, cancellations and overtime. Unfortunately, many of the dissatisfiers are occasionally necessary, but at what point do these instances impact turnover?
To uncover the answer and provide the industry with a few threshold benchmarks, Avantas looked at a number of metrics from 38 hospitals across six health systems. All of the data examined was for licensed direct patient care skills in the peer groups of Critical Care, Step Down, Medical Surgical and Behavioral.
For each metric, Avantas determined the average percentage of total hours per RN and identified at what point the metric played a factor in turnover. As the table below illustrates, nurses show great resilience in most cases, coping with above average exposure to the metrics studied. In some cases, however, such as overtime, the point at which turnover is affected is below the average.
|
Variable |
Average of total hours |
Level at which metric affects turnover |
|
Core Staff Floating |
12.9% |
> 14.2% |
|
Cancellations |
2.8% |
> 3.2% |
|
Extra |
9.2% |
> 12.3% |
|
Overtime |
4.6% |
> 3.1% |
|
Expected Time Off |
10.1% |
< 8.9% |
|
Unexpected Time Off |
7.2% |
> 7.9% |
|
Staff Member Tenure |
4 |
< 3 |
While some of the metrics included in the study may seem disparate, when they are taken as a whole common causes emerge, as does a related set of strategies that can alleviate the problem. Let's examine three of the main culprits behind these metrics:
Imbalanced schedules/not scheduling to demand
Imbalanced core staff schedules can happen in a few ways. First, organizations may not be developing staff schedules based on predicted volume — instead, they use a flat budgeted number. The ability to build core staff schedules in accordance with demand requires the utilization of a forecasting methodology that provides an accurate projection of needs/volumes at the time core staff schedules are built. Second, organizations may not balance their schedules based on patient demand — e.g., staffing the same on a Monday as they do on a Wednesday, even though Wednesdays generally have higher volume. Third, schedules are submitted with FTE leakage — i.e., staff not scheduled to their FTE commitment. When submitted schedules have FTE leakage, the department is playing catch up before the schedule period even begins.
Improperly sized core staff
How many core staff members does a unit or department need to handle the normal ebb and flow of patient demand? The point here is to hire the number of core staff needed to keep them consistently working to their FTE without the need for excessive floating or overtime (staff dissatisfiers that will lead to turnover). To determine this number, organizations can conduct census analysis, and take into account other factors that pull staff away from patient care, such as meetings, education and family and medical leave. This is not a one-and-done activity, however. Organizations should monitor this quarterly and reset goals annually as factors like physician hiring, network expansion and regional issues influence patient volumes.
Inadequate contingency staff layers
To fill in the gaps when core staff members are unavailable to take a patient or when census spikes or acuity calls for more staff, organizations must have the right size and layering of contingency staff. How many layers (types of float pools) you need and the size of those layers will vary depending on your organization's size and its unique challenges, but the process for determining size and layering involves analysis of core staff behaviors and trends (such as expected and unexpected time off), historical census levels and acuity spikes, predicted future census, staffing levels, payroll, and various HR information.
These three overarching issues affect the staffing metrics that lead to turnover. Frequent floating, overtime and cancellations create a stressful environment for staff. In healthcare every day is different, but there should be a sense of stability staff members can rely on, such as knowing that the vast majority of their time will be spent in their department working the hours they are scheduled. Occasional overtime and floating, is unavoidable, but organizations should create environments where they are the exception. This can be accomplished with effective workforce planning.
Chris Fox is chief executive officer at Avantas, a leading provider of strategic labor management technology, services, and strategies for the healthcare industry. He is an industry veteran and proven leader who has played a critical role in the company's rapid rise to leadership in healthcare enterprise labor management. Contact him at cfox@avantas.com
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